Nursing Board Practice Test Compilation TEST IV - Care of Clients with Physiologic and

Contents Psychosocial
Alterations .............................................. 111
NURSING PRACTICE I: FOUNDATION OF
NURSING Answers and Rationale – Care of Clients with

PRACTICE ............................................................. Physiologic and Psychosocial

............. 4 Alterations ................ 122

NURSING PRACTICE TEST V - Care of Clients with Physiologic and

II ..................................................... 15 Psychosocial

NURSING PRACTICE Alterations ...........................................................

III .................................................... 26 ......... 133

NURSING PRACTICE Answers and Rationale – Care of Clients with

IV.................................................... 36
Physiologic and Psychosocial
NURSING PRACTICE Alterations ................ 144
V..................................................... 46
PART III PRACTICE TEST I FOUNDATION OF
TEST I - Foundation of Professional Nursing NURSING . 153
Practice .... 56
ANSWERS AND RATIONALE – FOUNDATION OF
Answers and Rationale – Foundation of
NURSING .............................................................
Professional
..... 158
Nursing
PRACTICE TEST II Maternal and Child
Practice ......................................................... 66
Health ............... 162
TEST II - Community Health Nursing and Care of
ANSWERS AND RATIONALE – MATERNAL AND
the
CHILD
Mother and
HEALTH ................................................................
Child ........................................................... 74
..... 167
Answers and Rationale – Community Health
MEDICAL SURGICAL
Nursing
NURSING ..................................... 173
and Care of the Mother and
ANSWERS AND RATIONALE – MEDICAL
Child ............................. 84
SURGICAL
TEST III - Care of Clients with Physiologic and
NURSING .............................................................
Psychosocial ..... 178
Alterations ................................................ 91
PSYCHIATRIC
Answers and Rationale – Care of Clients with NURSING ................................................ 180

Physiologic and Psychosocial ANSWERS AND RATIONALE – PSYCHIATRIC

Alterations ................ 102 NURSING
............................................................................. TEST II - Community Health Nursing and Care of
.... 185 the

FOUNDATION OF PROFESSIONAL NURSING Mother and

PRACTICE 188 Child ......................................................... 273

ANSWER KEY - FOUNDATION OF PROFESSIONAL Answers and Rationale – Community Health

Nursing
NURSING
PRACTICE .................................................. 199 and Care of the Mother and
Child ........................... 283
COMMUNITY HEALTH NURSING AND CARE OF
THE TEST III - Care of Clients with Physiologic and

MOTHER AND Psychosocial

CHILD .................................................... 200 Alterations .............................................. 290

ANSWER KEY: COMMUNITY HEALTH NURSING Answers and Rationale – Care of Clients with
AND
Physiologic and Psychosocial
CARE OF THE MOTHER AND Alterations ................ 301
CHILD .......................... 211
TEST IV - Care of Clients with Physiologic and
Comprehensive Exam
Psychosocial
1................................................ 213
Alterations .............................................. 310
CARE OF CLIENTS WITH PHYSIOLOGIC AND
Answers and Rationale – Care of Clients with
PSYCHOSOCIAL
Physiologic and Psychosocial
ALTERATIONS ...................................... 222
Alterations ................ 321
ANSWER KEY: CARE OF CLIENTS WITH
TEST V - Care of Clients with Physiologic and
PHYSIOLOGIC
Psychosocial
AND PSYCHOSOCIAL
Alterations ...........................................................
ALTERATIONS ......................... 234
......... 332
Nursing Practice Test
Answers and Rationale – Care of Clients with
V ................................................ 235
Physiologic and Psychosocial
Nursing Practice Test
Alterations ................ 343
V ................................................ 245
PART
TEST I - Foundation of Professional Nursing
III .........................................................................
Practice .. 255
352
Answers and Rationale – Foundation of
PRACTICE TEST I FOUNDATION OF
Professional
NURSING .............. 352
Nursing
ANSWERS AND RATIONALE – FOUNDATION OF
Practice ....................................................... 265
NURSING ............................................................. MATERNITY NURSING Part
..... 357 1 ........................................ 409

PRACTICE TEST II Maternal and Child ANSWERS and RATIONALES for MATERNITY
Health ............... 361 NURSING

2 Part
1 ........................................................................
ANSWERS AND RATIONALE – MATERNAL AND
418
CHILD
MATERNITY NURSING Part
HEALTH ................................................................
2 ........................................ 428
..... 366
Answer for maternity part
MEDICAL SURGICAL
2 .................................... 433
NURSING ..................................... 372
PEDIATRIC
ANSWERS AND RATIONALE – MEDICAL
NURSING .................................................... 434
SURGICAL
ANSWERS and RATIONALES for PEDIATRIC
NURSING .............................................................
NURSING
..... 377
.............................................................................
PSYCHIATRIC
.... 439
NURSING ................................................ 379
COMMUNITY HEALTH NURSING Part
ANSWERS AND RATIONALE – PSYCHIATRIC
1........................ 444
NURSING
COMMUNITY HEALTH NURSING Part
.............................................................................
2........................ 454
.... 384
MEDICAL SURGICAL NURSING Part
FUNDAMENTALS OF NURSING PART
1 ........................... 475
1 ........................ 387
ANSWERS and RATIONALES for MEDICAL
FUNDAMENTALS OF NURSING PART
SURGICAL
2 ........................ 392
NURSING Part
ANSWERS and RATIONALES for FUNDAMENTALS
1 ........................................................ 479
OF
MEDICAL SURGICAL NURSING Part
NURSING PART
2 ........................... 481
2 ...................................................... 397
MEDICAL SURGICAL NURSING Part
FUNDAMENTALS OF NURSING PART
2 ....................... 485
3 ........................ 401
ANSWERS and RATIONALES for MEDICAL
ANSWERS and RATIONALES for FUNDAMENTALS
SURGICAL
OF
NURSING Part
NURSING PART
2 ........................................................ 489
3 ...................................................... 405
MEDICAL SURGICAL NURSING Part Nursing Research Suggested Answer
3 ........................... 491 Key ................ 546

ANSWERS and RATIONALES for MEDICAL 3

SURGICAL
4
NURSING Part
NURSING PRACTICE I: FOUNDATION OF
3 ........................................................ 495
NURSING
PSYCHIATRIC NURSING Part
PRACTICE
1 ...................................... 497
SITUATION: Nursing is a profession. The nurse
ANSWERS and RATIONALES for PSYCHIATRIC
should
NURSING
have a background on the theories and
Part
foundation of
1 ........................................................................
502 nursing as it influenced what is nursing today.
PSYCHIATRIC NURSING Part 1. Nursing is the protection, promotion and
2 ...................................... 504
optimization of health and abilities, prevention
ANSWERS and RATIONALES for PSYCHIATRIC
NURSING of illness and injury, alleviation of suffering

Part through the diagnosis and treatment of human

2 ........................................................................ response and advocacy in the care of the
509
individuals, families, communities and the
PSYCHIATRIC NURSING Part
3 ...................................... 512 population. This is the most accepted definition

ANSWERS and RATIONALES for PSYCHIATRIC of nursing as defined by the:

NURSING a. PNA
Part b. ANA
3 ........................................................................
516 c. Nightingale

PROFESSIONAL d. Henderson
ADJUSTMENT ...................................... 519
2. Advancement in Nursing leads to the
LEADERSHIP and
development of the Expanded Career Roles.
MANAGEMENT ................................. 522
Which of the following is NOT an expanded
NURSING RESEARCH Part
1 .......................................... 532 career role for nurses?

NURSING RESEARCH Part a. Nurse practitioner

2 .......................................... 542
b. Nurse Researcher
c. Clinical nurse specialist c. a holistic understanding and perception

d. Nurse anaesthesiologist of the client

3. The Board of Nursing regulated the Nursing d. intuitive and analytic ability in new

profession in the Philippines and is responsible situations

for the maintenance of the quality of nursing in SITUATION: The nurse has been asked to
administer an
the country. Powers and duties of the board of
injection via Z TRACK technique. Questions 6 to
nursing are the following, EXCEPT:
10 refer
a. Issue, suspend, revoke certificates of
to this.
registration
6. The nurse prepares an IM injection for an
b. Issue subpoena duces tecum, ad adult

testificandum client using the Z track technique. 4 ml of

c. Open and close colleges of nursing medication is to be administered to the client.

d. Supervise and regulate the practice of Which of the following site will you choose?

nursing a. Deltoid

4. A nursing student or a beginning staff nurse b. Rectus femoris

who
c. Ventrogluteal
has not yet experienced enough real situations
d. Vastus lateralis
to make judgments about them is in what stage
7. In infants 1 year old and below, which of the
of Nursing Expertise?
following is the site of choice for intramuscular
a. Novice
Injection?
b. Newbie
a. Deltoid
c. Advanced Beginner
b. Rectus femoris
d. Competent
c. Ventrogluteal
5. Benner’s “Proficient” nurse level is different
d. Vastus lateralis
from the other levels in nursing expertise in the
8. In order to decrease discomfort in Z track
context of having:
administration, which of the following is
a. the ability to organize and plan activities
applicable?
b. having attained an advanced level of
a. Pierce the skin quickly and smoothly at
education
a 90 degree angle
b. Inject the medication steadily at around of the muscle

10 minutes per millilitre d. It is much more convenient for the nurse

c. Pull back the plunger and aspirate for 1 SITUATION: A Client was rushed to the
emergency room
minute to make sure that the needle did
and you are his attending nurse. You are
not hit a blood vessel
performing a
d. Pierce the skin slowly and carefully at a
vital sign assessment.
90 degree angle
11. All of the following are correct methods in
9. After injection using the Z track technique,
assessment of the blood pressure EXCEPT:
the
a. Take the blood pressure reading on both
nurse should know that she needs to wait for a
arms for comparison
few seconds before withdrawing the needle and
b. Listen to and identify the phases of
this is to allow the medication to disperse into
Korotkoff’s sound
the muscle tissue, thus decreasing the client’s
c. Pump the cuff to around 50 mmHg
discomfort. How many seconds should the
nurse above the point where the pulse is

wait before withdrawing the needle? obliterated

a. 2 seconds d. Observe procedures for infection control

5 12. You attached a pulse oximeter to the client.

You
b. 5 seconds
know that the purpose is to:
c. 10 seconds
a. Determine if the client’s hemoglobin
d. 15 seconds
level is low and if he needs blood
10. The rationale in using the Z track technique
in an transfusion

intramuscular injection is: b. Check level of client’s tissue perfusion

a. It decreases the leakage of discolouring c. Measure the efficacy of the client’s

antihypertensive
and irritating medication into the
medications
subcutaneous tissues
d. Detect oxygen saturation of arterial
b. It will allow a faster absorption of the
blood before symptoms of hypoxemia
medication
develops
c. The Z track technique prevent irritation
13. After a few hours in the Emergency Room, c. Cover the fingertip sensor with a towel
The
or bedsheet
client is admitted to the ward with an order of
d. Change the location of the sensor every
hourly monitoring of blood pressure. The nurse
four hours
finds that the cuff is too narrow and this will
16. The nurse finds it necessary to recheck the
cause the blood pressure reading to be: blood

a. inconsistent pressure reading. In case of such re assessment,

b. low systolic and high diastolic the nurse should wait for a period of:

c. higher than what the reading should be a. 15 seconds

d. lower than what the reading should be b. 1 to 2 minutes

14. Through the client’s health history, you c. 30 minutes

gather
d. 15 minutes
that the patient smokes and drinks coffee.
17. If the arm is said to be elevated when taking
When
the
taking the blood pressure of a client who
blood pressure, it will create a:
recently smoked or drank coffee, how long
a. False high reading
should the nurse wait before taking the client’s
b. False low reading
blood pressure for accurate reading?
c. True false reading
a. 15 minutes
d. Indeterminate
b. 30 minutes
18. You are to assessed the temperature of the
c. 1 hour
client the next morning and found out that he
d. 5 minutes
ate ice cream. How many minutes should you
15. While the client has pulse oximeter on his
wait before assessing the client’s oral
fingertip, you notice that the sunlight is shining
temperature?
on the area where the oximeter is. Your action
a. 10 minutes
will be to:
b. 20 minutes
a. Set and turn on the alarm of the
c. 30 minutes
oximeter
d. 15 minutes
b. Do nothing since there is no identified
19. When auscultating the client’s blood
problem pressure
the nurse hears the following: From 150 mmHg d. Normal saline solution

to 130 mmHg: Silence, Then: a thumping sound 22. When performing oral care to an
unconscious
continuing down to 100 mmHg; muffled sound
client, which of the following is a special
continuing down to 80 mmHg and then silence.
consideration to prevent aspiration of fluids into
6
the lungs?
What is the client’s blood pressure?
a. Put the client on a sidelying position
a. 130/80
with head of bed lowered
b. 150/100
b. Keep the client dry by placing towel
c. 100/80
under the chin
d. 150/100
c. Wash hands and observes appropriate
20. In a client with a previous blood pressure of
infection control
130/80 4 hours ago, how long will it take to
d. Clean mouth with oral swabs in a careful
release the blood pressure cuff to obtain an
and an orderly progression
accurate reading?
23. The advantages of oral care for a client
a. 10-20 seconds
include
b. 30-45 seconds
all of the following, EXCEPT:
c. 1-1.5 minutes
a. decreases bacteria in the mouth and
d. 3-3.5 minutes
teeth
Situation: Oral care is an important part of
b. reduces need to use commercial
hygienic
mouthwash which irritate the buccal
practices and promoting client comfort.
mucosa
21. An elderly client, 84 years old, is
unconscious. c. improves client’s appearance and
selfconfidence
Assessment of the mouth reveals excessive
d. improves appetite and taste of food
dryness and presence of sores. Which of the
24. A possible problem while providing oral care
following is BEST to use for oral care?
to
a. lemon glycerine
unconscious clients is the risk of fluid aspiration
b. Mineral oil
to lungs. This can be avoided by:
c. hydrogen peroxide
a. Cleaning teeth and mouth with cotton
swabs soaked with mouthwash to avoid a. Clenching his fist every 2 minutes

rinsing the buccal cavity b. Breathing in and out through the nose

b. swabbing the inside of the cheeks and with his mouth open

lips, tongue and gums with dry cotton c. Tensing the shoulder muscles while lying

swabs on his back

c. use fingers wrapped with wet cotton d. Holding his breath periodically for 30

washcloth to rub inside the cheeks, seconds

tongue, lips and ums 27. Following a bronchoscopy, which of the

d. suctioning as needed while cleaning the following complains to Fernan should be noted

buccal cavity as a possible complication:

25. Your client has difficulty of breathing and is a. Nausea and vomiting

mouth breathing most of the time. This causes b. Shortness of breath and laryngeal

dryness of the mouth with unpleasant odor. stridor

Oral
c. Blood tinged sputum and coughing
hygiene is recommended for the client and in
d. Sore throat and hoarseness
addition, you will keep the mouth moistened by
28. Immediately after bronchoscopy, you
using: instructed

a. salt solution Fernan to:

b. petroleum jelly a. Exercise the neck muscles

c. water b. Refrain from coughing and talking

d. mentholated ointment 7

Situation – Ensuring safety before, during and c. Breathe deeply

after a
d. Clear his throat
diagnostic procedure is an important
29. Thoracentesis may be performed for
responsibility of
cytologic
the nurse.
study of pleural fluid. As a nurse your most
26. To help Fernan better tolerate the
important function during the procedure is to:
bronchoscopy, you should instruct him to
a. Keep the sterile equipment from
practice which of the following prior to the
contamination
procedure?
b. Assist the physician PCO2 32 mmHg, PO2 94 mmHg, HCO3 24
mEq/L.
c. Open and close the three-way stopcock
The nurse interprets that the client has which
d. Observe the patient’s vital signs
acid base disturbance?
30. Right after thoracentesis, which of the
following a. Respiratory acidosis

is most appropriate intervention? b. Metabolic acidosis

a. Instruct the patient not to cough or deep c. Respiratory alkalosis

breathe for two hours d. Metabolic alkalosis

b. Observe for symptoms of tightness of 33. A client has an order for ABG analysis on
radial
chest or bleeding
artery specimens. The nurse ensures that which
c. Place an ice pack to the puncture site
of the following has been performed or tested
d. Remove the dressing to check for
before the ABG specimens are drawn?
bleeding
a. Guthrie test
Situation: Knowledge of the acid-base
disturbance and b. Romberg’s test

the functions of the electrolytes is necessary to c. Allen’s test

determine appropriate intervention and nursing d. Weber’s test

actions.
34. A nurse is reviewing the arterial blood gas
31. A client with diabetes milletus has a blood values

glucose level of 644 mg/dL. The nurse interprets of a client and notes that the ph is 7.31, Pco2 is

that this client is at most risk for the 50 mmHg, and the bicarbonate is 27 mEq/L. The

development of which type of acid-base nurse concludes that which acid base

imbalance? disturbance is present in this client?

a. Respiratory acidosis a. Respiratory acidosis

b. Respiratory alkalosis b. Metabolic acidosis

c. Metabolic acidosis c. Respiratory alkalosis

d. Metabolic alkalosis d. Metabolic alkalosis

32. In a client in the health care clinic, arterial 35. Allen’s test checks the patency of the:
blood
a. Ulnar artery
gas analysis gives the following results: pH 7.48,
b. Carotid artery
c. Radial artery indwelling catheter and allow urine to

d. Brachial artery flow from catheter into the specimen

Situation 6: Eileen, 45 years old is admitted to container.

the
d. Disconnect the drainage from the
hospital with a diagnosis of renal calculi. She is
collecting bag and allow the urine to
experiencing severe flank pain, nauseated and
flow from the catheter into the
with a
specimen container.
temperature of 39 0C.
8
36. Given the above assessment data, the most
38. Where would the nurse tape Eileen’s
immediate goal of the nurse would be which of
indwelling
the following?
catheter in order to reduce urethral irritation?
a. Prevent urinary complication
a. to the patient’s inner thigh
b. maintains fluid and electrolytes
b. to the patient’ buttocks
c. Alleviate pain
c. to the patient’s lower thigh
d. Alleviating nausea
d. to the patient lower abdomen
37. After IVP a renal stone was confirmed, a left
39. Which of the following menu is appropriate
nephrectomy was done. Her post-operative for

order includes “daily urine specimen to be sent one with low sodium diet?

to the laboratory”. Eileen has a foley catheter a. instant noodles, fresh fruits and ice tea

attached to a urinary drainage system. How will b. ham and cheese sandwich, fresh fruits

you collect the urine specimen? and vegetables

a. remove urine from drainage tube with c. white chicken sandwich, vegetable

sterile needle and syringe and empty salad and tea

urine from the syringe into the d. canned soup, potato salad, and diet soda

specimen container 40. How will you prevent ascending infection to

b. empty a sample urine from the Eileen who has an indwelling catheter?

collecting bag into the specimen a. see to it that the drainage tubing

container touches the level of the urine

c. Disconnect the drainage tube from the b. change he catheter every eight hours
c. see to it that the drainage tubing does 44. Calcitonin, a hormone necessary for calcium

not touch the level of the urine regulation is secreted in the:

d. clean catheter may be used since a. Thyroid gland

urethral meatus is not a sterile area b. Parathyroid gland

Situation: Hormones are secreted by the various c. Hypothalamus

glands
d. Anterior pituitary gland
in the body. Basic knowledge of the endocrine
45. While Parathormone, a hormone that
system is
negates
necessary.
the effect of calcitonin is secreted by the:
41. Somatocrinin or the Growth hormone
a. Thyroid gland
releasing
b. Parathyroid gland
hormone is secreted by the:
c. Hypothalamus
a. Hypothalamus
d. Anterior pituitary gland
b. Posterior pituitary gland
Situation: The staff nurse supervisor requests all
c. Anterior pituitary gland
the staff
d. Thyroid gland
nurses to “brainstorm” and learn ways to
42. All of the following are secreted by the instruct
anterior
diabetic clients on self-administration of insulin.
pituitary gland except: She

a. Somatotropin/Growth hormone wants to ensure that there are nurses available

daily to
b. Thyroid stimulating hormone
do health education classes.
c. Follicle stimulating hormone
46. The plan of the nurse supervisor is an
d. Gonadotropin hormone releasing
example of
hormone
a. in service education process
43. All of the following hormones are hormones
b. efficient management of human
secreted by the Posterior pituitary gland except:
resources
a. Vasopressin
c. increasing human resources
b. Anti-diuretic hormone
d. primary prevention
c. Oxytocin
47. When Mrs. Guevarra, a nurse, delegates
d. Growth hormone aspects
of the clients care to the nurse-aide who is an 50. You are attending a certification on

unlicensed staff, Mrs. Guevarra cardiopulmonary resuscitation (CPR) offered

and
a. makes the assignment to teach the staff
required by the hospital employing you. This is
member
a. professional course towards credits
b. is assigning the responsibility to the
b. in-service education
aide but not the accountability for
c. advance training
those tasks
d. continuing education
c. does not have to supervise or evaluate
Situation: As a nurse, you are aware that proper
the aide
documentation in the patient chart is your
d. most know how to perform task
responsibility.
delegated
51. Which of the following is not a legally
48. Connie, the new nurse, appears tired and binding

sluggish and lacks the enthusiasm she had six document but nevertheless very important in

weeks ago when she started the job. The nurse the care of all patients in any health care

supervisor should setting?

a. empathize with the nurse and listen to a. Bill of rights as provided in the Philippine

her constitution

b. tell her to take the day off b. Scope of nursing practice as defined by

c. discuss how she is adjusting to her new RA 9173

job c. Board of nursing resolution adopting the

d. ask about her family life code of ethics

49. Process of formal negotiations of working d. Patient’s bill of rights

conditions between a group of registered nurses 52. A nurse gives a wrong medication to the
client.
and employer is
Another nurse employed by the same hospital
9 as
a. grievance a risk manager will expect to receive which of
b. arbitration the following communication?
c. collective bargaining a. Incident report
d. strike
b. Nursing kardex b. After a task has been delegated, it is no

c. Oral report longer a responsibility of the RN

d. Complain report c. The RN is responsible and accountable

53. Performing a procedure on a client in the for the delegated task in adjunct with

absence of an informed consent can lead to the delegate

which of the following charges? d. Follow up with a delegated task is

a. Fraud necessary only if the assistive personnel

b. Harassment is not trustworthy

c. Assault and battery Situation: When creating your lesson plan for

d. Breach of confidentiality cerebrovascular disease or STROKE. It is

important to
54. Which of the following is the essence of
include the risk factors of stroke.
informed consent?
56. The most important risk factor is:
a. It should have a durable power of
a. Cigarette smoking
attorney
b. binge drinking
b. It should have coverage from an
c. Hypertension
insurance company
d. heredity
c. It should respect the client’s freedom
57. Part of your lesson plan is to talk about
from coercion
etiology
d. It should disclose previous diagnosis,
or cause of stroke. The types of stroke based on
prognosis and alternative treatments
cause are the following EXCEPT:
available for the client
a. Embolic stroke
55. Delegation is the process of assigning tasks
b. diabetic stroke
that
c. Hemorrhagic stroke
can be performed by a subordinate. The RN
d. thrombotic stroke
should always be accountable and should not
58. Hemmorhagic stroke occurs suddenly
lose his accountability. Which of the following is
usually
a role included in delegation?
when the person is active. All are causes of
a. The RN must supervise all delegated
hemorrhage, EXCEPT:
tasks
a. phlebitis
b. damage to blood vessel hematocrit level for this client to be which of
the
c. trauma
following?
d. aneurysm
a. 60%
59. The nurse emphasizes that intravenous drug
b. 47%
abuse carries a high risk of stroke. Which drug is
c. 45%
closely linked to this?
d. 32%
a. Amphetamines
62. A nurse is reviewing the electrolyte results
b. shabu
of an
c. Cocaine
assigned client and notes that the potassium
d. Demerol
level is 5.6 mEq/L. Which of the following would
10
the nurse expect to note on the ECG as a result
60. A participant in the STROKE class asks what
of this laboratory value?
is a
a. ST depression
risk factor of stroke. Your best response is:
b. Prominent U wave
a. “More red blood cells thicken blood
c. Inverted T wave
and make clots more possible.”
d. Tall peaked T waves
b. “Increased RBC count is linked to high
63. A nurse is reviewing the electrolyte results
cholesterol.”
of an
c. “More red blood cell increases
assigned client and notes that the potassium
hemoglobin content.”
level is 3.2 mEq/L. Which of the following would
d. “High RBC count increases blood
the nurse expect to note on the ECG as a result
pressure.”
of this laboratory value?
Situation: Recognition of normal values is vital
a. U waves
in
b. Elevated T waves
assessment of clients with various disorders.
c. Absent P waves
61. A nurse is reviewing the laboratory test
results d. Elevated ST Segment

for a client with a diagnosis of severe 64. Dorothy underwent diagnostic test and the

dehydration. The nurse would expect the result of the blood examination are back. On

reviewing the result the nurse notices which of

the following as abnormal finding? sounds

a. Neutrophils 60% 67. Thoracentesis is performed to the client

with
b. White blood cells (WBC) 9000/mm
effusion. The nurse knows that the removal of
c. Erythrocyte sedimentation rate (ESR) is
fluid should be slow. Rapid removal of fluid in
39 mm/hr
thoracentesis might cause:
d. Iron 75 mg/100 ml
a. Pneumothorax
65. Which of the following laboratory test result
b. Cardiovascular collapse
indicate presence of an infectious process?
c. Pleurisy or Pleuritis
a. Erythrocyte sedimentation rate (ESR) 12
d. Hypertension
mm/hr
68. 3 Days after thoracentesis, the client again
b. White blood cells (WBC) 18,000/mm3
exhibited respiratory distress. The nurse will
c. Iron 90 g/100ml
know that pleural effusion has reoccurred when
d. Neutrophils 67%
she noticed a sharp stabbing pain during
Situation: Pleural effusion is the accumulation of
fluid in inspiration. The physician ordered a closed tube

the pleural space. Questions 66 to 70 refer to thoracotomy for the client. The nurse knows
this.
that the primary function of the chest tube is to:
66. Which of the following is a finding that the
a. Restore positive intrathoracic pressure
nurse
b. Restore negative intrathoracic pressure
will be able to assess in a client with Pleural
c. To visualize the intrathoracic content
effusion?
d. As a method of air administration via
a. Reduced or absent breath sound at the
ventilator
base of the lungs, dyspnea, tachpynea
69. The chest tube is functioning properly if:
and shortness of breath
a. There is an oscillation
b. Hypoxemia, hypercapnea and
b. There is no bubbling in the drainage
respiratory acidosis
bottle
c. Noisy respiration, crackles, stridor and
11
wheezing
c. There is a continuous bubbling in the
d. Tracheal deviation towards the affected
waterseal
side, increased fremitus and loud breath
d. The suction control bottle has a 73. Which makes nursing dynamic?

continuous bubbling a. Every patient is a unique physical,

70. In a client with pleural effusion, the nurse is emotional, social and spiritual being

instructing appropriate breathing technique. b. The patient participate in the overall

Which of the following is included in the nursing care plan

teaching? c. Nursing practice is expanding in the light

a. Breath normally of modern developments that takes

b. Hold the breath after each inspiration place

for 1 full minute d. The health status of the patient is

c. Practice abdominal breathing constantly changing and the nurse must

d. Inhale slowly and hold the breath for 3 be cognizant and responsive to these

to 5 seconds after each inhalation changes

SITUATION: Health care delivery system affects 74. Prevention is an important responsibility of
the the

health status of every filipino. As a Nurse, nurse in:

Knowledge of
a. Hospitals
this system is expected to ensure quality of life.
b. Community
71. When should rehabilitation commence?
c. Workplace
a. The day before discharge
d. All of the above
b. When the patient desires
75. This form of Health Insurance provides
c. Upon admission
comprehensive prepaid health services to
d. 24 hours after discharge
enrollees for a fixed periodic payment.
72. What exemplified the preventive and
a. Health Maintenance Organization
promotive
b. Medicare
programs in the hospital?
c. Philippine Health Insurance Act
a. Hospital as a center to prevent and
d. Hospital Maintenance Organization
control infection
Situation: Nursing ethics is an important part of
b. Program for smokers
the
c. Program for alcoholics and drug addicts
nursing profession. As the ethical situation
d. Hospital Wellness Center arises, so is
the need to have an accurate and ethical a worth of a person, ideas and belief. If Values
decision
are going to be a part of a research, this is
making.
categorized under:
76. The purpose of having a nurses’ code of
a. Qualitative
ethics is:
b. Experimental
a. Delineate the scope and areas of nursing
c. Quantitative
practice
d. Non Experimental
b. identify nursing action recommended for
80. The most important nursing responsibility
specific health care situations
where
c. To help the public understand
ethical situations emerge in patient care is to:
professional conduct expected of
a. Act only when advised that the action is
nurses
ethically sound
d. To define the roles and functions of the
12
health care givers, nurses, clients
b. Not takes sides, remain neutral and fair
77. The principles that govern right and proper
c. Assume that ethical questions are the
conduct of a person regarding life, biology and
responsibility of the health team
the health professionals is referred to as:
d. Be accountable for his or her own
a. Morality
actions
b. Religion
81. Why is there an ethical dilemma?
c. Values
a. the choices involved do not appear to be
d. Bioethics
clearly right or wrong
78. A subjective feeling about what is right or
b. a client’s legal right co-exist with the
wrong
nurse’s professional obligation
is said to be:
c. decisions has to be made based on
a. Morality
societal norms.
b. Religion
d. decisions has to be mad quickly, often
c. Values
under stressful conditions
d. Bioethics
82. According to the code of ethics, which of the
79. Values are said to be the enduring believe
about following is the primary responsibility of the
nurse? the revocation of the nursing license. Who

a. Assist towards peaceful death revokes the license?

b. Health is a fundamental right a. PRC

c. Promotion of health, prevention of b. PNA

illness, alleviation of suffering and c. DOH

restoration of health d. BON

d. Preservation of health at all cost 85. Based on the Code of Ethics for Filipino
Nurses,
83. Which of the following is TRUE about the
Code what is regarded as the hallmark of nursing

of Ethics of Filipino Nurses, except: responsibility and accountability?

a. The Philippine Nurses Association for a. Human rights of clients, regardless of

being the accredited professional creed and gender

organization was given the privilege to b. The privilege of being a registered

formulate a Code of Ethics for Nurses professional nurse

which the Board of Nursing c. Health, being a fundamental right of

promulgated every individual

b. Code for Nurses was first formulated in d. Accurate documentation of actions and

1982 published in the Proceedings of the outcomes

Third Annual Convention of the PNA Situation: As a profession, nursing is dynamic

and its
House of Delegates
practice is directed by various theoretical
c. The present code utilized the Code of
models. To
Good Governance for the Professions in
demonstrate caring behaviour, the nurse applies
the Philippines various

d. Certificates of Registration of registered nursing models in providing quality nursing care.

nurses may be revoked or suspended for 86. When you clean the bedside unit and
regularly
violations of any provisions of the Code
attend to the personal hygiene of the patient as
of Ethics.
well as in washing your hands before and after a
84. Violation of the code of ethics might equate
to procedure and in between patients, you indent
to facilitate the body’s reparative processes. 89. Virginia Henderson professes that the goal
of
Which of the following nursing theory are you
nursing is to work interdependently with other
applying in the above nursing action?
health care working in assisting the patient to
a. Hildegard Peplau
13
b. Dorothea Orem
gain independence as quickly as possible. Which
c. Virginia Henderson
of the following nursing actions best
d. Florence Nightingale
demonstrates this theory in taking care of a 94
87. A communication skill is one of the
important year old client with dementia who is totally

competencies expected of a nurse. immobile?

Interpersonal
a. Feeds the patient, brushes his teeth,
process is viewed as human to human
gives the sponge bath
relationship. This statement is an application of
b. Supervise the watcher in rendering
whose nursing model?
patient his morning care
a. Joyce Travelbee
c. Put the patient in semi fowler’s position,
b. Martha Rogers
set the over bed table so the patient can
c. Callista Roy
eat by himself, brush his teeth and
d. Imogene King
sponge himself
88. The statement “the health status of an
d. Assist the patient to turn to his sides and
individual
allow him to brush and feed himself only
is constantly changing and the nurse must be
when he feels ready
cognizant and responsive to these changes”
best 90. In the self-care deficit theory by Dorothea
Orem,
explains which of the following facts about
nursing care becomes necessary when a patient
nursing?
is unable to fulfil his physiological, psychological
a. Dynamic
and social needs. A pregnant client needing
b. Client centred
prenatal check-up is classified as:
c. Holistic
a. Wholly compensatory
d. Art
b. Supportive Educative
c. Partially compensatory include:

d. Non compensatory a. Prescription of the doctor to the

Situation: Documentation and reporting are just patient’s illness

as
b. Plan of care for patient
important as providing patient care, As such,
c. Patient’s perception of one’s illness
the nurse
d. Nursing problem and Nursing diagnosis
must be factual and accurate to ensure quality
94. The medical records that are organized into
documentation and reporting.
separate section from doctors or nurses has
91. Health care reports have different purposes.
The more disadvantages than advantages. This is
availability of patients’ record to all health team classified as what type of recording?
members demonstrates which of the following a. POMR
purposes: b. Modified POMR
a. Legal documentation c. SOAPIE
b. Research d. SOMR
c. Education 95. Which of the following is the advantage of
SOMR
d. Vehicle for communication
or Traditional recording?
92. When a nurse commits medication error,
she a. Increases efficiency in data gathering
should accurately document client’s response b. Reinforces the use of the nursing
and her corresponding action. This is very process
important for which of the following purposes: c. The caregiver can easily locate proper
a. Research section for making charting entries
b. Legal documentation d. Enhances effective communication
c. Nursing Audit among health care team members
d. Vehicle for communication Situation: June is a 24 year old client with
symptoms of
93. POMR has been widely used in many
teaching dyspnea, absent breath sounds on the right lung
and
hospitals. One of its unique features is SOAPIE
chest x ray revealed pleural effusion. The
charting. The P in SOAPIE charting should
physician will
perform thoracentesis. before thoracentesis is:

96. Thoracentesis is useful in treating all of the a. Orthopneic

following pulmonary disorders except: b. Low fowlers

a. Hemothorax c. Knee-chest

b. Hydrothorax d. Sidelying position on the affected side

c. Tuberculosis 100. Which of the following anaesthetics drug is

used
d. Empyema
for thoracentesis?
97. Which of the following psychological
preparation a. Procaine 2%

is not relevant for him? b. Demerol 75 mg

a. Telling him that the gauge of the needle c. Valium 250 mg

and anesthesia to be used d. Phenobartbital 50 mg

b. Telling him to keep still during the 15

procedure to facilitate the insertion of NURSING PRACTICE II

the needle in the correct place Situation: Mariah is a 31 year old lawyer who
has been
c. Allow June to express his feelings and
married for 6 months. She consults you for
concerns
guidance in
d. Physician’s explanation on the purpose
relation with her menstrual cycle and her desire
of the procedure and how it will be done to get

98. Before thoracentesis, the legal consideration pregnant.

you
1. She wants to know the length of her
must check is: menstrual

a. Consent is signed by the client cycle. Her previous menstrual period is October

14 22 to 26. Her LMB is November 21. Which of the

b. Medicine preparation is correct following number of days will be your correct

c. Position of the client is correct response?

d. Consent is signed by relative and A. 29

physician B. 28

99. As a nurse, you know that the position for C. 30

June
D. 31 4. She reports an increase in BBT on December
16.
2. You advised her to observe and record the
signs Which hormone brings about this change in her

of Ovulation. Which of the following signs will BBT?

she likely note down? A. Estrogen

1. A 1 degree Fahrenheit rise in basal body B. Gonadotropine

temperature C. Progesterone

2. Cervical mucus becomes copious and D. Follicle stimulating hormone

clear 5. The following month, Mariah suspects she is

3. One pound increase in weight pregnant. Her urine is positive for Human

4. Mittelschmerz chorionic gonadotrophin. Which structure

A. 1, 2, 4 produces Hcg?

B. 1, 2, 3 A. Pituitary gland

C. 2, 3, 4 B. Trophoblastic cells of the embryo

D. 1, 3, 4 C. Uterine deciduas

3. You instruct Mariah to keep record of her D. Ovarian follicles

basal
Situation: Mariah came back and she is now
temperature every day, which of the following pregnant.

instructions is incorrect? 6. At 5 month gestation, which of the following

A. If coitus has occurred; this should be fetal development would probably be achieve?

reflected in the chart A. Fetal movement are felt by Mariah

B. It is best to have coitus on the evening B. Vernix caseosa covers the entire body

following a drop in BBT to become C. Viable if delivered within this period

pregnant D. Braxton hicks contractions are observed

C. Temperature should be taken 7. The nurse palpates the abdomen of Mariah.

immediately after waking and before Now At 5 month gestation, What level of the

getting out of bed abdomen can the fundic height be palpated?

D. BBT is lowest during the secretory A. Symphysis pubis

phase B. Midpoint between the umbilicus and the

xiphoid process 10. Which of the following interventions will
likely
C. Midpoint between the symphysis pubis
ensure compliance of Mariah?
and the umbilicus
A. Incorporate her food preferences that
D. Umbilicus
are adequately nutritious in her meal
8. She worries about her small breasts, thinking
plan
that she probably will not be able to breastfeed
B. Consistently counsel toward optimum
her baby. Which of the following responses of
nutritional intake
the nurse is correct?
C. Respect her right to reject dietary
A. “The size of your breast will not affect
information if she chooses
your lactation”
D. Inform her of the adverse effects of
B. “You can switch to bottle feeding”
inadequate nutrition to her fetus
C. “You can try to have exercise to increase
Situation: Susan is a patient in the clinic where
the size of your breast”
you work.
D. “Manual expression of milk is possible”
She is inquiring about pregnancy.
9. She tells the nurse that she does not take milk
11. Susan tells you she is worried because she
regularly. She claims that she does not want to
develops breasts later than most of her friends.
gain too much weight during her pregnancy.
Breast development is termed as:
Which of the following nursing diagnosis is a
A. Adrenarche
priority?
B. Thelarche
A. Potential self-esteem disturbance
C. Mamarche
related to physiologic changes in
D. Menarche
pregnancy
12. Kevin, Susan’s husband tells you that he is
B. Ineffective individual coping related to
considering vasectomy After the birth of their
physiologic changes in pregnancy
new child. Vasectomy involves the incision of
C. Fear related to the effects of pregnancy
which organ?
D. Knowledge deficit regarding nutritional
A. The testes
16
B. The epididymis
requirements of pregnancies related to
C. The vas deferens
lack of information sources
D. The scrotum psychological cause of Vaginismus is related to:

13. On examination, Susan has been found of A. The male client inserted the penis too
having
deeply that it stimulates vaginal closure
a cystocele. A cystocele is:
B. The penis was too large that is why the
A. A sebaceous cyst arising from the vulvar
vagina triggered its defense to attempt
fold
to close it
B. Protrusion of intestines into the vagina
C. The vagina does not want to be
C. Prolapse of the uterus into the vagina
penetrated
D. Herniation of the bladder into the
D. It is due to learning patterns of the
vaginal wall
female client where she views sex as
14. Susan typically has menstrual cycle of 34
bad or sinful
days.
Situation: Overpopulation is one problem in the
She told you she had coitus on days 8, 10, 15
and Philippines that causes economic drain. Most
Filipinos
20 of her menstrual cycle. Which is the day on
are against in legalizing abortion. As a nurse,
which she is most likely to conceive?
Mastery of
A. 8th day
contraception is needed to contribute to the
B. Day 15 society and

C. 10th day economic growth.

D. Day 20 16. Supposed that Dana, 17 years old, tells you

she
15. While talking with Susan, 2 new patients
arrived wants to use fertility awareness method of

and they are covered with large towels and the contraception. How will she determine her

nurse noticed that there are many cameraman fertile days?

and news people outside of the OPD. Upon A. She will notice that she feels hot, as if

assessment the nurse noticed that both of them she has an elevated temperature.

are still nude and the male client’s penis is still B. She should assess whether her cervical

inside the female client’s vagina and the male mucus is thin, copious, clear and

client said that “I can’t pull it”. Vaginismus was watery.

your first impression. You know that The C. She should monitor her emotions for
sudden anger or crying D. Female condoms, unlike male condoms,

D. She should assess whether her breasts are reusable

feel sensitive to cool air 20. Dana has asked about GIFT procedure. What

17. Dana chooses to use COC as her family makes her a good candidate for GIFT?
planning
A. She has patent fallopian tubes, so
method. What is the danger sign of COC you
fertilized ova can be implanted on them
would ask her to report?
B. She is RH negative, a necessary
A. A stuffy or runny nose
stipulation to rule out RH incompatibility
B. Slight weight gain
C. She has normal uterus, so the sperm can
C. Arthritis like symptoms
be injected through the cervix into it
D. Migraine headache
D. Her husband is taking sildenafil, so all
18. Dana asks about subcutaneous implants and
sperms will be motile
she
Situation: Nurse Lorena is a Family Planning and
asks, how long will these implants be effective.
Infertility Nurse Specialist and currently attends
Your best answer is:
to
A. One month
FAMILY PLANNING CLIENTS AND INFERTILE
17 COUPLES.

B. Five years The following conditions pertain to meeting the

nursing
C. Twelve months
needs of this particular population group.
D. 10 years
21. Dina, 17 years old, asks you how a tubal
19. Dana asks about female condoms. Which of
ligation
the
prevents pregnancy. Which would be the best
following is true with regards to female
answer?
condoms?
A. Prostaglandins released from the cut
A. The hormone the condom releases
fallopian tubes can kill sperm
might cause mild weight gain
B. Sperm cannot enter the uterus because
B. She should insert the condom before
the cervical entrance is blocked.
any penile penetration
C. Sperm can no longer reach the ova,
C. She should coat the condom with
because the fallopian tubes are blocked
spermicide before use
D. The ovary no longer releases ova as B. The sonogram of the uterus will reveal

there is nowhere for them to go. any tumors present

22. The Dators are a couple undergoing testing C. Many women experience mild bleeding
for
as an after effect
infertility. Infertility is said to exist when:
D. She may feel some cramping when the
A. A woman has no uterus
dye is inserted
B. A woman has no children
25. Lilia’s cousin on the other hand, knowing
C. A couple has been trying to conceive for nurse

1 year Lorena’s specialization asks what artificial

D. A couple has wanted a child for 6 insemination by donor entails. Which would be

months your best answer if you were Nurse Lorena?

23. Another client named Lilia is diagnosed as A. Donor sperm are introduced vaginally
having
into the uterus or cervix
endometriosis. This condition interferes with
B. Donor sperm are injected intraabdominally
fertility because:
into each ovary
A. Endometrial implants can block the
C. Artificial sperm are injected vaginally to
fallopian tubes
test tubal patency
B. The uterine cervix becomes inflamed
D. The husband’s sperm is administered
and swollen
intravenously weekly
C. The ovaries stop producing adequate
Situation: You are assigned to take care of a
estrogen group of

D. Pressure on the pituitary leads to patients across the lifespan.

decreased FSH levels 26. Pain in the elder persons requires careful

24. Lilia is scheduled to have a assessment because they:

hysterosalphingogram. Which of the following A. experienced reduce sensory perception

instructions would you give her regarding this B. have increased sensory perception

procedure? C. are expected to experience chronic pain

A. She will not be able to conceive for 3 D. have a decreased pain threshold

months after the procedure 27. Administration of analgesics to the older

persons
requires careful patient assessment because of the following perspectives?

older people: A. Their peers

A. are more sensitive to drugs B. Their own and their mother’s

18 C. Their own and their caregivers’

B. have increased hepatic, renal and D. Only their own

gastrointestinal function 32. In conflict management, the win-win

approach
C. have increased sensory perception
occurs when:
D. mobilize drugs more rapidly
A. There are two conflicts and the parties
28. The elderly patient is at higher risk for
urinary agree to each one

incontinence because of: B. Each party gives in on 50% of the

A. increased glomerular filtration disagreements making up the conflict

B. decreased bladder capacity C. Both parties involved are committed to

C. diuretic use solving the conflict

D. dilated urethra D. The conflict is settled out of court so the

29. Which of the following is the MOST legal system and the parties win
COMMON
33. According to the social-interactional
sign of infection among the elderly? perspective

A. decreased breath sounds with crackles of child abuse and neglect, four factors place
the
B. pain
family members at risk for abuse. These risk
C. fever
factors are the family members at risk for abuse.
D. change in mental status
These risk factors are the family itself, the
30. Priorities when caring for the elderly trauma
caregiver, the child, and
patient:
A. The presence of a family crisis
A. circulation, airway, breathing
B. The national emphasis on sex
B. airway, breathing, disability (neurologic)
C. Genetics
C. disability (neurologic), airway, breathing
D. Chronic poverty
D. airway, breathing, circulation
34. Which of the following signs and symptoms
31. Preschoolers are able to see things from
which would you most likely find when assessing and
infant with Arnold-Chiari malformation? why periods may often be scant or

A. Weakness of the leg muscles, loss of skipped occasionally.”

sensation in the legs, and restlessness B. “If your friend has missed her period,

B. Difficulty swallowing, diminished or she should stop taking the pills and get a

absent gag reflex, and respiratory pregnancy test as soon as possible.”

distress C. “The pill should cause a normal

C. Difficulty sleeping, hypervigilant, and an menstrual period every month. It

arching of the back sounds like your friend has not been

D. Paradoxical irritability, diarrhea, and taking the pills properly.”

vomiting. D. “Missed period can be very dangerous

35. A parent calls you and frantically reports and may lead to the formation of
that her
precancerous cells.”
child has gotten into her famous ferrous sulfate
37. The nurse assessing newborn babies and
pills and ingested a number of these pills. Her infants

child is now vomiting, has bloody diarrhea, and during their hospital stay after birth will notice
is
which of the following symptoms as a primary
complaining of abdominal pain. You will tell the
manifestation of Hirschsprung’s disease?
mother to:
A. A fine rash over the trunk
A. Call emergency medical services (EMS)
B. Failure to pass meconium during the
and get the child to the emergency room
first 24 to 48 hours after birth
B. Relax because these symptoms will pass
19
and the child will be fine
C. The skin turns yellow and then brown
C. Administer syrup of ipecac
over the first 48 hours of life
D. Call the poison control center
D. High-grade fever
36. A client says she heard from a friend that
38. A client is 7 months pregnant and has just
you
been
stop having periods once you are on the “pill”.
diagnosed as having a partial placenta previa.
The most appropriate response would be:
She is stable and has minimal spotting and is
A. “The pill prevents the uterus from
being sent home. Which of these instructions to
making such endometrial lining, that is
the client may indicate a need for further outside of the diaper

teaching? 41. Which of the following factors is most

important
A. Maintain bed rest with bathroom
in determining the success of relationships used
privileges
in delivering nursing care?
B. Avoid intercourse for three days.
A. Type of illness of the client
C. Call if contractions occur.
B. Transference and counter transference
D. Stay on left side as much as possible
C. Effective communication
when lying down.
D. Personality of the participants
39. A woman has been rushed to the hospital
with 42. Grace sustained a laceration on her leg from

ruptured membrane. Which of the following automobile accident. Why are lacerations of

should the nurse check first? lower extremities potentially more serious

A. Check for the presence of infection among pregnant women than other?

B. Assess for Prolapse of the umbilical A. lacerations can provoke allergic

cord responses due to gonadotropic hormone

C. Check the maternal heart rate release

D. Assess the color of the amniotic fluid B. a woman is less able to keep the

40. The nurse notes that the infant is wearing a laceration clean because of her fatigue

plastic-coated diaper. If a topical medication C. healing is limited during pregnancy so

were to be prescribed and it were to go on the these will not heal until after birth

stomachs or buttocks, the nurse would teach D. increased bleeding can occur from
the
uterine pressure on leg veins
caregivers to:
43. In working with the caregivers of a client
A. avoid covering the area of the topical with an

medication with the diaper acute or chronic illness, the nurse would:

B. avoid the use of clothing on top of the A. Teach care daily and let the caregivers

diaper do a return demonstration just before

C. put the diaper on as usual discharge

D. apply an icepack for 5 minutes to the B. Difficulty swallowing, diminished or

absent gag reflex, and respiratory Which finding would most lead you to the

distress. conclusion that a relapse is happening?

C. Difficulty sleeping, hypervigilant, and an A. Elevated temperature, cough, sore

arching of the back throat, changing complete blood count

D. Paradoxical irritability, diarrhea, and (CBC) with diiferential

vomiting B. A urine dipstick measurement of 2+

44. Which of the following roles BEST proteinuria or more for 3 days, or the
exemplifies
child found to have 3-4+ proteinutria
the expanded role of the nurse?
plus edema.
A. Circulating nurse in surgery
20
B. Medication nurse
C. The urine dipstick showing glucose in the
C. Obstetrical nurse
urine for 3 days, extreme thirst, increase
D. Pediatric nurse practitioner
in urine output, and a moon face.
45. According to DeRosa and Kochura’s (2006)
D. A temperature of 37.8 degrees (100
article entitled “Implement Culturally
degrees F), flank pain, burning
Competent
frequency, urgency on voiding, and
Health Care in your work place,” cultures have
cloudy urine.
different patterns of verbal and nonverbal
47. The nurse is working with an adolescent
communication. Which difference does?
who
A. NOT necessarily belong?
complains of being lonely and having a lack of
B. Personal behavior
fulfillment in her life. This adolescent shies away
C. Subject matter
from intimate relationships at times yet at other
D. Eye contact
times she appears promiscuous. The nurse will
E. Conversational style
likely work with this adolescent in which of the
46. You are the nurse assigned to work with a
following areas?
child
A. Isolation
with acute glomerulonephritis. By following the
B. Lack of fulfillment
prescribed treatment regimen, the child
C. Loneliness
experiences a remission. You are now checking
D. Identity
to make sure the child does not have a relapse.
48. The use of interpersonal decision making, industrialized countries. In response to this, the
WHO
psychomotor skills, and application of
and UNICEF launched the protocol Integrated
knowledge expected in the role of a licensed
Management of Childhood Illnesses to reduce
health care professional in the context of public
the
health welfare and safety is an example of:
morbidity and mortality against childhood
A. Delegation illnesses.

B. Responsibility 51. If a child with diarrhea registers two signs in

the
C. Supervision
yellow row in the IMCI chart, we can classify the
D. Competence
patient as:
49. The painful phenomenon known as “back
labor” A. Moderate dehydration

occurs in a client whose fetus in what position? B. Severe dehydration

A. Brow position C. Some dehydration

B. Breech position D. No dehydration

C. Right Occipito-Anterior Position 52. Celeste has had diarrhea for 8 days. There is
no
D. Left Occipito-Posterior Position
blood in the stool, he is irritable, his eyes are
50. FOCUS methodology stands for:
sunken, the nurse offers fluid to Celeste and he
A. Focus, Organize, Clarify, Understand
drinks eagerly. When the nurse pinched the
and Solution
abdomen it goes back slowly. How will you
B. Focus, Opportunity, Continuous, Utilize,
classify Celeste’s illness?
Substantiate
A. Moderate dehydration
C. Focus, Organize, Clarify, Understand,
B. Severe dehydration
Substantiate
C. Some dehydration
D. Focus, Opportunity, Continuous
D. No dehydration
(process), Understand, Solution
53. A child who is 7 weeks has had diarrhea for
SITUATION: The infant and child mortality rate in 14
the low
days but has no sign of dehydration is classified
to middle income countries is ten times higher
than as:

A. Persistent diarrhea
B. Dysentery drives/campaign directed towards

C. Severe dysentery proper garbage disposal

D. Severe persistent diarrhea C. Explaining to the individuals, families,

54. The child with no dehydration needs home groups and community the nature of

treatment. Which of the following is not the disease and its causation

included in the rules for home treatment in this D. Practicing residual spraying with

case? insecticides

A. Forced fluids 57. Community health nurses should be alert in

B. When to return observing a Dengue suspect. The following is

C. Give vitamin A supplement NOT an indicator for hospitalization of H-fever

D. Feeding more suspects?

55. Fever as used in IMCI includes: A. Marked anorexia, abdominal pain and

A. Axillary temperature of 37.5 or higher vomiting

B. Rectal temperature of 38 or higher B. Increasing hematocrit count

C. Feeling hot to touch C. Cough of 30 days

D. All of the above D. Persistent headache

E. A and C only 58. The community health nurses’ primary

concern
Situation: Prevention of Dengue is an important
nursing in the immediate control of hemorrhage among

responsibility and controlling it’s spread is a patients with dengue is:

priority once
A. Advising low fiber and non-fat diet
outbreak has been observed.
B. Providing warmth through light weight
56. An important role of the community health
covers
nurse in the prevention and control of Dengue
C. Observing closely the patient for vital
H-fever includes:
signs leading to shock
A. Advising the elimination of vectors by
D. Keeping the patient at rest
keeping water containers covered
59. Which of these signs may NOT be
21 REGARDED as

B. Conducting strong health education a truly positive signs indicative of Dengue

Hfever?
A. Prolonged bleeding time D. Select the appropriate IEC strategies to

B. Appearance of at least 20 petechiae correct them

within 1cm square 62. How many percent of measles are prevented
by
C. Steadily increasing hematocrit count
immunization at 9 months of age?
D. Fall in the platelet count
A. 80%
60. Which of the following is the most
important B. 99%

treatment of patients with Dengue H-fever? C. 90%

A. Give aspirin for fever D. 95%

B. Replacement of body fluids 63. After TT3 vaccination a mother is said to be

C. Avoid unnecessary movement of patient protected to tetanus by around:

D. Ice cap over the abdomen in case of A. 80%

melena B. 99%

Situation: Health education and Health C. 85%

promotion is an
D. 90%
important part of nursing responsibility in the
64. If ever convulsions occur after administering
community. Immunization is a form of health
DPT, what should the nurse best suggest to the
promotion
mother?
that aims at preventing the common childhood
illnesses. A. Do not continue DPT vaccination
61. In correcting misconceptions and myths anymore
about
B. Advise mother to comeback after 1 week
certain diseases and their management, the
C. Give DT instead of DPT
health worker should first:
D. Give pertussis of the DPT and remove DT
A. Identify the myths and misconceptions
65. These vaccines are given 3 doses at one
prevailing in the community month
B. Identify the source of these myths and intervals:
misconceptions A. DPT, BCG, TT
C. Explain how and why these myths came B. OPV, HEP. B, DPT
about C. DPT, TT, OPV
D. Measles, OPV, DPT B. Those under post case treatment

Situation – With the increasing documented C. Those scheduled for surgery

cases of
D. Those undergoing treatment
CANCER the best alternative to treatment still
69. Who among the following are recipients of
remains to
the
be PREVENTION. The following conditions apply.
tertiary level of care for cancer cases?
66. Which among the following is the primary
A. Those under early treatment
focus
B. Those under early detection
of prevention of cancer?
C. Those under supportive care
A. Elimination of conditions causing cancer
D. Those scheduled for surgery
B. Diagnosis and treatment
70. In Community Health Nursing, despite the
C. Treatment at early stage
availability and use of many equipment and
D. Early detection
devices to facilitate the job of the community
67. In the prevention and control of cancer,
which of health nurse, the best tool any nurse should be
the following activities is the most important wel be prepared to apply is a scientific
approach.
22
This approach ensures quality of care even at
function of the community health nurse?
the
A. Conduct community assemblies.
community setting. This is nursing parlance is
B. Referral to cancer specialist those clients
nothing less than the:
with symptoms of cancer.
A. nursing diagnosis
C. Use the nine warning signs of cancer as
B. nursing research
parameters in our process of detection,
C. nursing protocol
control and treatment modalities.
D. nursing process
D. Teach woman about proper/correct
Situation – Two children were brought to you.
nutrition. One with

68. Who among the following are recipients of chest indrawing and the other had diarrhea. The
the
following questions apply:
secondary level of care for cancer cases?
71. Using Integrated Management and
A. Those under early case detection Childhood
Illness (IMCI) approach, how would you classify C. Give in the health center the

the 1st child? recommended amount of ORS for 4

A. Bronchopneumonia hours.

B. Severe pneumonia D. Do not give any other foods to the child

C. No pneumonia : cough or cold for home treatment

D. Pneumonia 75. While on treatment, Nina 18 months old

72. The 1st child who is 13 months has fast weighed 18 kgs. and her temperature registered

breathing using IMCI parameters he has: at 37 degrees C. Her mother says she developed

A. 40 breaths per minute or more cough 3 days ago. Nina has no general danger

B. 50 breaths per minute signs. She has 45 breaths/minute, no chest

indrawing,
C. 30 breaths per minute or more
no stridor. How would you classify
D. 60 breaths per minute
Nina’s manifestation?
73. Nina, the 2nd child has diarrhea for 5 days.
A. No pneumonia
There is no blood in the stool. She is irritable,
B. Pneumonia
and her eyes are sunken. The nurse offered
C. Severe pneumonia
fluids and and the child drinks eagerly. How
D. Bronchopneumonia
would you classify Nina’s illness?
76. Carol is 15 months old and weighs 5.5 kgs
A. Some dehydration
and it
B. Severe dehydration
is her initial visit. Her mother says that Carol is
C. Dysentery
not eating well and unable to breastfeed, he has
D. No dehydration
no vomiting, has no convulsion and not
74. Nina’s treatment should include the
abnormally sleepy or difficult to awaken. Her
following
temperature is 38.9 deg C. Using the integrated
EXCEPT:
management of childhood illness or IMCI
A. reassess the child and classify him for
strategy, if you were the nurse in charge of
dehydration
Carol, how will you classify her illness?
B. for infants under 6 months old who are
A. a child at a general danger sign
not breastfed, give 100-200 ml clean
B. severe pneumonia
water as well during this period
C. very severe febrile disease persistent vomiting, and positive

D. severe malnutrition tourniquet test

77. Why are small for gestational age newborns C. give aspirin
at
D. prevent low blood sugar
23
80. In assessing the patient’s condition using the
risk for difficulty maintaining body
Integrated Management of Childhood Illness
temperature?
approach strategy, the first thing that a nurse
A. their skin is more susceptible to
should do is to:
conduction of cold
A. ask what are the child’s problem
B. they are preterm so are born relatively
B. check for the four main symptoms
small in size
C. check the patient’s level of
C. they do not have as many fat stored as
consciousness
other infants
D. check for the general danger signs
D. they are more active than usual so they
81. A child with diarrhea is observed for the
throw off comes
following EXCEPT:
78. Oxytocin is administered to Rita to augment
A. how long the child has diarrhea
labor. What are the first symptoms of water
B. presence of blood in the stool
intoxication to observe for during this
C. skin Petechiae
procedure?
D. signs of dehydration
A. headache and vomiting
82. The child with no dehydration needs home
B. a high choking voice
treatment. Which of the following is NOT
C. a swollen tender tongue
included in the care for home management at
D. abdominal bleeding and pain
this case?
79. Which of the following treatment should
NOT be A. give drugs every 4 hours
considered if the child has severe dengue B. give the child more fluids
hemorrhagic fever? C. continue feeding the child
A. use plan C if there is bleeding from the D. inform when to return to the health
nose or gums center
B. give ORS if there is skin Petechiae,
83. Ms. Jordan, RN, believes that a patient D. “Miss, your hands are dirty. Wash your
should be
hands first before getting the bread”
treated as individual. This ethical principle that
Situation: The following questions refer to
the patient referred to: common

A. beneficence clinical encounters experienced by an entry

level nurse.
B. respect for person
86. A female client asks the nurse about the use
C. nonmaleficence
of a
D. autonomy
cervical cap. Which statement is correct
84. When patients cannot make decisions for
regarding the use of the cervical cap?
themselves, the nurse advocate relies on the
A. It may affect Pap smear results.
ethical principle of:
B. It does not need to be fitted by the
A. justice and beneficence
physician.
B. beneficence and nonmaleficence
C. It does not require the use of
C. fidelity and nonmaleficence
spermicide.
D. fidelity and justice
D. It must be removed within 24 hours.
85. Being a community health nurse, you have
87. The major components of the
the
communication
responsibility of participating in protecting the
process are:
health of people. Consider this situation:
A. Verbal, written and nonverbal
Vendors selling bread with their bare hands.
24
They receive money with these hands. You do
B. Speaker, listener and reply
not see them washing their hands. What should
C. Facial expression, tone of voice and
you say/do?
gestures
A. “Miss, may I get the bread myself
D. Message, sender, channel, receiver and
because you have not washed your
feedback
hands”
88. The extent of burns in children are normally
B. All of these
assessed and expressed in terms of:
C. “Miss, it is better to use a pick up
A. The amount of body surface that is
forceps/ bread tong”
unburned
B. Percentages of total body surface area 91. Which method of transmission is common
to
(TBSA)
contract AIDS?
C. How deep the deepest burns are
A. Syringe and needles
D. The severity of the burns on a 1 to 5
B. Sexual contact
burn scale.
C. Body fluids
89. The school nurse notices a child who is
wearing D. Transfusion

old, dirty, poor-fitting clothes; is always hungry; 92. Causative organism in AIDS is one of the

has no lunch money; and is always tired. When following;

the nurse asks the boy his tiredness, he talks of A. Fungus

playing outside until midnight. The nurse will B. retrovirus

suspect that this child is: C. Bacteria

A. Being raised by a parent of low D. Parasites

intelligence quotient (IQ) 93. You are assigned in a private room of Mike.

B. An orphan Which procedure should be of outmost

C. A victim of child neglect importance;

D. The victim of poverty A. Alcohol wash

90. Which of the following indicates the type(s) B. Washing Isolation

of
C. Universal precaution
acute renal failure?
D. Gloving technique
A. Four types: hemorrhagic with and
94. What primary health teaching would you
without clotting, and nonhemorrhagic give to

with and without clottings mike;

B. One type: acute A. Daily exercise

C. Three types: prerenal, intrarenal and B. reverse isolation

postrenal C. Prevent infection

D. Two types: acute and subacute D. Proper nutrition

Situation: Mike 16 y/o has been diagnosed to 95. Exercise precaution must be taken to protect
have AIDS;
health worker dealing with the AIDS patients .
he worked as entertainer in a cruise ship;
which among these must be done as priority: D. Salt

A. Boil used syringe and needles 98. As a public health nurse, you teach mother
and
B. Use gloves when handling specimen
family members the prevention of complication
C. Label personal belonging
of measles. Which of the following should be
D. Avoid accidental wound
25
Situation: Michelle is a 6 year old preschooler.
She was closely watched?

reported by her sister to have measles but she is A. Temperature fails to drop
at
B. Inflammation of the nasophraynx
home because of fever, upper respiratory
C. Inflammation of the conjunctiva
problem and
D. Ulcerative stomatitis
white sports in her mouth.
99. Source of infection of measles is secretion of
96. Rubeola is an Arabic term meaning Red, the
rash nose and throat of infection person. Filterable
appears on the skin in invasive stage prior to virus of measles is transmitted by:
eruption behind the ears. As a nurse, your A. Water supply
physical examination must determine B. Food ingestion
complication especially: C. Droplet
A. Otitis media D. Sexual contact
B. Inflammatory conjunctiva 100. Method of prevention is to avoid
C. Bronchial pneumonia exposure to an infection person. Nursing
D. Membranous laryngitis responsibility for rehabilitation of patient
97. To render comfort measure is one of the includes the provision of:
priorities, Which includes care of the skin, eyes, A. Terminal disinfection
ears, mouth and nose. To clean the mouth, your B. Immunization
antiseptic solution is in some form of which one C. Injection of gamma globulin
below? D. Comfort measures
A. Water 26
B. Alkaline NURSING PRACTICE III
C. Sulfur
Situation: Leo lives in the squatter area. He goes after eating and toileting
to
c. Use of attenuated vaccines
nearby school. He helps his mother gather
d. Boiling of food especially meat
molasses
4. Disaster control should be undertaken when
after school. One day, he was absent because of
fever, there are 3 or more hepatitis A cases. Which of
malaise, anorexia and abdominal discomfort. these measures is a priority?
1. Upon assessment, Leo was diagnosed to have a. Eliminate faecal contamination from
hepatitis A. Which mode of transmission has the foods
infection agent taken? b. Mass vaccination of uninfected
a. Fecal-oral individuals
b. Droplet c. Health promotion and education to
c. Airborne families and communities about the
d. Sexual contact disease it’s cause and transmission
2. Which of the following is concurrent d. Mass administration of Immunoglobulin
disinfection
5. What is the average incubation period of
in the case of Leo?
Hepatitis A?
a. Investigation of contact
a. 30 days
b. Sanitary disposal of faeces, urine and
b. 60 days
blood
c. 50 days
c. Quarantine of the sick individual
d. 14 days
d. removing all detachable objects in the
Situation: As a nurse researcher you must have
room, cleaning lighting and air duct a very
surfaces in the ceiling, and cleaning good understanding of the common terms of
concept
everything downward to the floor
used in research.
3. Which of the following must be emphasized
6. The information that an investigator collects
during mother’s class to Leo’s mother?
from the subjects or participants in a research
a. Administration of Immunoglobulin to
study is usually called;
families
a. Hypothesis
b. Thorough hand washing before and
b. Variable to when another person’s idea is inappropriate

c. Data credited as one’s own;

d. Concept a. Plagiarism

7. Which of the following usually refers to the b. assumption

independent variables in doing research c. Quotation

a. Result d. Paraphrase

b. output Situation – Mrs. Pichay is admitted to your ward.

The
c. Cause
MD ordered “Prepare for thoracentesis this pm
d. Effect
to
8. The recipients of experimental treatment is
remove excess air from the pleural cavity.”
an
27
experimental design or the individuals to be
11. Which of the following nursing
observed in a non experimental design are
responsibilities is
called;
essential in Mrs. Pichay who will undergo
a. Setting
thoracentesis?
b. Treatment
a. Support and reassure client during the
c. Subjects
procedure
d. Sample
b. Ensure that informed consent has been
9. The device or techniques an investigator
signed
employs to collect data is called;
c. Determine if client has allergic reaction
a. Sample
to local anesthesia
b. hypothesis
d. Ascertain if chest x-rays and other tests
c. Instrument
have been prescribed and completed
d. Concept
12. Mrs. Pichay who is for thoracentesis is
10. The use of another person’s ideas or assigned
wordings
by the nurse to which of the following
without giving appropriate credit results from positions?

inaccurate or incomplete attribution of a. Trendelenburg position

materials
b. Supine position
to its sources. Which of the following is referred
c. Dorsal Recumbent position he had experienced seizure in his office.

d. Orthopneic position 16. Just as the nurse was entering the room, the

13. During thoracentesis, which of the following patient who was sitting on his chair begins to

nursing intervention will be most crucial? have a seizure. Which of the following must the

a. Place patient in a quiet and cool room nurse do first?

b. Maintain strict aseptic technique a. Ease the patient to the floor

c. Advice patient to sit perfectly still b. Lift the patient and put him on the bed

during needle insertion until it has been c. Insert a padded tongue depressor

withdrawn from the chest between his jaws

d. Apply pressure over the puncture site as d. Restraint patient’s body movement

soon as the needle is withdrawn 17. Mr Santos is scheduled for CT SCAN for the
next
14. To prevent leakage of fluid in the thoracic
cavity, day, noon time. Which of the following is the

how will you position the client after correct preparation as instructed by the nurse?

thoracentesis? a. Shampoo hair thoroughly to remove oil

a. Place flat in bed and dirt

b. Turn on the unaffected side b. No special preparation is needed.

c. Turn on the affected side Instruct the patient to keep his head

d. On bed rest still and stead

15. Chest x-ray was ordered after thoracentesis. c. Give a cleansing enema and give fluids

When your client asks what is the reason for until 8 AM

another chest x-ray, you will explain: d. Shave scalp and securely attach

a. To rule out pneumothorax electrodes to it

b. To rule out any possible perforation 18. Mr Santos is placed on seizure precaution.

c. To decongest Which of the following would be

d. To rule out any foreign body contraindicated?

Situation: A computer analyst, Mr. Ricardo J. a. Obtain his oral temperature

Santos, 25
b. Encourage to perform his own personal
was brought to the hospital for diagnostic
hygiene
workup after
c. Allow him to wear his own clothing 22. The simplest pain relieving technique is:

d. Encourage him to be out of bed a. Distraction

19. Usually, how does the patient behave after b. Deep breathing exercise
his
c. Taking aspirin
seizure has subsided?
d. Positioning
a. Most comfortable walking and moving
23. Which of the following statement on pain is
about
TRUE?
b. Becomes restless and agitated
a. Culture and pain are not associated
c. Sleeps for a period of time
b. Pain accompanies acute illness
d. Say he is thirsty and hungry
c. Patient’s reaction to pain Varies
20. Before, during and after seizure. The nurse
d. Pain produces the same reaction such as
knows that the patient is ALWAYS placed in what
groaning and moaning
position?
24. In pain assessment, which of the following
a. Low fowler’s
condition is a more reliable indicator?
b. Side lying
a. Pain rating scale of 1 to 10
c. Modified trendelenburg
b. Facial expression and gestures
d. Supine
c. Physiological responses
Situation: Mrs. Damian an immediate post op
d. Patients description of the pain
cholecystectomy and choledocholithotomy
sensation
patient,
25. When a client complains of pain, your initial
complained of severe pain at the wound site.
response is:
21. Choledocholithotomy is:
a. Record the description of pain
a. The removal of the gallbladder
b. Verbally acknowledge the pain
b. The removal of the stones in the
c. Refer the complaint to the doctor
gallbladder
d. Change to a more comfortable position
c. The removal of the stones in the
Situation: You are assigned at the surgical ward
28
and
common bile duct
clients have been complaining of post pain at
d. The removal of the stones in the kidney varying
degrees. Pain as you know, is very subjective. c. Offer hot and clear soup

26. A one-day postoperative abdominal surgery d. Turn to sides frequently and avoid too

client has been complaining of severe throbbing much talking

abdominal pain described as 9 in a 1-10 pain 29. Surgical pain might be minimized by which

rating. Your assessment reveals bowel sounds nursing action in the O.R.
on
a. Skill of surgical team and lesser
all quadrants and the dressing is dry and intact.
manipulation
What nursing intervention would you take?
b. Appropriate preparation for the
a. Medicate client as prescribed
scheduled procedure
b. Encourage client to do imagery
c. Use of modern technology in closing the
c. Encourage deep breathing and turning
wound
d. Call surgeon stat
d. Proper positioning and draping of clients
27. Pentoxidone 5 mg IV every 8 hours was
30. Inadequate anesthesia is said to be one of
prescribed for post abdominal pain. Which will the

be your priority nursing action? common cause of pain both in intra and post op

a. Check abdominal dressing for possible patients. If General anesthesia is desired, it will

swelling involve loss of consciousness. Which of the

b. Explain the proper use of PCA to following are the 2 general types of GA?

alleviate anxiety a. Epidural and Spinal

c. Avoid overdosing to prevent b. Subarachnoid block and Intravenous

dependence/tolerance c. Inhalation and Regional

d. Monitor VS, more importantly RR d. Intravenous and Inhalation

28. The client complained of abdominal Situation: Nurse’s attitudes toward the pain
distention influence

and pain. Your nursing intervention that can the way they perceive and interact with clients
in pain.
alleviate pain is:
31. Nurses should be aware that older adults
a. Instruct client to go to sleep and relax
are at
b. Advice the client to close the lips and
risk of underrated pain. Nursing assessment and
avoid deep breathing and talking
management of pain should address the
following beliefs EXCEPT: especially among elderly clients who are in
pain?
a. Older patients seldom tend to report
a. Forgetfulness
pain than the younger ones
b. Drowsiness
b. Pain is a sign of weakness
c. Constipation
c. Older patients do not believe in
d. Allergic reactions like pruritis
analgesics, they are tolerant
35. Physical dependence occurs in anyone who
d. Complaining of pain will lead to being
takes opiods over a period of time. What do you
labeled a ‘bad’ patient
tell a mother of a ‘dependent’ when asked for
32. Nurses should understand that when a client
advice?
responds favorably to a placebo, it is known as
a. Start another drug and slowly lessen the
the ‘placebo effect’. Placebos do not indicate
opioid dosage
29
b. Indulge in recreational outdoor activities
whether or not a client has:
c. Isolate opioid dependent to a restful
a. Conscience
resort
b. Disease
d. Instruct slow tapering of the drug
c. Real pain
dosage and alleviate physical
d. Drug tolerance
withdrawal symptoms
33. You are the nurse in the pain clinic where
you Situation: The nurse is performing health
education
have client who has difficulty specifying the
activities for Janevi Segovia, a 30 year old
location of pain. How can you assist such client?
Dentist with
a. The pain is vague
Insulin dependent diabetes Miletus.
b. By charting-it hurts all over
36. Janevi is preparing a mixed dose of insulin.
c. Identify the absence and presence of The

pain nurse is satisfied with her performance when

d. As the client to point to the painful are she:

by just one finger a. Draw insulin from the vial of clear

34. What symptom, more distressing than pain, insulin first

should the nurse monitor when giving opioids b. Draw insulin from the vial of the
intermediate acting insulin first nurse should monitor which of the following
test
c. Fill both syringes with the prescribed
to evaluate the overall therapeutic compliance
insulin dosage then shake the bottle
of a diabetic patient?
vigorously
a. Glycosylated hemoglobin
d. Withdraw the intermediate acting
b. Ketone levels
insulin first before withdrawing the short
c. Fasting blood glucose
acting insulin first
d. Urine glucose level
37. Janevi complains of nausea, vomiting,
40. Upon the assessment of Hba1c of Mrs.
diaphoresis and headache. Which of the
Segovia,
following nursing intervention are you going to
The nurse has been informed of a 9% Hba1c
carry out first?
result. In this case, she will teach the patient to:
a. Withhold the client’s next insulin
a. Avoid infection
injection
b. Prevent and recognize hyperglycaemia
b. Test the client’s blood glucose level
c. Take adequate food and nutrition
c. Administer Tylenol as ordered
d. Prevent and recognize hypoglycaemia
d. Offer fruit juice, gelatine and chicken
41. The nurse is teaching plan of care for Jane
bouillon with

38. Janevi administered regular insulin at 7 A.M regards to proper foot care. Which of the
and
following should be included in the plan?
the nurse should instruct Jane to avoid
a. Soak feet in hot water
exercising at around:
b. Avoid using mild soap on the feet
a. 9 to 11 A.M
c. Apply a moisturizing lotion to dry feet
b. Between 8 A.M to 9 A.M
but not between the toes
c. After 8 hours
d. Always have a podiatrist to cut your toe
d. In the afternoon, after taking lunch
nails; never cut them yourself
39. Janevi was brought at the emergency room
42. Another patient was brought to the
after
emergency
four month because she fainted in her clinic.
room in an unresponsive state and a diagnosis
The
of
hyperglycaemic hyperosmolar nonketotic d. Fruity breath odour

syndrome is made. The nurse immediately 45. Jane has been scheduled to have a FBS
taken in
30
the morning. The nurse tells Jane not to eat or
prepares to initiate which of the following
drink after midnight. Prior to taking the blood
anticipated physician’s order?
specimen, the nurse noticed that Jane is holding
a. Endotracheal intubation
a bottle of distilled water. The nurse asked Jane
b. 100 unites of NPH insulin
if she drink any, and she said “yes.” Which of the
c. Intravenous infusion of normal saline
following is the best nursing action?
d. Intravenous infusion of sodium
a. Administer syrup of ipecac to remove
bicarbonate
the distilled water from the stomach
43. Jane eventually developed DKA and is being
b. Suction the stomach content using NGT
treated in the emergency room. Which finding
prior to specimen collection
would the nurse expect to note as confirming
c. Advice to physician to reschedule to
this diagnosis?
diagnostic examination next day
a. Comatose state
d. Continue as usual and have the FBS
b. Decreased urine output
analysis performed and specimen be
c. Increased respiration and an increase in
taken
pH
Situation: Elderly clients usually produce
d. Elevated blood glucose level and low
unusual signs
plasma bicarbonate level
when it comes to different diseases. The ageing
44. The nurse teaches Jane to know the process
difference
is a complicated process and the nurse should
between hypoglycaemia and ketoacidosis. Jane
understand that it is an inevitable fact and she
demonstrates understanding of the teaching by must be

stating that glucose will be taken if which of the prepared to care for the growing elderly
population.
following symptoms develops?
46. Hypoxia may occur in the older patients
a. Polyuria because
b. Shakiness of which of the following physiologic changes
c. Blurred Vision associated with aging.
a. Ineffective airway clearance d. Decreased breath sounds with crackles

b. Decreased alveolar surfaced area Situation – In the OR, there are safety protocols
that
c. Decreased anterior-posterior chest
should be followed. The OR nurse should be
diameter
well versed
d. Hyperventilation
with all these to safeguard the safety and
47. The older patient is at higher risk for quality of

incontinence because of: patient delivery outcome.

a. Dilated urethra 51. Which of the following should be given

highest
b. Increased glomerular filtration rate
priority when receiving patient in the OR?
c. Diuretic use
a. Assess level of consciousness
d. Decreased bladder capacity
b. Verify patient identification and
48. Merle, age 86, is complaining of dizziness
when informed consent

she stands up. This may indicate: c. Assess vital signs

a. Dementia d. Check for jewelry, gown, manicure, and

b. Functional decline dentures

c. A visual problem 52. Surgeries like I and D (incision and drainage)

and
d. Drug toxicity
debridement are relatively short procedures but
49. Cardiac ischemia in an older patient usually
considered ‘dirty cases’. When are these
produces:
31
a. ST-T wave changes
procedures best scheduled?
b. Chest pain radiating to the left arm
a. Last case
c. Very high creatinine kinase level
b. In between cases
d. Acute confusion
c. According to availability of
50. The most dependable sign of infection in the
anaesthesiologist
older patient is:
d. According to the surgeon’s preference
a. Change in mental status
53. OR nurses should be aware that maintaining
b. Fever the
c. Pain client’s safety is the overall goal of nursing care
during the intraoperative phase. As the Situation: Sterilization is the process of
removing ALL
circulating nurse, you make certain that
living microorganism. To be free of ALL living
throughout the procedure…
microorganism is sterility.
a. the surgeon greets his client before
56. There are 3 general types of sterilization use
induction of anesthesia
in
b. the surgeon and anesthesiologist are in
the hospital, which one is not included?
tandem
a. Steam sterilization
c. strap made of strong non-abrasive
b. Physical sterilization
materials are fastened securely around
c. Chemical sterilization
the joints of the knees and ankles and
d. Sterilization by boiling
around the 2 hands around an arm
57. Autoclave or steam under pressure is the
board. most

d. Client is monitored throughout the common method of sterilization in the hospital.

surgery by the assistant anesthesiologist The nurse knows that the temperature and time

54. Another nursing check that should not be is set to the optimum level to destroy not only
missed
the microorganism, but also the spores. Which
before the induction of general anesthesia is:
of the following is the ideal setting of the
a. check for presence underwear
autoclave machine?
b. check for presence dentures
a. 10,000 degree Celsius for 1 hour
c. check patient’s ID
b. 5,000 degree Celsius for 30 minutes
d. check baseline vital signs
c. 37 degree Celsius for 15 minutes
55. Some lifetime habits and hobbies affect
d. 121 degree Celsius for 15 minutes
postoperative respiratory function. If your client
58. It is important that before a nurse prepares
smokes 3 packs of cigarettes a day for the past the

10 years, you will anticipate increased risk for: material to be sterilized, a chemical indicator

a. perioperative anxiety and stress strip should be placed above the package,

b. delayed coagulation time preferably, Muslin sheet. What is the color of

c. delayed wound healing the striped produced after autoclaving?

d. postoperative respiratory infection a. Black

b. Blue needles, supplies, used during the

c. Gray surgical procedure.

d. Purple d. Evaluate the type of anesthesia

59. Chemical indicators communicate that: appropriate for the surgical client

a. The items are sterile 32

b. That the items had undergone 62. As a perioperative nurse, how can you best
meet
sterilization process but not necessarily
the safety need of the client after administering
sterile
preoperative narcotic?
c. The items are disinfected
a. Put side rails up and ask the client not
d. That the items had undergone
to get out of bed
disinfection process but not necessarily
b. Send the client to OR with the family
disinfected
c. Allow client to get up to go to the
60. If a nurse will sterilize a heat and moisture
labile comfort room

instruments, It is according to AORN d. Obtain consent form

recommendation to use which of the following 63. It is the responsibility of the pre-op nurse to
do
method of sterilization?
skin prep for patients undergoing surgery. If hair
a. Ethylene oxide gas
at the operative site is not shaved, what should
b. Autoclaving
be done to make suturing easy and lessen
c. Flash sterilizer
chance of incision infection?
d. Alcohol immersion
a. Draped
Situation 5 – Nurses hold a variety of roles when
b. Pulled
providing care to a perioperative patient.
c. Clipped
61. Which of the following role would be the
d. Shampooed
responsibility of the scrub nurse?
64. It is also the nurse’s function to determine
a. Assess the readiness of the client prior
when
to surgery
infection is developing in the surgical incision.
b. Ensure that the airway is adequate
The perioperative nurse should observe for
c. Account for the number of sponges, what
signs of impending infection? to a surge of trauma patient. One of the last

a. Localized heat and redness patients will need surgical amputation but there

b. Serosanguinous exudates and skin are no sterile surgical equipments. In this case,

blanching which of the following will the nurse expect?

c. Separation of the incision a. Equipments needed for surgery need not

d. Blood clots and scar tissue are visible be sterilized if this is an emergency

65. Which of the following nursing interventions necessitating life saving measures
is
b. Forwarding the trauma client to the
done when examining the incision wound and
nearest hospital that has available sterile
changing the dressing?
equipments is appropriate
a. Observe the dressing and type and odor
c. The nurse will need to sterilize the item
of drainage if any
before using it to the client using the
b. Get patient’s consent
regular sterilization setting at 121
c. Wash hands
degree Celsius in 15 minutes
d. Request the client to expose the incision
d. In such cases, flash sterlizer will be use
wound
at 132 degree Celsius in 3 minutes
Situation – The preoperative nurse collaborates
68. Tess, the PACU nurse, discovered that
with the
Malou,
client significant others, and healthcare
who weighs 110 lbs prior to surgery, is in severe
providers.
pain 3 hrs after cholecystectomy. Upon checking
66. To control environmental hazards in the OR,
the the chart, Malou found out that she has an
order
nurse collaborates with the following
of Demerol 100 mg I.M. prn for pain. Tess
departments EXCEPT:
should
a. Biomedical division
verify the order with:
b. Infection control committee
a. Nurse Supervisor
c. Chaplaincy services
b. Surgeon
d. Pathology department
c. Anesthesiologist
67. An air crash occurred near the hospital
d. Intern on duty
leading
69. Rosie, 57, who is diabetic is for debridement 71. If you are the nurse in charge for scheduling
if
surgical cases, what important information do
incision wound. When the circulating nurse
you need to ask the surgeon?
checked the present IV fluid, she found out that
a. Who is your internist
there is no insulin incorporated as ordered.
b. Who is your assistant and
What should the circulating nurse do?
anaesthesiologist, and what is your
a. Double check the doctor’s order and
preferred time and type of surgery?
call the attending MD
c. Who are your anaesthesiologist,
b. Communicate with the ward nurse to
internist, and assistant
verify if insulin was incorporated or not
d. Who is your anaesthesiologist
c. Communicate with the client to verify if
72. In the OR, the nursing tandem for every
insulin was incorporated surgery

d. Incorporate insulin as ordered. is:

70. The documentation of all nursing activities a. Instrument technician and circulating

performed is legally and professionally vital. nurse

Which of the following should NOT be included b. Nurse anaesthetist, nurse assistant, and

in the patient’s chart? instrument technician

a. Presence of prosthetoid devices such as c. Scrub nurse and nurse anaesthetist

dentures, artificial limbs hearing aid, etc. d. Scrub and circulating nurses

b. Baseline physical, emotional, and 73. While team effort is needed in the OR for

psychosocial data efficient and quality patient care delivery, we

c. Arguments between nurses and should limit the number of people in the room

residents regarding treatments for infection control. Who comprise this team?

d. Observed untoward signs and symptoms a. Surgeon, anaesthesiologist, scrub nurse,

and interventions including contaminant radiologist, orderly

intervening factors b. Surgeon, assistants, scrub nurse,

33 circulating nurse, anaesthesiologist

Situation – Team efforts is best demonstrated in c. Surgeon, assistant surgeon,

the OR.
anaesthesiologist, scrub nurse,
pathologist solutions will most likely be prescribed to

d. Surgeon, assistant surgeon, increase intravascular volume, replace

anaesthesiologist, intern, scrub nurse immediate blood loss and increase blood

74. Who usually act as an important part of the pressure?

OR
a. 0.45% sodium chloride
personnel by getting the wheelchair or
b. 0.33% sodium chloride
stretcher,
c. Normal saline solution
and pushing/pulling them towards the
operating d. Lactated ringer’s solution
room? 77. The physician orders the nurse to prepare an
a. Orderly/clerk isotonic solution. Which of the following IV
b. Nurse Supervisor solution would the nurse expect the intern to
c. Circulating Nurse prescribe?
d. Anaesthesiologist a. 5% dextrose in water
75. The breakdown in teamwork is often times a b. 0.45% sodium chloride
failure in: c. 10% dextrose in water
a. Electricity d. 5% dextrose in 0.9% sodium chloride
b. Inadequate supply 78. The nurse is making initial rounds on the
nursing
c. Leg work
unit to assess the condition of assigned clients.
d. Communication
The nurse notes that the client’s IV Site is cool,
Situation: Basic knowledge on Intravenous
solutions is pale and swollen and the solution is not
infusing.
necessary for care of clients with problems with
fluids The nurse concludes that which of the following
and electrolytes. complications has been experienced by the
76. A client involved in a motor vehicle crash client?
presents to the emergency department with a. Infection
severe internal bleeding. The client is severely b. Phlebitis
hypotensive and unresponsive. The nurse c. Infiltration
anticipates which of the following intravenous d. Thrombophelibitis
79. A nurse reviews the client’s electrolyte alternatives

laboratory report and notes that the potassium b. It should contain a thorough and

level is 3.2 mEq/L. Which of the following would detailed explanation of the procedure

the nurse note on the electrocardiogram as a to be done

result of the laboratory value? c. It should describe the client’s diagnosis

a. U waves d. It should give an explanation of the

b. Absend P waves client’s prognosis

c. Elevated T waves 83. You know that the hallmark of nursing

d. Elevated ST segment accountability is the:

80. One patient had a ‘runaway’ IV of 50% a. accurate documentation and reporting
dextrose.
b. admitting your mistakes
To prevent temporary excess of insulin or
c. filing an incidence report
transient hyperinsulin reaction what solution
d. reporting a medication error
you prepare in anticipation of the doctor’s
84. A nurse is assigned to care for a group of
34 clients.

order? On review of the client’s medical records, the

a. Any IV solution available to KVO nurse determines that which client is at risk for

b. Isotonic solution excess fluid volume?

c. Hypertonic solution a. The client taking diuretics

d. Hypotonic solution b. The client with renal failure

81. An informed consent is required for: c. The client with an ileostomy

a. closed reduction of a fracture d. The client who requires gastrointestinal

b. irrigation of the external ear canal suctioning

c. insertion of intravenous catheter 85. A nurse is assigned to care for a group of

clients.
d. urethral catheterization
On review of the client’s medical records, the
82. Which of the following is not true with
regards nurse determines that which client is at risk for

to the informed consent? deficient fluid volume?

a. It should describe different treatment a. A client with colostomy

b. A client with congestive heart failure c. Test the potency of the high level

c. A client with decreased kidney function disinfectant

d. A client receiving frequent wound d. Prolong the exposure time according to

irrigation manufacturer’s direction

Situation: As a perioperative nurse, you are 89. To achieve sterilization using disinfectants,
aware of the
which of the following is used?
correct processing methods for preparing
a. Low level disinfectants immersion in 24
instruments
hours
and other devices for patient use to prevent
infection. b. Intermediate level disinfectants
86. As an OR nurse, what are your foremost immersion in 12 hours
considerations for selecting chemical agents for c. High level disinfectants immersion in 1
disinfection? hour
a. Material compatibility and efficiency d. High level disinfectant immersion in 10
b. Odor and availability hours
c. Cost and duration of disinfection process 90. Bronchoscope, Thermometer, Endoscope, ET
d. Duration of disinfection and efficiency tube, Cytoscope are all BEST sterilized using
87. Before you use a disinfected instrument it is which of the following?
essential that you: a. Autoclaving at 121 degree Celsius in 15
a. Rinse with tap water followed by alcohol minutes
b. Wrap the instrument with sterile water b. Flash sterilizer at 132 degree Celsius in 3
c. Dry the instrument thoroughly minutes
d. Rinse with sterile water c. Ethylene Oxide gas aeration for 20 hours
88. You have a critical heat labile instrument to d. 2% Glutaraldehyde immersion for 10
sterilize and are considering to use high level hours
disinfectant. What should you do? Situation: The OR is divided into three zones to
control
a. Cover the soaking vessel to contain the
traffic flow and contamination
vapor
35
b. Double the amount of high level

disinfectant
91. What OR attires are worn in the restricted many degrees of needle insertion?
area?
a. 45
a. Scrub suit, OR shoes, head cap
b. 180
b. Head cap, scrub suit, mask, OR shoes
c. 90
c. Mask, OR shoes, scrub suit
d. 15
d. Cap, mask, gloves, shoes
Situation: Maintenance of sterility is an
92. Nursing intervention for a patient on low important
dose IV
function a nurse should perform in any OR
insulin therapy includes the following, EXCEPT: setting.

a. Elevation of serum ketones to monitor 96. Which of the following is true with regards
to
ketosis
sterility?
b. Vital signs including BP
a. Sterility is time related, items are not
c. Estimate serum potassium
considered sterile after a period of 30
d. Elevation of blood glucose levels
days of being not use.
93. The doctor ordered to incorporate 1000”u”
b. for 9 months, sterile items are
insulin to the remaining on-going IV. The
considered sterile as long as they are
strength is 500 /ml. How much should you
covered with sterile muslin cover and
incorporate into the IV solution?
stored in a dust proof covers.
a. 10 ml
c. Sterility is event related, not time
b. 0.5 ml
related
c. 2 ml
d. For 3 weeks, items double covered with
d. 5 ml
muslin are considered sterile as long as
94. Multiple vial-dose-insulin when in use
should be they have undergone the sterilization

a. Kept at room temperature process

b. Kept in narcotic cabinet 97. 2 organizations endorsed that sterility are

c. Kept in the refrigerator affected by factors other than the time itself,

d. Store in the freezer these are:

95. Insulins using insulin syringe are given using a. The PNA and the PRC
how
b. AORN and JCAHO
c. ORNAP and MCNAP c. Sharps are sterilized using autoclave and

d. MMDA and DILG not cidex

98. All of these factors affect the sterility of the d. If liquid sterilizer is used, rinsing it
OR
before using is not necessary
equipments, these are the following except:
36
a. The material used for packaging
NURSING PRACTICE IV
b. The handling of the materials as well as
Situation: After an abdominal surgery, the
its transport circulating

c. Storage and scrub nurses have critical responsibility

about
d. The chemical or process used in
sponge and instrument count.
sterililzing the material
1. Counting is performed thrice: During the
99. When you say sterile, it means:
preincision phase, the operative phase and
a. The material is clean
closing phase. Who counts the sponges, needles
b. The material as well as the equipments
and instruments?
are sterilized and had undergone a
a. The scrub nurse only
rigorous sterilization process
b. The circulating nurse only
c. There is a black stripe on the paper
c. The surgeon and the assistant surgeon
indicator
d. The scrub nurse and the circulating
d. The material has no microorganism nor
nurse
spores present that might cause an
2. The layer of the abdomen is divided into 5.
infection
Arrange the following from the first layer going
100. In using liquid sterilizer versus autoclave
to the deepest layer:
machine, which of the following is true?
1. Fascia
a. Autoclave is better in sterilizing OR
2. Muscle
supplies versus liquid sterilizer
3. Peritoneum
b. They are both capable of sterilizing the
4. Subcutaneous/Fat
equipments, however, it is necessary to
5. Skin
soak supplies in the liquid sterilizer for
a. 5,4,3,2,1
a longer period of time
b. 5,4,1,3,2 nursing skills.

c. 5,4,2,1,3 6. A client has an indwelling urinary catheter

and
d. 5,4,1,2,3
she is suspected of having urinary infection.
3. When is the first sponge/instrument count
How
reported?
should you collect a urine specimen for culture
a. Before closing the subcutaneous layer
and sensitivity?
b. Before peritoneum is closed
a. clamp tubing for 60 minutes and insert a
c. Before closing the skin
sterile needle into the tubing above the
d. Before the fascia is sutured
clamp to aspirate urine
4. Like any nursing interventions, counts should
b. drain urine from the drainage bag into
be
the sterile container
documented. To whom does the scrub nurse
c. disconnect the tubing from the urinary
report any discrepancy of counts so that
catheter and let urine flow into a sterile
immediate and appropriate action is instituted?
container
a. Anaesthesiologists
d. wipe the self-sealing aspiration port
b. Surgeon
with antiseptic solution and insert a
c. OR nurse supervisor
sterile needle into the self-sealing port
d. Circulating nurse
7. To obtain specimen for sputum culture and
5. Which of the following are 2 interventions of
the sensitivity, which of the following instruction is

surgical team when an instrument was best?

confirmed missing? a. Upon waking up, cough deeply and

a. MRI and Incidence report expectorate into container

b. CT Scan, MRI, Incidence report b. Cough after pursed lip breathing

c. X-RAY and Incidence report c. Save sputum for two days in covered

d. CT Scan and Incidence report container

Situation: An entry level nurse should be able to d. After respiratory treatment, expectorate
apply
into a container
theoretical knowledge in the performance of
8. The best time for collecting the sputum
the basic
specimen for culture and sensitivity is: to multiple problems like scantly urination,
hematuria
a. Before retiring at night
and dysuria.
b. Anytime of the day
11. You are the nurse in charge in Mr. Santos.
c. Upon waking up in the morning
When
d. Before meals
asked what are the organs to be examined
9. When suctioning the endotracheal tube, the
during cystoscopy, you will enumerate as
nurse should:
follows:
a. Explain procedure to patient; insert
a. Urethra, kidney, bladder, urethra
catheter gently applying suction.
b. Urethra, bladder wall, trigone, ureteral
Withdrawn using twisting motion
opening
b. Insert catheter until resistance is met,
c. Bladder wall, uterine wall, and urethral
and then withdraw slightly, applying
opening
suction intermittently as catheter is
d. Urethral opening, ureteral opening
withdrawn
bladder
c. Hyperoxygenate client insert catheter
12. In the OR, you will position Mr. Santos who
using back and forth motion is

d. Insert suction catheter four inches into cystoscopy in:

the tube, suction 30 seconds using a. Supine

37 b. Lithotomy

twirling motion as catheter is withdrawn c. Semi-fowler

10. The purpose of NGT IMMEDIATELY after an d. Trendelenburg

operation is: 13. After cystoscopy, Mr. Santos asked you to

a. For feeding or gavage explain why there is no incision of any kind.

b. For gastric decompression What do you tell him?

c. For lavage, or the cleansing of the a. “Cystoscopy is direct visualization and

stomach content examination by urologist”.

d. For the rapid return of peristalsis b. “Cystoscopy is done by x-ray

Situation - Mr. Santos, 50, is to undergo visualization of the urinary tract”.

cystoscopy due
c. “Cystoscopy is done by using lasers on
the urinary tract”. c. Amber

d. “Cystoscopy is an endoscopic procedure d. Pinkish to red

of the urinary tract”. 17. The purpose of the continuous bladder

irrigation
14. Within 24-48 hours post cystoscopy, it is
normal is to:

to observe one the following: a. Allow continuous monitoring of the fluid

a. Pink-tinged urine output status

b. Distended bladder b. Provide continuous flushing of clots and

c. Signs of infection debris from the bladder

d. Prolonged hematuria c. Allow for proper exchange of

15. Leg cramps are NOT uncommon post electrolytes and fluid
cystoscopy.
d. Ensure accurate monitoring of intake
Nursing intervention includes:
and output
a. Bed rest
18. Mang Felix informs you that he feels some
b. Warm moist soak
discomfort on the hypogastric area and he has
c. Early ambulation to

d. Hot sitz bath void. What will be your most appropriate

action?
Situation – Mang Felix, a 79 year old man who is
brought a. Remove his catheter then allow him to

to the Surgical Unit from PACU after a void on his own

transurethral
b. Irrigate his catheter
resection. You are assigned to receive him. You
c. Tell him to “Go ahead and void. You
noted
have an indwelling catheter.”
that he has a 3-way indwelling urinary catheter
for d. Assess color and rate of outflow, if
continuous fast drip bladder irrigation which is there is changes refer to urologist for
connected to a straight drainage. possible irrigation.
16. Immediately after surgery, what would you 19. You decided to check on Mang Felix’s IV fluid
expect his urine to be? infusion. You noted a change in flow rate, pallor
a. Light yellow and coldness around the insertion site. What is
b. Bright red your assessment finding?
a. Phlebitis and food manufacturers add melamine in order

b. Infiltration to subcutaneous tissue to:

c. Pyrogenic reaction a. It has a bacteriostatic property leading

d. Air embolism to increase food and milk life as a way of

20. Knowing that proper documentation of preserving the foods

38 b. Gives a glazy and more edible look on

assessment findings and interventions are foods

important responsibilities of the nurse during c. Make milks more tasty and creamy

first post-operative day, which of the following is d. Create an illusion of a high protein

the LEAST relevant to document in the case of content on their products

Mang Felix? 22. Most of the milks contaminated by

Melamine
a. Chest pain and vital signs
came from which country?
b. Intravenous infusion rate
a. India
c. Amount, color, and consistency of
b. China
bladder irrigation drainage
c. Philippines
d. Activities of daily living started
d. Korea
Situation: Melamine contamination in milk has
brought 23. Which government agency is responsible for

worldwide crisis both in the milk production testing the melamine content of foods and food
sector as
products?
well as the health and economy. Being aware of
a. DOH
the
b. MMDA
current events is one quality that a nurse should
possess c. NBI
to prove that nursing is a dynamic profession d. BFAD
that will
24. Infants are the most vulnerable to melamine
adapt depending on the patient’s needs.
poisoning. Which of the following is NOT a sign
21. Melamine is a synthetic resin used for
of melamine poisoning?
whiteboards, hard plastics and jewellery box
a. Irritability, Back ache, Urolithiasis
covers due to its fire retardant properties. Milk
b. High blood pressure, fever
c. Anuria, Oliguria or Hematuria cause the most danger is:

d. Fever, Irritability and a large output of a. Neutropenia causing infection, anemia

diluted urine causing impaired oxygenation and

25. What kind of renal failure will melamine thrombocytopenia leading to bleeding

poisoning cause? tendencies

a. Chronic, Prerenal b. Central nervous system infiltration,

b. Chronic, Intrarenal anemia causing impaired oxygenation

c. Acute, Postrenal and thrombocytopenia leading to

d. Acute, Prerenal bleeding tendencies

Situation: Leukemia is the most common type of c. Splenomegaly, hepatomegaly, fractures

childhood cancer. Acute Lymphoid Leukemia is d. Invasion by the leukemic cells to the
the cause
bone causing severe bone pain
of almost 1/3 of all cancer that occurs in
29. Gold standard in the diagnosis of leukemia is
children under
by
age 15.
which of the following?
26. The survival rate for Acute Lymphoid
a. Blood culture and sensitivity
Leukemia is
b. Bone marrow biopsy
approximately:
c. Blood biopsy
a. 25%
d. CSF aspiration and examination
b. 40%
30. Adriamycin,Vincristine,Prednisone and L
c. 75%
asparaginase are given to the client for long
d. 95%
term therapy. One common side effect,
27. Whereas acute nonlymphoid leukemia has a
39
survival rate of:
especially of adriamycin is alopecia. The child
a. 25%
asks: “Will I get my hair back once again?” The
b. 40%
nurse best respond is by saying:
c. 75%
a. “Don’t be silly, ofcourse you will get your
d. 95%
hair back”
28. The three main consequence of leukemia
that b. “We are not sure, let’s hope it’ll grow”
c. “This side effect is usually permanent, b. Breast feeding

But I will get the doctor to discuss it for c. Prophylactic Tamoxifen

you” d. Alcohol intake

d. “Your hair will regrow in 3 to 6 months 33. A patient diagnosed with breast cancer has
been
but of different color, usually darker
offered the treatment choices of breast
and of different texture”
conservation surgery with radiation or a
Situation: Breast Cancer is the 2nd most
common type of modified radical mastectomy. When questioned

cancer after lung cancer and 99% of which, by the patient about these options, the nurse
occurs in
informs the patient that the lumpectomy with
woman. Survival rate is 98% if this is detected
radiation:
early and
a. reduces the fear and anxiety that
treated promptly. Carmen is a 53 year old
patient in the accompany the diagnosis and treatment
high risk group for breast cancer was recently of cancer
diagnosed
b. has about the same 10-year survival rate
with Breast cancer.
as the modified radical mastectomy
31. All of the following are factors that said to
c. provides a shorter treatment period with
contribute to the development of breast cancer
a fewer long term complications
except:
d. preserves the normal appearance and
a. Prolonged exposure to estrogen such as
sensitivity of the breast.
an early menarche or late menopause,
34. Carmen, who is asking the nurse the most
nulliparity and childbirth after age 30
appropriate time of the month to do her
b. Genetics selfexamination
c. Increasing Age of the breast. The MOST
d. Prolonged intake of Tamoxifen appropriate reply by the nurse would be:
(Nolvadex) a. the 26th day of the menstrual cycle
32. Protective factors for the development of b. 7 to 8 days after conclusion of the
breast
menstrual period
cancer includes which of the following except:
c. during her menstruation
a. Exercise
d. the same day each month d. changes from previous BSE

35. Carmen being treated with radiation 38. If you are to instruct a postmenopausal
therapy. woman

What should be included in the plan of care to about BSE, when would you tell her to do BSE:

minimize skin damage from the radiation a. on the same day of each month

therapy? b. on the first day of her menstruation

a. Cover the areas with thick clothing c. right after the menstrual period

materials d. on the last day of her menstruation

b. Apply a heating pad to the site 39. During breast self-examination, the purpose
of
c. Wash skin with water after the therapy
standing in front of the mirror it to observe the
d. Avoid applying creams and powders to
breast for:
the area
a. thickening of the tissue
36. Based on the DOH and World Health
40
Organization (WHO) guidelines, the mainstay for
b. lumps in the breast tissue
early detection method for breast cancer that is
c. axillary lymphnodes
recommended for developing countries is:
d. change in size and contour
a. a monthly breast self-examination (BSE)
40. When preparing to examine the left breast
and an annual health worker breast
in a
examination (HWBE)
reclining position, the purpose of placing a small
b. an annual hormone receptor assay
folded towel under the client’s left shoulder is
c. an annual mammogram
to:
d. a physician conduct a breast clinical
a. bring the breast closer to the examiner’s
examination every 2 years
right hand
37. The purpose of performing the breast
b. tense the pectoral muscle
selfexamination
c. balance the breast tissue more evenly
(BSE) regularly is to discover:
on the chest wall
a. fibrocystic masses
d. facilitate lateral positioning of the breast
b. areas of thickness or fullness
Situation – Radiation therapy is another
c. cancerous lumps
modality of
cancer management. With emphasis on hepatomegaly
multidisciplinary
44. What nursing diagnosis should be of highest
management you have important
priority?
responsibilities as
a. Knowledge deficit regarding
nurse.
thrombocytopenia precautions
41. Albert is receiving external radiation therapy
and b. Activity intolerance
he complains of fatigue and malaise. Which of c. Impaired tissue integrity
the following nursing interventions would be d. Ineffective tissue perfusion, peripheral,
most helpful for Albert? cerebral, cardiovascular,
a. Tell him that sometimes these feelings gastrointestinal, renal
can be psychogenic 45. What intervention should you include in
your
b. Refer him to the physician
care plan?
c. Reassure him that these feelings are
a. Inspect his skin for petechiae, bruising,
normal
GI bleeding regularly
d. Help him plan his activities
b. Place Albert on strict isolation
42. Immediately following the radiation
teletherapy, precaution
Albert is c. Provide rest in between activities
a. Considered radioactive for 24 hrs d. Administer antipyretics if his
b. Given a complete bath temperature exceeds 38C
c. Placed on isolation for 6 hours Situation: Burn are cause by transfer of heat
source to
d. Free from radiation
the body. It can be thermal, electrical, radiation
43. Albert is admitted with a radiation induced
or
thrombocytopenia. As a nurse you should
chemical.
observe the following symptoms:
46. A burn characterized by Pale white
a. Petechiae, ecchymosis, epistaxis appearance,

b. Weakness, easy fatigability, pallor charred or with fat exposed and painlessness is:

c. Headache, dizziness, blurred vision a. Superficial partial thickness burn

d. Severe sore throat, bacteremia, b. Deep partial thickness burn

c. Full thickness burn fluid resuscitation

d. Deep full thickness burn 41

47. Which of the following BEST describes 51. The MOST effective method of delivering
superficial pain

partial thickness burn or first degree burn? medication during the emergent phase is:

a. Structures beneath the skin are damage a. intramuscularly

b. Dermis is partially damaged b. orally

c. Epidermis and dermis are both damaged c. subcutaneously

d. Epidermis is damaged d. intravenously

48. A burn that is said to be “WEEPING” is 52. When a client accidentally splashes
classified chemicals to

as: his eyes, The initial priority care following the

a. Superficial partial thickness burn chemical burn is to:

b. Deep partial thickness burn a. irrigate with normal saline for 1 to 15

c. Full thickness burn minutes

d. Deep full thickness burn b. transport to a physician immediately

49. During the Acute phase of the burn injury, c. irrigate with water for 15 minutes or
which
longer
of the following is a priority?
d. cover the eyes with a sterile gauze
a. wound healing
53. Which of the following can be a fatal
b. emotional support
complication of upper airway burns?
c. reconstructive surgery
a. stress ulcers
d. fluid resuscitation
b. shock
50. While in the emergent phase, the nurse
c. hemorrhage
knows
d. laryngeal spasms and swelling
that the priority is to:
54. When a client will rush towards you and he
a. Prevent infection
has a
b. Prevent deformities and contractures
burning clothes on, It is your priority to do
c. Control pain which

d. Return the hemodynamic stability via of the following first?

a. log roll on the grass/ground 58. A 165 lbs trauma client was rushed to the

b. slap the flames with his hands emergency room with full thickness burns on
the
c. Try to remove the burning clothes
whole face, right and left arm, and at the
d. Splash the client with 1 bucket of cool
anterior upper chest sparing the abdominal
water
area.
55. Once the flames are extinguished, it is most
He also has superficial partial thickness burn at
important to:
the posterior trunk and at the half upper
a. cover clientwith a warm blanket portion

b. give him sips of water of the left leg. He is at the emergent phase of

c. calculate the extent of his burns burn. Using the parkland’s formula, you know

d. assess the Sergio’s breathing that during the first 8 hours of burn, the amount

56. During the first 24 hours after the thermal of fluid will be given is:
injury,
a. 5,400 ml
you should asses Sergio for:
b. 9, 450 ml
a. hypokalemia and hypernatremia
c. 10,800 ml
b. hypokalemia and hyponatremia
d. 6,750 ml
c. hyperkalemia and hyponatremia
59. The doctor incorporated insulin on the
d. hyperkalemia and hypernatremia client’s

57. A client who sustained deep partial fluid during the emergent phase. The nurse
thickness
knows that insulin is given because:
and full thickness burns of the face, whole
a. Clients with burn also develops
anterior chest and both upper extremities two
Metabolic acidosis
days ago begins to exhibit extreme restlessness.
b. Clients with burn also develops
You recognize that this most likely indicates that
hyperglycemia
the client is developing:
c. Insulin is needed for additional energy
a. Cerebral hypoxia
and glucose burning after the stressful
b. metabolic acidosis
incidence to hasten wound healing,
c. Hypervolemia
regain of consciousness and rapid return
d. Renal failure
of hemodynamic stability
d. For hyperkalemia d. After Fermin accepts alteration in body

60. The IV fluid of choice for burn as well as image

dehydration is: 63. When observing a return demonstration of a

a. 0.45% NaCl colostomy irrigation, you know that more

b. Sterile water teaching is required if Fermin:

c. NSS a. Lubricates the tip of the catheter prior to

d. D5LR inserting into the stoma

Situation: ENTEROSTOMAL THERAPY is now b. Hangs the irrigating bag on the

considered a
bathroom door cloth hook during fluid
specialty in nursing. You are participating in the
insertion
OSTOMY
c. Discontinues the insertion of fluid after
CARE CLASS.
500 ml of fluid has been instilled
61. You plan to teach Fermin how to irrigate the
d. Clamps of the flow of fluid when felling
colostomy when:
uncomfortable
a. The perineal wound heals And Fermin
64. You are aware that teaching about
can sit comfortably on the commode
colostomy
b. Fermin can lie on the side comfortably,
care is understood when Fermin states, “I will
about the 3rd postoperative day
contact my physician and report:
c. The abdominal incision is closed and
a. If I have any difficulty inserting the
42
irrigating tub into the stoma.”
contamination is no longer a danger
b. If I noticed a loss of sensation to touch in
d. The stools starts to become formed,
the stoma tissue.”
around the 7th postoperative day
c. The expulsion of flatus while the
62. When preparing to teach Fermin how to
irrigating fluid is running out.”
irrigate
d. When mucus is passed from the stoma
colostomy, you should plan to do the procedure:
between the irrigations.”
a. When Fermin would have normal bowel
65. You would know after teaching Fermin that
movement
dietary instruction for him is effective when he
b. At least 2 hours before visiting hours
states, “It is important that I eat:
c. Prior to breakfast and morning care
a. Soft food that is easily digested and 68. Which of the following factors may inhibit

absorbed by my large intestines.” learning in critically ill patients?

b. Bland food so that my intestines do not a. Gender

become irritated.” b. Educational level

c. Food low in fiber so that there are fewer c. Medication

stools.” d. Previous knowledge of illness

d. Everything that I ate before the 69. Which of the following statements does not

operation, while avoiding foods that apply to critically ill patients?

cause gas”. a. Majority need extensive rehabilitation

Situation: Based on studies of nurses working in b. All have been hospitalized previously
special
c. Are physically unstable
units like the intensive care unit and coronary
d. Most have chronic illness
care unit,
70. Families of critically ill patients desire which
it is important for nurses to gather as much
of
information
the following needs to be met first by the
to be able to address their needs for nursing
nurse?
care.
a. Provision of comfortable space
66. Critically ill patients frequently complain
about b. Emotional support
which of the following when hospitalized? c. Updated information on client’s status
a. Hospital food d. Spiritual counselling
b. Lack of privacy Situation: Johnny, sought consultation to the
hospital
c. Lack of blankets
because of fatigability, irritability, jittery and he
d. Inadequate nursing staff
has been
67. Who of the following is at greatest risk of
experiencing this sign and symptoms for the
developing sensory problem? past 5

a. Female patient months.

b. Transplant patient 71. His diagnosis was hyperthyroidism, the

following
c. Adoloscent
are expected symptoms except:
d. Unresponsive patient
a. Anorexia
b. Fine tremors of the hand neck

c. Palpitation b. Check for hypotension

d. Hyper alertness c. Apply neck collar to prevent

72. She has to take drugs to treat her haemorrhage

hyperthyroidism. Which of the following will d. Observe the dressing if it is soaked with
you
blood
NOT expect that the doctor will prescribe?
76. Basal Metabolic rate is assessed on Johnny
43 to

a. Colace (Docusate) determine his metabolic rate. In assessing the

b. Tapazole (Methimazole) BMR using the standard procedure, you need to

c. Cytomel (Liothyronine) tell Johnny that:

d. Synthroid (Levothyroxine) a. Obstructing his vision

73. The nurse knows that Tapazole has which of b. Restraining his upper and lower
the
extremities
following side effect that will warrant
c. Obstructing his hearing
immediate
d. Obstructing his nostrils with a clamp
withholding of the medication?
77. The BMR is based on the measurement that:
a. Death
a. Rate of respiration under different
b. Hyperthermia
condition of activities and rest
c. Sore throat
b. Amount of oxygen consumption under
d. Thrombocytosis
resting condition over a measured
74. You asked questions as soon as she regained
period of time
consciousness from thyroidectomy primarily to
c. Amount of oxygen consumption under
assess the evidence of:
stressed condition over a measured
a. Thyroid storm
period of time
b. Damage to the laryngeal nerve
d. Ratio of respiration to pulse rate over a
c. Mediastinal shift
measured period of time
d. Hypocalcaemia tetany
78. Her physician ordered lugol’s solution in
75. Should you check for haemorrhage, you will:
order
a. Slip your hand under the nape of her
to: classified as either CRITICAL, SEMI CRITICAL and

a. Decrease the vascularity and size of the NON CRITICAL. If the instrument are introduced

thyroid gland directly into the blood stream or into any

b. Decrease the size of the thyroid gland normally sterile cavity or area of the body it is

only classified as:

c. Increase the vascularity and size of the a. Critical

thyroid gland b. Non Critical

d. Increase the size of the thyroid gland c. Semi Critical

only d. Ultra Critical

79. Which of the following is a side effect of 82. Instruments that do not touch the patient or
Lugol’s
have contact only to intact skin is classified as:
solution?
a. Critical
a. Hypokalemia
b. Non Critical
b. Enlargement of the Thryoid gland
c. Semi Critical
c. Nystagmus
d. Ultra Critical
d. Excessive salivation
83. If an instrument is classified as Semi Critical,
80. In administering Lugol’s solution, the an

precautionary measure should include: acceptable method of making the instrument

a. Administer with glass only ready for surgery is through:

b. Dilute with juice and administer with a a. Sterilization

straw b. Disinfection

c. Administer it with milk and drink it c. Decontamination

d. Follow it with milk of magnesia 44

Situation: Pharmacological treatment was not d. Cleaning

effective
84. While critical items and should be:
for Johnny’s hyperthyroidism and now, he is
a. Clean
scheduled
b. Sterilized
for Thyroidectomy.
c. Decontaminated
81. Instruments in the surgical suite for surgery
is d. Disinfected
85. As a nurse, you know that intact skin acts as 88. Which of the following nursing interventions
an is

effective barrier to most microorganisms. appropriate after a total thyroidectomy?

Therefore, items that come in contact with the a. Place pillows under your patient’s

intact skin or mucus membranes should be: shoulders.

a. Disinfected b. Raise the knee-gatch to 30 degrees

b. Clean c. Keep you patient in a high-fowler’s

c. Sterile position.

d. Alcoholized d. Support the patient’s head and neck

86. You are caring for Johnny who is scheduled with pillows and sandbags.
to
89. If there is an accidental injury to the
undergo total thyroidectomy because of a parathyroid

diagnosis of thyroid cancer. Prior to total gland during a thyroidectomy which of the

thyroidectomy, you should instruct Johnny to: following might Leda develops postoperatively?

a. Perform range and motion exercise on a. Cardiac arrest

the head and neck b. Respiratory failure

b. Apply gentle pressure against the c. Dyspnea

incision when swallowing d. Tetany

c. Cough and deep breathe every 2 hours 90. After surgery Johnny develops peripheral

d. Support head with the hands when numbness, tingling and muscle twitching and

changing position spasm. What would you anticipate to

87. As Johnny’s nurse, you plan to set up administer?

emergency
a. Magnesium sulfate
equipment at her bedside following
b. Potassium iodide
thyroidectomy. You should include:
c. Calcium gluconate
a. An airway and rebreathing tube
d. Potassium chloride
b. A tracheostomy set and oxygen
Situation: Budgeting is an important part of a
c. A crush cart with bed board nurse

d. Two ampules of sodium bicarbonate managerial activity. The correct allocation and
distribution of resources is vital in the a. Budget to estimate the cost of direct
harmonious
labour, number of staff to be hired and
operation of the financial balance of the agency.
necessary number of workers to meet
91. Which of the following best defines Budget?
the general patient needs
a. Plan for the allocation of resources for
b. Includes the monthly and daily
future use
expenses and expected revenue and
b. The process of allocating resources for
expenses
future use
c. These are related to long term planning
c. Estimate cost of expenses
and includes major replacement or
d. Continuous process in seeing that the
45
goals and objective of the agency is met
expansion of the plant, major
92. Which of the following best defines Capital
equipments and inventories.
Budget?
d. These are expenses that are not
a. Budget to estimate the cost of direct
dependent on the level of production or
labour, number of staff to be hired and
sales. They tend to be time-related, such
necessary number of workers to meet
as rent
the general patient needs
94. Which of the following accurately describes
b. Includes the monthly and daily expenses a

and expected revenue and expenses Fixed Cost in budgeting?

c. These are related to long term planning a. These are usually the raw materials and

and includes major replacement or labour salaries that depend on the

expansion of the plant, major production or sales

equipment and inventories. b. These are expenses that change in

d. These are expenses that are not proportion to the activity of a business

dependent on the level of production or c. These are expenses that are not

sales. They tend to be time-related, such dependent on the level of production or

as salaries or rents being paid per month sales. They tend to be time-related,

93. Which of the following best described such as rent

Operational Budget? d. This is the summation of the Variable

Cost and the Fixed Cost d. Eupnea

95. Which of the following accurately describes 97. What do you call the triad of sign and
symptoms
Variable Cost in budgeting?
seen in a client with increasing ICP?
a. These are related to long term planning
a. Virchow’s Triad
and include major replacement or
b. Cushing’s Triad
expansion of the plant, major
c. The Chinese Triad
equipments and inventories.
d. Charcot’s Triad
b. These are expenses that change in
98. Which of the following is true with the Triad
proportion to the activity of a business
seen in head injuries?
c. These are expenses that are not
a. Narrowing of Pulse pressure, Cheyne
dependent on the level of production or
stokes respiration, Tachycardia
sales. They tend to be time-related, such
b. Widening Pulse pressure, Irregular
as rent
respiration, Bradycardia
d. This is the summation of the Variable
c. Hypertension, Kussmaul’s respiration,
Cost and the Fixed Cost
Tachycardia
Situation – Andrea is admitted to the ER
following an d. Hypotension, Irregular respiration,

assault where she was hit in the face and head. Bradycardia
She was
99. In a client with a Cheyne stokes respiration,
brought to the ER by a police woman.
which of the following is the most appropriate
Emergency
nursing diagnosis?
measures were started.
a. Ineffective airway clearance
96. Andrea’s respiration is described as waxing
and b. Impaired gas exchange
waning. You know that this rhythm of c. Ineffective breathing pattern
respiration
d. Activity intolerance
is defined as:
100. You know the apnea is seen in client’s with
a. Biot’s
cheyne stokes respiration, APNEA is defined as:
b. Cheyne stokes
a. Inability to breathe in a supine position
c. Kussmaul’s
so the patient sits up in bed to breathe
b. The patient is dead, the breathing stops D. A behavioural approach to changing

c. There is an absence of breathing for a behaviour

period of time, usually 15 seconds or 3. A nurse is caring for a client with phobia who
is
more
being treated for the condition. The client is
d. A period of hypercapnea and hypoxia
introduced to short periods of exposure to the
due to the cessation of respiratory effort
phobic object while in relaxed state. The nurse
inspite of normal respiratory functioning
understands that this form of behaviour
46
modification can be best described as:
NURSING PRACTICE V
A. Systematic desensitization
Situation: Understanding different models of
care is a B. Self-control therapy

necessary part of the nurse patient relationship. C. Aversion Therapy

1. The focus of this therapy is to have a positive D. Operant conditioning

environmental manipulation, physical and social 4. A client with major depression is considering

to effect a positive change. cognitive therapy. The client say to the nurse,

A. Milieu “How does this treatment works?” The nurse

B. Psychotherapy responds by telling the client that:

C. Behaviour A. “This type of treatment helps you

D. Group examine how your thoughts and

2. The client asks the nurse about Milieu feelings contribute to your difficulties”
therapy.
B. “This type of treatment helps you
The nurse responds knowing that the primary
examine how your past life has
focus of milieu therapy can be best described by
contributed to your problems.”
which of the following?
C. “This type of treatment helps you to
A. A form of behavior modification therapy
confront your fears by exposing you to
B. A cognitive approach of changing the
the feared object abruptly.
behaviour
D. “This type of treatment will help you
C. A living, learning or working
relax and develop new coping skills.”
environment
5. A Client state, “I get down on myself when I
make mistake.” Using Cognitive therapy D. Examine intrapsychic conflicts and past

approach, the nurse should: events in life

A. Teach the client relaxation exercise to 8. The nurse is preparing to provide

reminiscence
diminish stress
therapy for a group of clients. Which of the
B. Provide the client with Mastery
following clients will the nurse select for this
experience to boost self esteem
group?
C. Explore the client’s past experiences that
A. A client who experiences profound
causes the illness
depression with moderate cognitive
D. Help client modify the belief that
impairment
anything less than perfect is horrible
B. A catatonic, immobile client with
6. The most advantageous therapy for a
preschool moderate cognitive impairment

age child with a history of physical and sexual C. An undifferentiated schizophrenic client

abuse would be: with moderate cognitive impairment

A. Play D. A client with mild depression who

B. Psychoanalysis exhibits who demonstrates normal

C. Group cognition

D. Family 9. Which intervention would be typical of a

nurse
7. An 18 year old client is admitted with the
using cognitive-behavioral approach to a client
diagnosis of anorexia nervosa. A cognitive
experiencing low self-esteem?
behavioural approach is used as part of her
47
treatment plan. The nurse understands that the
A. Use of unconditional positive regard
purpose of this approach is to:
B. Analysis of free association
A. Help the client identify and examine
C. Classical conditioning
dysfunctional thoughts and beliefs
D. Examination of negative thought
B. Emphasize social interaction with clients
patterns
who withdraw
10. Which of the following therapies has been
C. Provide a supportive environment and a
strongly advocated for the treatment of
therapeutic community
posttraumatic
stress disorders? health care providers

A. ECT B. Providing emergency psychiatric

B. Group Therapy services

C. Hypnotherapy C. Being politically active in relation to

D. Psychoanalysis mental health issues

11. The nurse knows that in group therapy, the D. Providing mental health education to

maximum number of members to include is: members of the community

A. 4 15. When the nurse identifies a client who has

B. 8 attempted to commit suicide the nurse should:

C. 10 A. call a priest

D. 16 B. counsel the client

12. The nurse is providing information to a client C. refer the client to the psychiatrist

with the use of disulfiram (antabuse) for the D. refer the matter to the police

treatment of alcohol abuse. The nurse Situation: Rose seeks psychiatric consultation
because of
understands that this form of therapy works on
intense fear of flying in an airplane which has
what principle?
greatly
A. Negative Reinforcement
affected her chances of success in her job.
B. Operant Conditioning
16. The most common defense mechanism used
C. Aversion Therapy by

D. Gestalt therapy phobic clients is:

13. A biological or medical approach in treating A. Supression

psychiatric patient is: B. Denial

A. Million therapy C. Rationalization

B. Behavioral therapy D. Displacement

C. Somatic therapy 17. The goal of the therapy in phobia is:

D. Psychotherapy A. Change her lifestyle

14. Which of these nursing actions belong to the B. Ignore tension producing situation

secondary level of preventive intervention? C. Change her reaction towards anxiety

A. Providing mental health consultation to D. Eliminate fear producing situations

18. The therapy most effective for client’s with B. Rationalization

phobia is: C. Suppression

A. Hypnotherapy D. Projection

B. Cognitive therapy 48

C. Group therapy 22. When Mang Jose says to you: “The voices
are
D. Behavior therapy
telling me bad things again!” The best response
19. The fear and anxiety related to phobia is
said to is:

be abruptly decreased when the patient is A. “Whose voices are those?”

exposed to what is feared through: B. “I doubt what the voices are telling you”

A. Guided Imagery C. “I do not hear the voice you say you

B. Systematic desensitization hear”

C. Flooding D. “Are you sure you hear these voices?”

D. Hypotherapy 23. A relevant nursing diagnosis for clients with

20. Based on the presence of symptom, the auditory hallucination is:

appropriate nursing diagnosis is: A. Sensory perceptual alteration

A. Self-esteem disturbance B. Altered thought process

B. Activity intolerance C. Impaired social interaction

C. Impaired adjustment D. Impaired verbal communication

D. Ineffective individual coping 24. During mealtime, Jose refused to eat telling
that
Situation: Mang Jose, 39 year old farmer,
unmarried, had the food was poisoned. The nurse should:

been confined in the National center for mental A. Ignore his remark
health
B. Offer him food in his own container
for three years with a diagnosis of
C. Show him how irrational his thinking is
schizophrenia.
D. Respect his refusal to eat
21. The most common defense mechanism used
by 25. When communicating with Jose, The nurse
a paranoid client is: considers the following except:
A. Displacement A. Be warm and enthusiastic
B. Refrain from touching Jose kept out of awareness by developing the

C. Do not argue regarding his hallucination opposite behavior or emotion

and delusion B. Consciously unacceptable instinctual

D. Use simple, clear language drives are diverted into personally and

Situation: Gringo seeks psychiatric counselling socially acceptable channels

for his
C. Something unacceptable already done
ritualistic behavior of counting his money as
is symbolically acted out in reverse
many as 10
D. Transfer of emotions associated with a
times before leaving home.
particular person, object or situation to
26. An initial appropriate nursing diagnosis is:
another less threatening person, object
A. Impaired social interaction
or situation
B. Ineffective individual coping
29. To be more effective, the nurse who cares
C. Impaired adjustment
for
D. Anxiety Moderate
persons with obsessive compulsive disorder
27. Obsessive compulsive disorder is BEST
must possess one of the following qualities:
described
A. Compassion
by:
B. Patience
A. Uncontrollable impulse to perform an
C. Consistency
act or ritual repeatedly
D. Friendliness
B. Persistent thoughts
30. Persons with OCD usually manifest:
C. Recurring unwanted and disturbing
A. Fear
thought alternating with a behavior
B. Apathy
D. Pathological persistence of unwilled
C. Suspiciousness
thought, feeling or impulse
D. Anxiety
28. The defense mechanism used by persons
with Situation: The patient who is depressed will
undergo
obsessive compulsive disorder is undoing and it
electroconvulsive therapy.
is best described in one of the following
31. Studies on biological depression support
statements:
electroconvulsive therapy as a mode of
A. Unacceptable feelings or behavior are
treatment. The rationale is: D. confusion, disorientation and short

A. ECT produces massive brain damage term memory loss

which destroys the specific area 34. Informed consent is necessary for the
treatment
containing memories related to the
for involuntary clients. When this cannot be
events surrounding the development of
obtained, permission may be taken from the:
psychotic condition
A. social worker
B. The treatment serves as a symbolic
B. next of kin or guardian
punishment for the client who feels
C. doctor
guilty and worthless
D. chief nurse
C. ECT relieves depression psychologically
35. After ECT, the nurse should do this action
by increasing the norepinephrine level
before
D. ECT is seen as a life-threatening
giving the client fluids, food or medication:
experience and depressed patients
A. assess the gag reflex
mobilize all their bodily defences to deal
B. next of kin or guardian
with this attack.
C. assess the sensorium
32. The preparation of a patient for ECT ideally
D. check O2 Sat with a pulse oximeter
is
Situation: Mrs Ethel Agustin 50 y/o, teacher is
MOST similar to preparation for a patient for:
afflicted
A. electroencephalogram
with myasthenia gravis.
49
36. Looking at Mrs Agustin, your assessment
B. general anesthesia would

C. X-ray include the following except;

D. electrocardiogram A. Nystagmus

33. Which of the following is a possible side B. Difficulty of hearing

effect
C. Weakness of the levator palpebrae
which you will discuss with the patient?
D. Weakness of the ocular muscle
A. hemorrhage within the brain
37. In an effort to combat complications which
B. encephalitis
might occur relatives should he taught;
C. robot-like body stiffness
A. Checking cardiac rate
B. Taking blood pressure reading with antiseptic solution.

C. Techniques of oxygen inhalation 41. The fear of using “contaminated” toilet seat
can
D. Administration of oxygen inhalation
be attributed to Rosanna’s inability to;
38. The drug of choice for her condition is;
A. Adjust to a strange environment
A. Prostigmine
B. Express her anxiety
B. Morphine
C. Develop the sense of trust in other
C. Codeine
person
D. Prednisone
D. Control unacceptable impulses or
39. As her nurse, you have to be cautious about
feelings
administration of medication, if she is under
42. Assessment data upon admission help the
medicated this can cause;
nurse
A. Emotional crisis
to identify this appropriate nursing diagnosis
B. Cholinergic crisis
A. Ineffective denial
C. Menopausal crisis
B. Impaired adjustment
D. Myasthenia crisis
C. Ineffective individual coping
40. If you are not extra careful and by chance
D. Impaired social interaction
you
43. An effective nursing intervention to help
give over medication, this would lead to;
Rosana
A. Cholinergic crisis
is;
B. Menopausal crisis
A. Convincing her to use the toilet after the
C. Emotional crisis
nurse has used it first
D. Myasthenia crisis
B. Explaining to her that AIDS cannot be
Situation: Rosanna 20 y/o unmarried patient
transmitted by using the toilet
believes
C. Allowing her to flush and clear the
that the toilet for the female patient in
contaminated toilet seat until she can manage her

with AIDS virus and refuses to use it unless she anxiety

flushes it
D. Explaining to her how AIDS is
three times and wipes the seat same number of
transmitted
times
44. The goal for treatment for Rosana must be
directed toward helping her to; A. Denial

A. Walk freely about her past experience B. Projection

B. Develop trusting relationship with others C. Rationalization

C. Gain insight that her behaviour is due D. Displacement

to feeling of anxiety 47. One morning, Dennis was seen tilting his
head as
D. Accept the environment unconditionally
if he was listening to someone. An appropriate
50
nursing intervention would be;
45. Psychotherapy which is prescribed for
Rosana is A. Tell him to socialize with other patient to

described as; divert his attention

A. Establishing an environment adapted to B. Involve him in group activities

an individual patient needs C. Address him by name to ask if he is

B. Sustained interaction between the hearing voices again

therapist and client to help her develop D. Request for an order of antipsychotic

more functional behaviour medicine

C. Using dramatic techniques to portray 48. When he says, “these voices are telling me
my
interpersonal conflicts
wife is going to kill me.” A therapeutic
D. Biologic treatment for mental disorder
communication of the nurse is which one of the
Situation: Dennis 40 y/o married man, an
electrical following;

engineer was admitted with the diagnosis of A. “i do not hear the voices you say you
paranoid
hear”
disorders. He has become suspicious and
B. “are you really sure you heard those
distrustful 2
voices?”
months before admission. Upon admission, he
kept on C. “I do not think you heard those
saying, “my wife has been planning to kill me.” voices?”
46. A paranoid individual who cannot accept the D. “Whose voices are those?”
guilt demonstrate one of the following defense 49. The nurse confirms that Dennis is
manifesting
mechanism;
auditory hallucination. The appropriate nursing
diagnosis she identifiesis; searching any belongings.

A. Sensory perceptual alteration D. Remind all staff members to check on

B. Self-esteem disturbance the client frequently.

C. Ineffective individual coping 52. In planning activities for the depressed

client,
D. Defensive coping
especially during the early stages of
50. Most appropriate nursing intervention for a
hospitalization, which of the following plan is
client with suspicious behavior is one of the
best?
following;
A. Provide an activity that is quiet and
A. Talk to the client constantly to reinforce
solitary to avoid increased fatigue such
reality
as working on a puzzle and reading a
B. Involve him in competitive activities
book.
C. Use Non Judgmental and Consistent
B. Plan nothing until the client asks to
approach
participate in the milieu
D. Project cheerfulness in interacting with
C. Offer the client a menu of daily activities
the patient
and ask the client to participate in all of
Situation: Clients with Bipolar disorder receives
a very them

high nursing attention due to the increasing rate D. Provide a structured daily program of
of
activities and encourage the client to
suicide related to the illness.
participate
51. The nurse is assigned to care for a recently
53. A client with a diagnosis of major
admitted client who has attempted suicide. depression,

What should the nurse do? recurrent with psychotic features is admitted to

A. Search the client's belongings and room the mental health unit. To create a safe

carefully for items that could be used to environment for the client, the nurse most

attempt suicide. 51

B. Express trust that the client won't cause importantly devises a plan of care that deals

self-harm while in the facility. specifically with the clients:

C. Respect the client's privacy by not A. Disturbed thought process

B. Imbalanced nutrition D. Basketball

C. Self-Care Deficit 57. The nurse assesses a client with admitted

D. Deficient Knowledge diagnosis of bipolar affective disorder, mania.

54. The client is taking a Tricyclic anti- The symptom presented by the client that
depressant,
requires the nurse’s immediate intervention is
which of the following is an example of TCA?
the client’s:
A. Paxil
A. Outlandish behaviour and inappropriate
B. Nardil
dress
C. Zoloft
B. Grandiose delusion of being a royal
D. Pamelor
descendant of king arthut
55. A client visits the physician's office to seek
C. Nonstop physical activity and poor
treatment for depression, feelings of
nutritional intake
hopelessness, poor appetite, insomnia, fatigue,
D. Constant incessant talking that includes
low self-esteem, poor concentration, and
sexual topics and teasing the staff
difficulty making decisions. The client states that
58. A nurse is conducting a group therapy
these symptoms began at least 2 years ago. session

Based on this report, the nurse suspects: and during the session, A client with mania

A. cyclothymic disorder. consistently talks and dominates the group. The

B. Bipolar disorder behaviour is disrupting the group interaction.

C. major depression. The nurse would initially:

D. dysthymic disorder. A. Ask the client to leave the group session

56. The nurse is planning activities for a client B. Tell the client that she will not be
who
allowed to attend any more group
has bipolar disorder, which aggressive social
sessions
behaviour. Which of the following activities
C. Tell the client that she needs to allow
would be most appropriate for this client?
other client in a group time to talk
A. Ping Pong
D. Ask another nurse to escort the client
B. Linen delivery
out of the group session
C. Chess
59. A professional artist is admitted to the
psychiatric unit for treatment of bipolar provoking situations through imagery.

disorder. During the last 2 weeks, the client has B. To provide corrective emotional

created 154 paintings, slept only 2 to 3 hours experiences through a one-to-one

every 2 days, and lost 18 lb (8.2 kg). Based on intensive relationship.

Maslow's hierarchy of needs, what should the C. To help clients in a group therapy setting

nurse provide this client with first? to take on specific roles and reenact in

A. The opportunity to explore family front of an audience, situations in which

dynamics interpersonal conflict is involved.

B. Help with re-establishing a normal D. To help clients cope with their problems

sleep pattern by learning behaviors that are more

C. Experiences that build self-esteem functional and be better equipped to

D. Art materials and equipment face reality and make decisions.

60. The physician orders lithium carbonate 52

(Lithonate) for a client who's in the manic phase 62. It is essential in desensitization for the
patient
of bipolar disorder. During lithium therapy, the
to:
nurse should watch for which adverse
reactions? A. Have rapport with the therapist

A. Anxiety, restlessness, and sleep B. Use deep breathing or another

disturbance relaxation technique

B. Nausea, diarrhea, tremor, and lethargy C. Assess one’s self for the need of an

C. Constipation, lethargy, and ataxia anxiolytic drug

D. Weakness, tremor, and urine retention D. Work through unresolved unconscious

Situation – Annie has a morbid fear of heights. conflicts

She asks
63. In this level of anxiety, cognitive capacity
the nurse what desensitization therapy is:
diminishes. Focus becomes limited and client
61. The accurate information of the nurse of the
experiences tunnel vision. Physical signs of
goal of desensitization is:
anxiety become more pronounced.
A. To help the clients relax and
A. Severe anxiety
progressively work up a list of anxiety
B. Mild anxiety
C. Panic research participation

D. Moderate anxiety B. To validate results of new nursing

64. Antianxiety medications should be used with modalities

extreme caution because long term use can lead C. For financial gains

to: D. To improve nursing care

A. Parkinsonian like syndrome 67. Each nurse participants was asked to identify
a
B. Hepatic failure
problem. After the identification of the research
C. Hypertensive crisis
problem, which of the following should be
D. Risk of addiction
done?
65. The nursing management of anxiety related
A. Methodology
with
B. Acknowledgement
post-traumatic stress disorder includes all of the
C. Review of related literature
following EXCEPT:
D. Formulate hypothesis
A. Encourage participation in recreation or
68. Which of the following communicate the
sports activities
results
B. Reassure client’s safety while touching
of the research to the readers. They facilitate
client the

C. Speak in a calm soothing voice description of the data.

D. Remain with the client while fear level is A. Hypothesis

high B. Research problem

SITUATION: You are fortunate to be chosen as C. Statistics

part of
D. Tables and Graphs
the research team in the hospital. A review of
69. In Quantitative date, which of the following
the
is
following IMPORTANT nursing concepts was
described as the distance in the scoring unites
made.
of
66. As a professional, a nurse can do research
the variable from the highest to the lower?
for
A. Frequency
varied reason except:
B. Median
A. Professional advancement through
C. Mean
D. Range D. Range

70. This expresses the variability of the data in 53

reference to the mean. It provides as with a 73. In the value: 87, 85, 88, 92, 90; what is the

numerical estimate of how far, on the average mean?

the separate observation are from the mean: A. 88.2

A. Mode B. 88.4

B. Median C. 87

C. Standard deviation D. 90

D. Frequency 74. In the value: 80, 80, 80, 82, 82, 90, 90, 100;
what
Situation: Survey and Statistics are important
part of is the mode?

research that is necessary to explain the A. 80

characteristics
B. 82
of the population.
C. 90
71. According to the WHO statistics on the
D. 85.5
Homeless
75. In the value: 80, 80, 10, 10, 25, 65, 100, 200;
population around the world, which of the
what is the median?
following groups of people in the world
A. 71.25
disproportionately represents the homeless
B. 22.5
population?
C. 10 and 25
A. Hispanics
D. 72.5
B. Asians
76. Draw Lots, Lottery, Table of random
C. African Americans
numbers or
D. Caucasians
a sampling that ensures that each element of
72. All but one of the following is not a measure the
of
population has an equal and independent
Central Tendency:
chance of being chosen is called:
A. Mode
A. Cluster
B. Standard Deviation
B. Stratified
C. Variance
C. Simple
D. Systematic C. Selection of subjects in the control group

77. An investigator wants to determine some of is randomized

the
D. There is a careful selection of subjects
problems that are experienced by diabetic
in the experimental group
clients when using an insulin pump. The
80. The researcher implemented a medication
investigator went into a clinic where he
regimen using a new type of combination drugs
personally knows several diabetic clients having
to manic patients while another group of manic
problem with insulin pump. The type of
patient receives the routine drugs. The
sampling
researcher however handpicked the
done by the investigator is called:
experimental group for they are the clients with
A. Probability
multiple episodes of bipolar disorder. The
B. Snowball
researcher utilized which research design?
C. Purposive
A. Quasi-experimental
D. Incidental
B. Phenomenological
78. If the researcher implemented a new
structured C. Pure experimental
counselling program with a randomized group D. Longitudinal
of
Situation 19: As a nurse, you are expected to
subject and a routine counselling program with participate
another randomized group of subject, the in initiating or participating in the conduct of
research
research is utilizing which design?
studies to improve nursing practice. You to be
A. Quasi experimental
updated
B. Comparative
on the latest trends and issues affected the
C. Experimental profession

D. Methodological and the best practices arrived at by the

profession.
79. Which of the following is not true about a
Pure 81. You are interested to study the effects of

Experimental research? mediation and relaxation on the pain

A. There is a control group experienced by cancer patients. What type of

B. There is an experimental group variable is pain?

A. Dependent 83. You would like to compare the support
system
B. Independent
of patients with chronic illness to those with
C. Correlational
acute illness. Considering that the hypothesis
D. Demographic
was: “Client’s with chronic illness have lesser
82. You would like to compare the support
system support system than client’s with acute illness.”

of patient with chronic illness to those with What type of research is this?

acute illness. How will you best state your A. Descriptive

problem? B. Correlational, Non experimental

A. A descriptive study to compare the C. Experimental

support system of patients with chronic D. Quasi Experimental

illness and those with acute illness in 84. In any research study where individual
persons
terms of demographic data and
are involved, it is important that an informed
knowledge about intervention.
consent of the study is obtained. The following
B. The effects of the types of support
are essential information about the consent that
system of patients with chronic illness
you should disclose to the prospective subjects
and those with acute illness.
except:
C. A comparative analysis of the support
A. Consent to incomplete disclosure
system of patients with chronic illness
B. Description of benefits, risks and
and those with acute illness.
discomforts
D. A study to compare the support system
C. Explanation of procedure
of patients with chronic illness and those
D. Assurance of anonymity and
with acute illness.
confidentiality
54
85. In the Hypothesis: “The utilization of
E. What are the differences of the support
technology
system being received by patient with
in teaching improves the retention and
chronic illness and patients with acute attention

illness? of the nursing students.” Which is the

dependent variable?
A. Utilization of technology deprivation on wound healing

B. Improvement in the retention and D. A study examining client’s feelings

attention before, during and after bone marrow

C. Nursing students aspiration.

D. Teaching 88. Which of the following studies is based on

the
Situation: You are actively practicing nurse who
has just qualitative research?

finished you graduate studies. You learned the A. A study examining clients’ reaction to
value of
stress after open heart surgery
research and would like to utilize the knowledge
B. A study measuring nutrition and weight
and
loss/gain in clients with cancer
skills gained in the application of research to the
nursing C. A study examining oxygen levels after
service. The following questions apply to endotracheal suctioning
research.
D. A study measuring differences in blood
86. Which type of research inquiry investigates
the pressure before, during and after

issues of human complexity (e.g understanding procedure

the human expertise)? 89. An 85 year old client in a nursing home tells
a
A. Logical position
nurse, “I signed the papers of that research
B. Positivism
study because the doctor was so insistent and I
C. Naturalistic inquiry
want him to continue taking care for me” Which
D. Quantitative research
client right is being violated?
87. Which of the following studies is based on
A. Right of self determination
quantitative research?
B. Right to full disclosure
A. A study examining the bereavement
C. Right to privacy and confidentiality
process in spouse of clients with
D. Right not to be harmed
terminal cancer
90. A supposition or system of ideas that is
B. A study exploring the factors influencing
proposed to explain a given phenomenon best
weight control behaviour
defines:
C. A Study measuring the effects of sleep
A. A paradigm C. Correlational

B. A theory D. Longitudinal

C. A Concept 93. Community A was selected randomly as well

as
D. A conceptual framework
community B, nurse Edna conducted teaching to
Situation: Mastery of research design
determination is community A and assess if community A will

essential in passing the NLE. have a better status than community B. This is

91. Ana wants to know if the length of time she an example of:
will
A. Comparative
study for the board examination is proportional
B. Experimental
to her board rating. During the June 2008 board
C. Correlational
examination, she studied for 6 months and
D. Qualitative
gained 68%, On the next board exam, she
94. Ana researched on the development of a
studied for 6 months again for a total of 1 year new

and gained 74%, On the third board exam, She way to measure intelligence by creating a 100

studied for 6 months for a total of 1 and a half item questionnaire that will assess the cognitive

55 skills of an individual. The design best suited for

year and gained 82%. The research design she this study is:

used is: A. Historical

A. Comparative B. Survey

B. Experimental C. Methodological

C. Correlational D. Case study

D. Qualitative 95. Gen is conducting a research study on how

mark,
92. Anton was always eating high fat diet. You
want an AIDS client lives his life. A design suited for

to determine if what will be the effect of high this is:

cholesterol food to Anton in the next 10 years. A. Historical

You will use: B. Phenomenological

A. Comparative C. Case Study

B. Historical D. Ethnographic
96. Marco is to perform a study about how 99. Anjoe researched on TB. Its transmission,
nurses
Causative agent and factors, treatment sign and
perform surgical asepsis during World War II. A
symptoms as well as medication and all other in
design best for this study is:
depth information about tuberculosis. This
A. Historical study

B. Phenomenological is best suited for which research design?

C. Case Study A. Historical

D. Ethnographic B. Phenomenological

97. Tonyo conducts sampling at barangay 412. C. Case Study

He
D. Ethnographic
collected 100 random individuals and determine
100. Diana is to conduct a study about the
who is their favourite comedian actor. 50% said
relationship of the number of family members
Dolphy, 20% said Vic Sotto, while some in

answered Joey de Leon, Allan K, Michael V. the household and the electricity bill. Which of

Tonyo conducted what type of research study? the following is the best research design suited

A. Phenomenological for this study?

B. Non experimental 1. Descriptive

C. Case Study 2. Exploratory

D. Survey 3. Explanatory

98. Jane visited a tribe located somewhere in 4. Correlational

China,
5. Comparative
it is called the Shin Jea tribe. She studied the
6. Experimental
way
A. 1,4
of life, tradition and the societal structure of
B. 2,5
these people. Jane will best use which research
C. 3,6
design?
D. 1,5
A. Historical
E. 2,4
B. Phenomenological
56
C. Case Study
TEST I - Foundation of Professional Nursing
D. Ethnographic
Practice 3. Dr. Garcia writes the following order for the

1. The nurse In-charge in labor and delivery unit client who has been recently admitted “Digoxin

administered a dose of terbutaline to a client .125 mg P.O. once daily.” To prevent a dosage

without checking the client’s pulse. The error, how should the nurse document this
standard order

that would be used to determine if the nurse onto the medication administration record?

was negligent is: a. “Digoxin .1250 mg P.O. once daily”

a. The physician’s orders. b. “Digoxin 0.1250 mg P.O. once daily”

b. The action of a clinical nurse specialist c. “Digoxin 0.125 mg P.O. once daily”

who is recognized expert in the field. d. “Digoxin .125 mg P.O. once daily”

c. The statement in the drug literature 4. A newly admitted female client was
diagnosed
about administration of terbutaline.
with deep vein thrombosis. Which nursing
d. The actions of a reasonably prudent
diagnosis should receive the highest priority?
nurse with similar education and
a. Ineffective peripheral tissue perfusion
experience.
related to venous congestion.
2. Nurse Trish is caring for a female client with a
b. Risk for injury related to edema.
history of GI bleeding, sickle cell disease, and a
c. Excess fluid volume related to peripheral
platelet count of 22,000/μl. The female client is
vascular disease.
dehydrated and receiving dextrose 5% in
halfnormal d. Impaired gas exchange related to

saline solution at 150 ml/hr. The client increased blood flow.

complains of severe bone pain and is scheduled 5. Nurse Betty is assigned to the following
clients.
to receive a dose of morphine sulfate. In
The client that the nurse would see first after
administering the medication, Nurse Trish
endorsement?
should avoid which route?
a. A 34 year-old post-operative
a. I.V
appendectomy client of five hours who
b. I.M
is complaining of pain.
c. Oral
b. A 44 year-old myocardial infarction (MI)
d. S.C
client who is complaining of nausea.
c. A 26 year-old client admitted for action should the nurse take?

dehydration whose intravenous (IV) has a. Increase the I.V. fluid infusion rate

infiltrated. b. Irrigate the indwelling urinary catheter

d. A 63 year-old post operative’s c. Notify the physician

abdominal hysterectomy client of three d. Continue to monitor and record hourly

days whose incisional dressing is urine output

saturated with serosanguinous fluid. 9. Tony, a basketball player twist his right ankle

6. Nurse Gail places a client in a four-point while playing on the court and seeks care for
restraint
ankle pain and swelling. After the nurse applies
following orders from the physician. The client
ice to the ankle for 30 minutes, which statement
care plan should include:
by Tony suggests that ice application has been
a. Assess temperature frequently.
effective?
b. Provide diversional activities.
a. “My ankle looks less swollen now”.
c. Check circulation every 15-30 minutes.
b. “My ankle feels warm”.
d. Socialize with other patients once a shift.
c. “My ankle appears redder now”.
7. A male client who has severe burns is
57
receiving
d. “I need something stronger for pain
H2 receptor antagonist therapy. The nurse
Incharge relief”
knows the purpose of this therapy is to: 10. The physician prescribes a loop diuretic for a
a. Prevent stress ulcer client. When administering this drug, the nurse
b. Block prostaglandin synthesis anticipates that the client may develop which
c. Facilitate protein synthesis. electrolyte imbalance?
d. Enhance gas exchange a. Hypernatremia
8. The doctor orders hourly urine output b. Hyperkalemia
measurement for a postoperative male client. c. Hypokalemia
The nurse Trish records the following amounts d. Hypervolemia
of
11. She finds out that some managers have
output for 2 consecutive hours: 8 a.m.: 50 ml; 9
benevolent-authoritative style of management.
a.m.: 60 ml. Based on these amounts, which
Which of the following behaviors will she exhibit
most likely? 15. Nurse Linda prepares to perform an
otoscopic
a. Have condescending trust and
examination on a female client. For proper
confidence in their subordinates.
visualization, the nurse should position the
b. Gives economic and ego awards.
client's ear by:
c. Communicates downward to staffs.
a. Pulling the lobule down and back
d. Allows decision making among
b. Pulling the helix up and forward
subordinates.
c. Pulling the helix up and back
12. Nurse Amy is aware that the following is
true d. Pulling the lobule down and forward

about functional nursing 16. Which instruction should nurse Tom give to
a
a. Provides continuous, coordinated and
male client who is having external radiation
comprehensive nursing services.
therapy:
b. One-to-one nurse patient ratio.
a. Protect the irritated skin from sunlight.
c. Emphasize the use of group
b. Eat 3 to 4 hours before treatment.
collaboration.
c. Wash the skin over regularly.
d. Concentrates on tasks and activities.
d. Apply lotion or oil to the radiated area
13. Which type of medication order might read
when it is red or sore.
"Vitamin K 10 mg I.M. daily × 3 days?"
17. In assisting a female client for immediate
a. Single order
surgery, the nurse In-charge is aware that she
b. Standard written order
should:
c. Standing order
a. Encourage the client to void following
d. Stat order
preoperative medication.
14. A female client with a fecal impaction
frequently b. Explore the client’s fears and anxieties

exhibits which clinical manifestation? about the surgery.

a. Increased appetite c. Assist the client in removing dentures

b. Loss of urge to defecate and nail polish.

c. Hard, brown, formed stools d. Encourage the client to drink water prior

d. Liquid or semi-liquid stools to surgery.

18. A male client is admitted and diagnosed a. Takes a set of vital signs.
with
58
acute pancreatitis after a holiday celebration of
b. Call the radiology department for X-ray.
excessive food and alcohol. Which assessment
c. Reassure the client that everything will
finding reflects this diagnosis?
be alright.
a. Blood pressure above normal range.
d. Immobilize the leg before moving the
b. Presence of crackles in both lung fields.
client.
c. Hyperactive bowel sounds
22. A male client is being transferred to the
d. Sudden onset of continuous epigastric nursing

and back pain. unit for admission after receiving a radium

19. Which dietary guidelines are important for implant for bladder cancer. The nurse in-charge
nurse
would take which priority action in the care of
Oliver to implement in caring for the client with
this client?
burns?
a. Place client on reverse isolation.
a. Provide high-fiber, high-fat diet
b. Admit the client into a private room.
b. Provide high-protein, high-carbohydrate
c. Encourage the client to take frequent
diet.
rest periods.
c. Monitor intake to prevent weight gain.
d. Encourage family and friends to visit.
d. Provide ice chips or water intake.
23. A newly admitted female client was
20. Nurse Hazel will administer a unit of whole diagnosed

blood, which priority information should the with agranulocytosis. The nurse formulates

nurse have about the client? which priority nursing diagnosis?

a. Blood pressure and pulse rate. a. Constipation

b. Height and weight. b. Diarrhea

c. Calcium and potassium levels c. Risk for infection

d. Hgb and Hct levels. d. Deficient knowledge

21. Nurse Michelle witnesses a female client 24. A male client is receiving total parenteral
sustain
nutrition suddenly demonstrates signs and
a fall and suspects that the leg may be broken.
symptoms of an air embolism. What is the
The nurse takes which priority action?
priority action by the nurse? fluid in an 8 hour shift. The IV drip factor is 60.

a. Notify the physician. The IV rate that will deliver this amount is:

b. Place the client on the left side in the a. 50 cc/ hour

Trendelenburg position. b. 55 cc/ hour

c. Place the client in high-Fowlers position. c. 24 cc/ hour

d. Stop the total parenteral nutrition. d. 66 cc/ hour

25. Nurse May attends an educational 28. The nurse is aware that the most important
conference
nursing action when a client returns from
on leadership styles. The nurse is sitting with a
surgery is:
nurse employed at a large trauma center who
a. Assess the IV for type of fluid and rate of
states that the leadership style at the trauma
flow.
center is task-oriented and directive. The nurse
b. Assess the client for presence of pain.
determines that the leadership style used at the
c. Assess the Foley catheter for patency
trauma center is:
and urine output
a. Autocratic.
d. Assess the dressing for drainage.
b. Laissez-faire.
29. Which of the following vital sign
c. Democratic. assessments

d. Situational that may indicate cardiogenic shock after

26. The physician orders DS 500 cc with KCl 10 myocardial infarction?

mEq/liter at 30 cc/hr. The nurse in-charge is a. BP – 80/60, Pulse – 110 irregular

going to hang a 500 cc bag. KCl is supplied 20 b. BP – 90/50, Pulse – 50 regular

mEq/10 cc. How many cc’s of KCl will be added c. BP – 130/80, Pulse – 100 regular

to the IV solution? d. BP – 180/100, Pulse – 90 irregular

a. .5 cc 30. Which is the most appropriate nursing

action in
b. 5 cc
obtaining a blood pressure measurement?
c. 1.5 cc
a. Take the proper equipment, place the
d. 2.5 cc
client in a comfortable position, and
27. A child of 10 years old is to receive 400 cc of
IV record the appropriate information in
the client’s chart. 33. In preventing the development of an
external
b. Measure the client’s arm, if you are not
rotation deformity of the hip in a client who
sure of the size of cuff to use.
must remain in bed for any period of time, the
c. Have the client recline or sit comfortably
most appropriate nursing action would be to
in a chair with the forearm at the level of
use:
the heart.
a. Trochanter roll extending from the crest
d. Document the measurement, which
of the ileum to the mid-thigh.
extremity was used, and the position
b. Pillows under the lower legs.
that the client was in during the
c. Footboard
measurement.
d. Hip-abductor pillow
31. Asking the questions to determine if the
person 34. Which stage of pressure ulcer development
does
understands the health teaching provided by
the the ulcer extend into the subcutaneous tissue?

nurse would be included during which step of a. Stage I

the nursing process? b. Stage II

a. Assessment c. Stage III

b. Evaluation d. Stage IV

c. Implementation 35. When the method of wound healing is one

in
59
which wound edges are not surgically
d. Planning and goals
approximated and integumentary continuity is
32. Which of the following item is considered
the restored by granulations, the wound healing is

single most important factor in assisting the termed

health professional in arriving at a diagnosis or a. Second intention healing

determining the person’s needs? b. Primary intention healing

a. Diagnostic test results c. Third intention healing

b. Biographical date d. First intention healing

c. History of present illness 36. An 80-year-old male client is admitted to the

d. Physical examination hospital with a diagnosis of pneumonia. Nurse

Oliver learns that the client lives alone and measure of weight or quantity.

hasn’t been eating or drinking. When assessing 39. Nurse Oliver measures a client’s
temperature at
him for dehydration, nurse Oliver would expect
102° F. What is the equivalent Centigrade
to find:
temperature?
a. Hypothermia
a. 40.1 °C
b. Hypertension
b. 38.9 °C
c. Distended neck veins
c. 48 °C
d. Tachycardia
d. 38 °C
37. The physician prescribes meperidine
(Demerol), 40. The nurse is assessing a 48-year-old client
who
75 mg I.M. every 4 hours as needed, to control a
has come to the physician’s office for his annual
client’s postoperative pain. The package insert is
physical exam. One of the first physical signs of
“Meperidine, 100 mg/ml.” How many milliliters
aging is:
of meperidine should the client receive?
a. Accepting limitations while developing
a. 0.75
assets.
b. 0.6
b. Increasing loss of muscle tone.
c. 0.5
c. Failing eyesight, especially close vision.
d. 0.25
d. Having more frequent aches and pains.
38. A male client with diabetes mellitus is
receiving 41. The physician inserts a chest tube into a
female
insulin. Which statement correctly describes an
client to treat a pneumothorax. The tube is
insulin unit?
connected to water-seal drainage. The nurse
a. It’s a common measurement in the
incharge
metric system.
can prevent chest tube air leaks by:
b. It’s the basis for solids in the avoirdupois
a. Checking and taping all connections.
system.
b. Checking patency of the chest tube.
c. It’s the smallest measurement in the
c. Keeping the head of the bed slightly
apothecary system.
elevated.
d. It’s a measure of effect, not a standard
d. Keeping the chest drainage system
below the level of the chest. admitted to the facility. While assessing the

42. Nurse Trish must verify the client’s identity client, Nurse Hazel inspects the client’s
abdomen
before administering medication. She is aware
and notice that it is slightly concave. Additional
that the safest way to verify identity is to:
assessment should proceed in which order:
a. Check the client’s identification band.
a. Palpation, auscultation, and percussion.
b. Ask the client to state his name.
b. Percussion, palpation, and auscultation.
60
c. Palpation, percussion, and auscultation.
c. State the client’s name out loud and
d. Auscultation, percussion, and palpation.
wait a client to repeat it.
46. Nurse Betty is assessing tactile fremitus in a
d. Check the room number and the client’s
client with pneumonia. For this examination,
name on the bed.
nurse Betty should use the:
43. The physician orders dextrose 5 % in water,
a. Fingertips
1,000 ml to be infused over 8 hours. The I.V.
b. Finger pads
tubing delivers 15 drops/ml. Nurse John should
c. Dorsal surface of the hand
run the I.V. infusion at a rate of:
d. Ulnar surface of the hand
a. 30 drops/minute
47. Which type of evaluation occurs
b. 32 drops/minute
continuously
c. 20 drops/minute
throughout the teaching and learning process?
d. 18 drops/minute
a. Summative
44. If a central venous catheter becomes
b. Informative
disconnected accidentally, what should the
c. Formative
nurse in-charge do immediately?
d. Retrospective
a. Clamp the catheter
48. A 45 year old client, has no family history of
b. Call another nurse
breast cancer or other risk factors for this
c. Call the physician
disease. Nurse John should instruct her to have
d. Apply a dry sterile dressing to the site.
mammogram how often?
45. A female client was recently admitted. She
a. Twice per year
has
b. Once per year
fever, weight loss, and watery diarrhea is being
c. Every 2 years a. Massaging the area with an astringent

d. Once, to establish baseline every 2 hours.

49. A male client has the following arterial blood b. Applying an antibiotic cream to the area
gas
three times per day.
values: pH 7.30; Pao2 89 mmHg; Paco2 50
c. Using normal saline solution to clean the
mmHg; and HCO3 26mEq/L. Based on these
ulcer and applying a protective dressing
values, Nurse Patricia should expect which
as necessary.
condition?
d. Using a povidone-iodine wash on the
a. Respiratory acidosis
ulceration three times per day.
b. Respiratory alkalosis
52. Nurse Oliver must apply an elastic bandage
c. Metabolic acidosis to a

d. Metabolic alkalosis client’s ankle and calf. He should apply the

50. Nurse Len refers a female client with bandage beginning at the client’s:
terminal
a. Knee
cancer to a local hospice. What is the goal of
b. Ankle
this
c. Lower thigh
referral?
d. Foot
a. To help the client find appropriate
53. A 10 year old child with type 1 diabetes
treatment options.
develops
b. To provide support for the client and
diabetic ketoacidosis and receives a continuous
family in coping with terminal illness.
insulin infusion. Which condition represents the
c. To ensure that the client gets counseling
greatest risk to this child?
regarding health care costs.
a. Hypernatremia
d. To teach the client and family about
b. Hypokalemia
cancer and its treatment.
c. Hyperphosphatemia
51. When caring for a male client with a 3-cm
61
stage I
d. Hypercalcemia
pressure ulcer on the coccyx, which of the
54. Nurse Len is administering sublingual
following actions can the nurse institute
nitrglycerin
independently?
(Nitrostat) to the newly admitted client.
Immediately afterward, the client may determines that the standard of care had been

experience: maintained if which of the following data is

a. Throbbing headache or dizziness observed?

b. Nervousness or paresthesia. a. Urine output: 45 ml/hr

c. Drowsiness or blurred vision. b. Capillary refill: 5 seconds

d. Tinnitus or diplopia. c. Serum pH: 7.32

55. Nurse Michelle hears the alarm sound on d. Blood pressure: 90/48 mmHg
the
58. Nurse Amy has an order to obtain a
telemetry monitor. The nurse quickly looks at urinalysis

the monitor and notes that a client is in a from a male client with an indwelling urinary

ventricular tachycardia. The nurse rushes to the catheter. The nurse avoids which of the

client’s room. Upon reaching the client’s following, which contaminate the specimen?

bedside, the nurse would take which action a. Wiping the port with an alcohol swab

first? before inserting the syringe.

a. Prepare for cardioversion b. Aspirating a sample from the port on the

b. Prepare to defibrillate the client drainage bag.

c. Call a code c. Clamping the tubing of the drainage bag.

d. Check the client’s level of consciousness d. Obtaining the specimen from the urinary

56. Nurse Hazel is preparing to ambulate a drainage bag.

female
59. Nurse Meredith is in the process of giving a
client. The best and the safest position for the
client a bed bath. In the middle of the
nurse in assisting the client is to stand:
procedure, the unit secretary calls the nurse on
a. On the unaffected side of the client.
the intercom to tell the nurse that there is an
b. On the affected side of the client.
emergency phone call. The appropriate nursing
c. In front of the client.
action is to:
d. Behind the client.
a. Immediately walk out of the client’s
57. Nurse Janah is monitoring the ongoing care
room and answer the phone call.
given to the potential organ donor who has
b. Cover the client, place the call light
been
within reach, and answer the phone call.
diagnosed with brain death. The nurse
c. Finish the bed bath before answering the walker forward, and then walks into

the phone call. it.

d. Leave the client’s door open so the client d. Walks into the walker, puts weight on

can be monitored and the nurse can the hand pieces, and then puts all four

answer the phone call. points of the walker flat on the floor.

60. Nurse Janah is collecting a sputum specimen 62. Nurse Amy has documented an entry
for regarding

culture and sensitivity testing from a client who client care in the client’s medical record. When

has a productive cough. Nurse Janah plans to checking the entry, the nurse realizes that

implement which intervention to obtain the 62

specimen? incorrect information was documented. How

a. Ask the client to expectorate a small does the nurse correct this error?

amount of sputum into the emesis basin. a. Erases the error and writes in the correct

b. Ask the client to obtain the specimen information.

after breakfast. b. Uses correction fluid to cover up the

c. Use a sterile plastic container for incorrect information and writes in the

obtaining the specimen. correct information.

d. Provide tissues for expectoration and c. Draws one line to cross out the incorrect

obtaining the specimen. information and then initials the change.

61. Nurse Ron is observing a male client using a d. Covers up the incorrect information

walker. The nurse determines that the client is completely using a black pen and writes

using the walker correctly if the client: in the correct information

a. Puts all the four points of the walker flat 63. Nurse Ron is assisting with transferring a
client
on the floor, puts weight on the hand
from the operating room table to a stretcher. To
pieces, and then walks into it.
provide safety to the client, the nurse should:
b. Puts weight on the hand pieces, moves
a. Moves the client rapidly from the table
the walker forward, and then walks into
to the stretcher.
it.
b. Uncovers the client completely before
c. Puts weight on the hand pieces, slides
transferring to the stretcher. on a chest X-ray is being prepared for

c. Secures the client safety belts after thoracentesis. The client experiences severe

transferring to the stretcher. dizziness when sitting upright. To provide a safe

d. Instructs the client to move self from the environment, the nurse assists the client to

table to the stretcher. which position for the procedure?

64. Nurse Myrna is providing instructions to a a. Prone with head turned toward the side

nursing assistant assigned to give a bed bath to supported by a pillow.

a
b. Sims’ position with the head of the bed
client who is on contact precautions. Nurse
flat.
Myrna instructs the nursing assistant to use
c. Right side-lying with the head of the bed
which of the following protective items when
elevated 45 degrees.
giving bed bath?
d. Left side-lying with the head of the bed
a. Gown and goggles
elevated 45 degrees.
b. Gown and gloves
67. Nurse John develops methods for data
c. Gloves and shoe protectors
gathering. Which of the following criteria of a
d. Gloves and goggles
good instrument refers to the ability of the
65. Nurse Oliver is caring for a client with
instrument to yield the same results upon its
impaired
repeated administration?
mobility that occurred as a result of a stroke.
The a. Validity
client has right sided arm and leg weakness. The b. Specificity
nurse would suggest that the client use which of c. Sensitivity
the following assistive devices that would d. Reliability
provide the best stability for ambulating? 68. Harry knows that he has to protect the
rights of
a. Crutches
human research subjects. Which of the
b. Single straight-legged cane
following
c. Quad cane
actions of Harry ensures anonymity?
d. Walker
a. Keep the identities of the subject secret
66. A male client with a right pleural effusion
b. Obtain informed consent
noted
c. Provide equal treatment to all the d. Post-test only design

subjects of the study. 72. Cherry notes down ideas that were derived
from
d. Release findings only to the participants
the description of an investigation written by
of the study
the
69. Patient’s refusal to divulge information is a
person who conducted it. Which type of
limitation because it is beyond the control of
reference source refers to this?
Tifanny”. What type of research is appropriate
a. Footnote
for this study?
b. Bibliography
a. Descriptive- correlational
c. Primary source
b. Experiment
d. Endnotes
c. Quasi-experiment
73. When Nurse Trish is providing care to his
d. Historical
patient, she must remember that her duty is
70. Nurse Ronald is aware that the best tool for
bound not to do doing any action that will cause
data
the patient harm. This is the meaning of the
gathering is?
bioethical principle:
a. Interview schedule
a. Non-maleficence
b. Questionnaire
b. Beneficence
c. Use of laboratory data
c. Justice
d. Observation
d. Solidarity
71. Monica is aware that there are times when
only 74. When a nurse in-charge causes an injury to a

manipulation of study variables is possible and female patient and the injury caused becomes

the elements of control or randomization are the proof of the negligent act, the presence of

not attendant. Which type of research is the injury is said to exemplify the principle of:

referred to this? a. Force majeure

a. Field study b. Respondeat superior

b. Quasi-experiment c. Res ipsa loquitor

c. Solomon-Four group design d. Holdover doctrine

63 75. Nurse Myrna is aware that the Board of

Nursing
has quasi-judicial power. An example of this b. Review related literature

power is: c. Formulating and delimiting the research

a. The Board can issue rules and problem

regulations that will govern the practice d. Design the theoretical and conceptual

of nursing framework

b. The Board can investigate violations of 78. The leader of the study knows that certain

the nursing law and code of ethics patients who are in a specialized research
setting
c. The Board can visit a school applying for
tend to respond psychologically to the
a permit in collaboration with CHED
conditions of the study. This referred to as :
d. The Board prepares the board
a. Cause and effect
examinations
b. Hawthorne effect
76. When the license of nurse Krina is revoked,
it c. Halo effect

means that she: d. Horns effect

a. Is no longer allowed to practice the 79. Mary finally decides to use judgment
sampling
profession for the rest of her life
on her research. Which of the following actions
b. Will never have her/his license re-issued
of is correct?
since it has been revoked
a. Plans to include whoever is there during
c. May apply for re-issuance of his/her
his study.
license based on certain conditions
b. Determines the different nationality of
stipulated in RA 9173
patients frequently admitted and
d. Will remain unable to practice
decides to get representations samples
professional nursing
from each.
77. Ronald plans to conduct a research on the
use of c. Assigns numbers for each of the

a new method of pain assessment scale. Which patients, place these in a fishbowl and

of the following is the second step in the draw 10 from it.

conceptualizing phase of the research process? d. Decides to get 20 samples from the

a. Formulating the research hypothesis admitted patients

80. The nursing theorist who developed personnel reporting to her. This principle refers

transcultural nursing theory is: to:

a. Florence Nightingale a. Span of control

b. Madeleine Leininger b. Unity of command

c. Albert Moore c. Downward communication

d. Sr. Callista Roy d. Leader

81. Marion is aware that the sampling method 85. Ensuring that there is an informed consent
that on

gives equal chance to all units in the population the part of the patient before a surgery is done,

to get picked is: illustrates the bioethical principle of:

a. Random a. Beneficence

b. Accidental b. Autonomy

c. Quota c. Veracity

d. Judgment d. Non-maleficence

64 86. Nurse Reese is teaching a female client with

82. John plans to use a Likert Scale to his study peripheral vascular disease about foot care;
to
Nurse Reese should include which instruction?
determine the:
a. Avoid wearing cotton socks.
a. Degree of agreement and disagreement
b. Avoid using a nail clipper to cut toenails.
b. Compliance to expected standards
c. Avoid wearing canvas shoes.
c. Level of satisfaction
d. Avoid using cornstarch on feet.
d. Degree of acceptance
87. A client is admitted with multiple pressure
83. Which of the following theory addresses the
ulcers. When developing the client's diet plan,
four
the nurse should include:
modes of adaptation?
a. Fresh orange slices
a. Madeleine Leininger
b. Steamed broccoli
b. Sr. Callista Roy
c. Ice cream
c. Florence Nightingale
d. Ground beef patties
d. Jean Watson
88. The nurse prepares to administer a cleansing
84. Ms. Garcia is responsible to the number of
enema. What is the most common client thrombophlebitis. The Nurse Betty notes that

position used for this procedure? the client's leg is pain-free, without redness or

a. Lithotomy edema. The nurse's actions reflect which step of

b. Supine the nursing process?

c. Prone a. Assessment

d. Sims’ left lateral b. Diagnosis

89. Nurse Marian is preparing to administer a c. Implementation

blood
d. Evaluation
transfusion. Which action should the nurse take
92. Nursing care for a female client includes
first?
removing elastic stockings once per day. The
a. Arrange for typing and cross matching of
Nurse Betty is aware that the rationale for this
the client’s blood.
intervention?
b. Compare the client’s identification
a. To increase blood flow to the heart
wristband with the tag on the unit of
b. To observe the lower extremities
blood.
c. To allow the leg muscles to stretch and
c. Start an I.V. infusion of normal saline
relax
solution.
d. To permit veins in the legs to fill with
d. Measure the client’s vital signs.
blood.
90. A 65 years old male client requests his
93. Which nursing intervention takes highest
medication at 9 p.m. instead of 10 p.m. so that priority

he can go to sleep earlier. Which type of nursing when caring for a newly admitted client who's

intervention is required? receiving a blood transfusion?

a. Independent a. Instructing the client to report any

b. Dependent itching, swelling, or dyspnea.

c. Interdependent b. Informing the client that the transfusion

d. Intradependent usually take 1 ½ to 2 hours.

91. A female client is to be discharged from an c. Documenting blood administration in

acute
the client care record.
care facility after treatment for right leg
65
d. Assessing the client’s vital signs when position if possible.

the transfusion ends. c. Apply the face mask from the client's

94. A male client complains of abdominal chin up over the nose.

discomfort
d. Loosen the connectors between the
and nausea while receiving tube feedings.
oxygen equipment and humidifier.
Which
97. The maximum transfusion time for a unit of
intervention is most appropriate for this
packed red blood cells (RBCs) is:
problem?
a. 6 hours
a. Give the feedings at room temperature.
b. 4 hours
b. Decrease the rate of feedings and the
c. 3 hours
concentration of the formula.
d. 2 hours
c. Place the client in semi-Fowler's position
98. Nurse Monique is monitoring the
while feeding.
effectiveness
d. Change the feeding container every 12
of a client's drug therapy. When should the
hours.
nurse Monique obtain a blood sample to
95. Nurse Patricia is reconstituting a powdered
measure the trough drug level?
medication in a vial. After adding the solution to
a. 1 hour before administering the next
the powder, she nurse should:
dose.
a. Do nothing.
b. Immediately before administering the
b. Invert the vial and let it stand for 3 to 5
next dose.
minutes.
c. Immediately after administering the
c. Shake the vial vigorously.
next dose.
d. Roll the vial gently between the palms.
d. 30 minutes after administering the next
96. Which intervention should the nurse Trish
dose.
use
99. Nurse May is aware that the main advantage
when administering oxygen by face mask to a
of
female client?
using a floor stock system is:
a. Secure the elastic band tightly around
a. The nurse can implement medication
the client's head.
orders quickly.
b. Assist the client to the semi-Fowler
b. The nurse receives input from the because the area is a highly vascular and can

pharmacist. bleed readily when penetrated by a needle.

c. The system minimizes transcription The bleeding can be difficult to stop.

errors. 3. Answer: (C) “Digoxin 0.125 mg P.O. once

daily”
d. The system reinforces accurate
Rationale: The nurse should always place a
calculations.
zero before a decimal point so that no one
100. Nurse Oliver is assessing a client's
abdomen. misreads the figure, which could result in a

Which finding should the nurse report as dosage error. The nurse should never insert a

abnormal? zero at the end of a dosage that includes a

a. Dullness over the liver. decimal point because this could be misread,

b. Bowel sounds occurring every 10 possibly leading to a tenfold increase in the

seconds. dosage.

c. Shifting dullness over the abdomen. 4. Answer: (A) Ineffective peripheral tissue

d. Vascular sounds heard over the renal perfusion related to venous congestion.

arteries. Rationale: Ineffective peripheral tissue

66 perfusion related to venous congestion takes

Answers and Rationale – Foundation of the highest priority because venous

Professional Nursing Practice inflammation and clot formation impede blood

1. Answer: (D) The actions of a reasonably flow in a client with deep vein thrombosis.

prudent nurse with similar education and 5. Answer: (B) A 44 year-old myocardial

experience. infarction (MI) client who is complaining of

Rationale: The standard of care is determined nausea.

by the average degree of skill, care, and Rationale: Nausea is a symptom of impending

diligence by nurses in similar circumstances. myocardial infarction (MI) and should be

2. Answer: (B) I.M assessed immediately so that treatment can

Rationale: With a platelet count of 22,000/μl, be instituted and further damage to the heart

the clients tends to bleed easily. Therefore, is avoided.

the nurse should avoid using the I.M. route 6. Answer: (C) Check circulation every 15-30
minutes. Rationale: A loop diuretic removes water and,

Rationale: Restraints encircle the limbs, which along with it, sodium and potassium. This may

place the client at risk for circulation being result in hypokalemia, hypovolemia, and

restricted to the distal areas of the hyponatremia.

extremities. Checking the client’s circulation 11. Answer:(A) Have condescending trust and

every 15-30 minutes will allow the nurse to confidence in their subordinates

adjust the restraints before injury from Rationale: Benevolent-authoritative managers

decreased blood flow occurs. pretentiously show their trust and confidence

7. Answer: (A) Prevent stress ulcer to their followers.

Rationale: Curling’s ulcer occurs as a 12. Answer: (A) Provides continuous,

coordinated
generalized stress response in burn patients.
and comprehensive nursing services.
This results in a decreased production of
Rationale: Functional nursing is focused on
mucus and increased secretion of gastric acid.
tasks and activities and not on the care of the
The best treatment for this prophylactic use of
patients.
antacids and H2 receptor blockers.
13. Answer: (B) Standard written order
8. Answer: (D) Continue to monitor and record
Rationale: This is a standard written order.
hourly urine output
Prescribers write a single order for
Rationale: Normal urine output for an adult is
medications given only once. A stat order is
approximately 1 ml/minute (60 ml/hour).
written for medications given immediately for
Therefore, this client's output is normal.
an urgent client problem. A standing order,
Beyond continued evaluation, no nursing
also known as a protocol, establishes
action is warranted.
guidelines for treating a particular disease or
9. Answer: (B) “My ankle feels warm”.
set of symptoms in special care areas such as
Rationale: Ice application decreases pain and
the coronary care unit. Facilities also may
swelling. Continued or increased pain, redness,
institute medication protocols that specifically
and increased warmth are signs of
designate drugs that a nurse may not give.
inflammation that shouldn't occur after ice
14. Answer: (D) Liquid or semi-liquid stools
application
Rationale: Passage of liquid or semi-liquid
10. Answer: (B) Hyperkalemia
stools results from seepage of unformed observing the nail beds.

bowel contents around the impacted stool in 18. Answer: (D) Sudden onset of continuous

the rectum. Clients with fecal impaction don't epigastric and back pain.

pass hard, brown, formed stools because the Rationale: The autodigestion of tissue by the

feces can't move past the impaction. These pancreatic enzymes results in pain from

67 inflammation, edema, and possible

clients typically report the urge to defecate hemorrhage. Continuous, unrelieved epigastric

(although they can't pass stool) and a or back pain reflects the inflammatory process

decreased appetite. in the pancreas.

15. Answer: (C) Pulling the helix up and back 19. Answer: (B) Provide high-protein,
highcarbohydrate
Rationale: To perform an otoscopic
diet.
examination on an adult, the nurse grasps the
Rationale: A positive nitrogen balance is
helix of the ear and pulls it up and back to
important for meeting metabolic needs, tissue
straighten the ear canal. For a child, the nurse
repair, and resistance to infection. Caloric
grasps the helix and pulls it down to straighten
goals may be as high as 5000 calories per day.
the ear canal. Pulling the lobule in any
20. Answer: (A) Blood pressure and pulse rate.
direction wouldn't straighten the ear canal for
Rationale: The baseline must be established to
visualization.
recognize the signs of an anaphylactic or
16. Answer: (A) Protect the irritated skin from
hemolytic reaction to the transfusion.
sunlight.
21. Answer: (D) Immobilize the leg before
Rationale: Irradiated skin is very sensitive and
moving
must be protected with clothing or sunblock.
the client.
The priority approach is the avoidance of
Rationale: If the nurse suspects a fracture,
strong sunlight.
splinting the area before moving the client is
17. Answer: (C) Assist the client in removing
imperative. The nurse should call for
dentures and nail polish.
emergency help if the client is not hospitalized
Rationale: Dentures, hairpins, and combs must
and call for a physician for the hospitalized
be removed. Nail polish must be removed so
client.
that cyanosis can be easily monitored by
22. Answer: (B) Admit the client into a private 500 cc bag of solution is being medicated

room. instead of a 1 liter.

Rationale: The client who has a radiation 27. Answer: (A) 50 cc/ hour

implant is placed in a private room and has a Rationale: A rate of 50 cc/hr. The child is to

limited number of visitors. This reduces the receive 400 cc over a period of 8 hours = 50

exposure of others to the radiation. cc/hr.

23. Answer: (C) Risk for infection 28. Answer: (B) Assess the client for presence of

Rationale: Agranulocytosis is characterized by pain.

a reduced number of leukocytes (leucopenia) Rationale: Assessing the client for pain is a

and neutrophils (neutropenia) in the blood. very important measure. Postoperative pain is

The client is at high risk for infection because an indication of complication. The nurse

of the decreased body defenses against should also assess the client for pain to

microorganisms. Deficient knowledge related provide for the client’s comfort.

to the nature of the disorder may be 29. Answer: (A) BP – 80/60, Pulse – 110 irregular

appropriate diagnosis but is not the priority. Rationale: The classic signs of cardiogenic

24. Answer: (B) Place the client on the left side shock are low blood pressure, rapid and weak
in
irregular pulse, cold, clammy skin, decreased
the Trendelenburg position.
urinary output, and cerebral hypoxia.
Rationale: Lying on the left side may prevent
30. Answer: (A) Take the proper equipment,
air from flowing into the pulmonary veins. The place

Trendelenburg position increases intrathoracic the client in a comfortable position, and

pressure, which decreases the amount of record the appropriate information in the

blood pulled into the vena cava during client’s chart.

aspiration. Rationale: It is a general or comprehensive

25. Answer: (A) Autocratic. statement about the correct procedure, and it

Rationale: The autocratic style of leadership is includes the basic ideas which are found in the

a task-oriented and directive. other options

26. Answer: (D) 2.5 cc 31. Answer: (B) Evaluation

Rationale: 2.5 cc is to be added, because only a 68

Rationale: Evaluation includes observing the uses the fraction method in the following

person, asking questions, and comparing the equation.

patient’s behavioral responses with the 75 mg/X ml = 100 mg/1 ml

expected outcomes. To solve for X, cross-multiply:

32. Answer: (C) History of present illness 75 mg x 1 ml = X ml x 100 mg

Rationale: The history of present illness is the 75 = 100X

single most important factor in assisting the 75/100 = X

health professional in arriving at a diagnosis or 0.75 ml (or ¾ ml) = X

determining the person’s needs. 38. Answer: (D) it’s a measure of effect, not a

33. Answer: (A) Trochanter roll extending from standard measure of weight or quantity.
the
Rationale: An insulin unit is a measure of
crest of the ileum to the mid-thigh.
effect, not a standard measure of weight or
Rationale: A trochanter roll, properly placed,
quantity. Different drugs measured in units
provides resistance to the external rotation of
may have no relationship to one another in
the hip.
quality or quantity.
34. Answer: (C) Stage III
39. Answer: (B) 38.9 °C
Rationale: Clinically, a deep crater or without
Rationale: To convert Fahrenheit degreed to
undermining of adjacent tissue is noted.
Centigrade, use this formula
35. Answer: (A) Second intention healing
°C = (°F – 32) ÷ 1.8
Rationale: When wounds dehisce, they will
°C = (102 – 32) ÷ 1.8
allowed to heal by secondary Intention
°C = 70 ÷ 1.8
36. Answer: (D) Tachycardia
°C = 38.9
Rationale: With an extracellular fluid or plasma
40. Answer: (C) Failing eyesight, especially close
volume deficit, compensatory mechanisms
vision.
stimulate the heart, causing an increase in
Rationale: Failing eyesight, especially close
heart rate.
vision, is one of the first signs of aging in
37. Answer: (A) 0.75
middle life (ages 46 to 64). More frequent
Rationale: To determine the number of
aches and pains begin in the early late years
milliliters the client should receive, the nurse
(ages 65 to 79). Increase in loss of muscle tone
occurs in later years (age 80 and older). 2.1 ml/X gtt = 1 ml/ 15 gtt

41. Answer: (A) Checking and taping all X = 32 gtt/minute, or 32 drops/minute

connections 44. Answer: (A) Clamp the catheter

Rationale: Air leaks commonly occur if the Rationale: If a central venous catheter

system isn’t secure. Checking all connections becomes disconnected, the nurse should

and taping them will prevent air leaks. The immediately apply a catheter clamp, if

chest drainage system is kept lower to available. If a clamp isn’t available, the nurse

promote drainage – not to prevent leaks. can place a sterile syringe or catheter plug in

42. Answer: (A) Check the client’s identification the catheter hub. After cleaning the hub with

band. alcohol or povidone-iodine solution, the nurse

Rationale: Checking the client’s identification must replace the I.V. extension and restart the

band is the safest way to verify a client’s infusion.

identity because the band is assigned on 45. Answer: (D) Auscultation, percussion, and

admission and isn’t be removed at any time. (If palpation.

it is removed, it must be replaced). Asking the Rationale: The correct order of assessment for

client’s name or having the client repeated his examining the abdomen is inspection,

name would be appropriate only for a client auscultation, percussion, and palpation. The

who’s alert, oriented, and able to understand reason for this approach is that the less

what is being said, but isn’t the safe standard intrusive techniques should be performed

of practice. Names on bed aren’t always 69

reliable before the more intrusive techniques.

43. Answer: (B) 32 drops/minute Percussion and palpation can alter natural

Rationale: Giving 1,000 ml over 8 hours is the findings during auscultation.

same as giving 125 ml over 1 hour (60 46. Answer: (D) Ulnar surface of the hand

minutes). Find the number of milliliters per Rationale: The nurse uses the ulnar surface, or

minute as follows: ball, of the hand to assess tactile fremitus,

125/60 minutes = X/1 minute thrills, and vocal vibrations through the chest

60X = 125 = 2.1 ml/minute wall. The fingertips and finger pads best

To find the number of drops per minute: distinguish texture and shape. The dorsal
surface best feels warmth. 50. Answer: (B) To provide support for the client

47. Answer: (C) Formative and family in coping with terminal illness.

Rationale: Formative (or concurrent) Rationale: Hospices provide supportive care

evaluation occurs continuously throughout the for terminally ill clients and their families.

teaching and learning process. One benefit is Hospice care doesn’t focus on counseling

that the nurse can adjust teaching strategies regarding health care costs. Most client

as necessary to enhance learning. Summative, referred to hospices have been treated for

or retrospective, evaluation occurs at the their disease without success and will receive

conclusion of the teaching and learning only palliative care in the hospice.

session. Informative is not a type of 51. Answer: (C) Using normal saline solution to

evaluation. clean the ulcer and applying a protective

48. Answer: (B) Once per year dressing as necessary.

Rationale: Yearly mammograms should begin Rationale: Washing the area with normal

at age 40 and continue for as long as the saline solution and applying a protective

woman is in good health. If health risks, such dressing are within the nurse’s realm of

as family history, genetic tendency, or past interventions and will protect the area. Using a

breast cancer, exist, more frequent povidone-iodine wash and an antibiotic cream

examinations may be necessary. require a physician’s order. Massaging with an

49. Answer: (A) Respiratory acidosis astringent can further damage the skin.

Rationale: The client has a below-normal 52. Answer: (D) Foot

(acidic) blood pH value and an above-normal Rationale: An elastic bandage should be

partial pressure of arterial carbon dioxide applied form the distal area to the proximal

(Paco2) value, indicating respiratory acidosis. area. This method promotes venous return. In

In respiratory alkalosis, the pH value is above this case, the nurse should begin applying the

normal and in the Paco2 value is below bandage at the client’s foot. Beginning at the

normal. In metabolic acidosis, the pH and ankle, lower thigh, or knee does not promote

bicarbonate (Hco3) values are below normal. venous return.

In metabolic alkalosis, the pH and Hco3 values 53. Answer: (B) Hypokalemia

are above normal. Rationale: Insulin administration causes

glucose and potassium to move into the cells, Rationale: Adequate perfusion must be

causing hypokalemia. maintained to all vital organs in order for the

54. Answer: (A) Throbbing headache or client to remain visible as an organ donor. A
dizziness
urine output of 45 ml per hour indicates
Rationale: Headache and dizziness often occur
adequate renal perfusion. Low blood pressure
when nitroglycerin is taken at the beginning of
and delayed capillary refill time are circulatory
therapy. However, the client usually develops
system indicators of inadequate perfusion. A
tolerance
serum pH of 7.32 is acidotic, which adversely
55. Answer: (D) Check the client’s level of
affects all body tissues.
consciousness
58. Answer: (D ) Obtaining the specimen from
Rationale: Determining unresponsiveness is the

the first step assessment action to take. When urinary drainage bag.

a client is in ventricular tachycardia, there is a 70

significant decrease in cardiac output. Rationale: A urine specimen is not taken from

However, checking the unresponsiveness the urinary drainage bag. Urine undergoes

ensures whether the client is affected by the chemical changes while sitting in the bag and

decreased cardiac output. does not necessarily reflect the current client

56. Answer: (B) On the affected side of the status. In addition, it may become
client.
contaminated with bacteria from opening the
Rationale: When walking with clients, the
system.
nurse should stand on the affected side and
59. Answer: (B) Cover the client, place the call
grasp the security belt in the midspine area of
light within reach, and answer the phone call.
the small of the back. The nurse should
Rationale: Because telephone call is an
position the free hand at the shoulder area so
emergency, the nurse may need to answer it.
that the client can be pulled toward the nurse
The other appropriate action is to ask another
in the event that there is a forward fall. The
nurse to accept the call. However, is not one of
client is instructed to look up and outward
the options. To maintain privacy and safety,
rather than at his or her feet.
the nurse covers the client and places the call
57. Answer: (A) Urine output: 45 ml/hr
light within the client’s reach. Additionally, the
client’s door should be closed or the room initials the error. An error is never erased and

curtains pulled around the bathing area. correction fluid is never used in the medical

60. Answer: (C) Use a sterile plastic container for record.

obtaining the specimen. 63. Answer: (C) Secures the client safety belts

Rationale: Sputum specimens for culture and after transferring to the stretcher.

sensitivity testing need to be obtained using Rationale: During the transfer of the client

sterile techniques because the test is done to after the surgical procedure is complete, the

determine the presence of organisms. If the nurse should avoid exposure of the client

procedure for obtaining the specimen is not because of the risk for potential heat loss.

sterile, then the specimen is not sterile, then Hurried movements and rapid changes in the

the specimen would be contaminated and the position should be avoided because these

results of the test would be invalid. predispose the client to hypotension. At the

61. Answer: (A) Puts all the four points of the time of the transfer from the surgery table to

walker flat on the floor, puts weight on the the stretcher, the client is still affected by the

hand pieces, and then walks into it. effects of the anesthesia; therefore, the client

Rationale: When the client uses a walker, the should not move self. Safety belts can prevent

nurse stands adjacent to the affected side. The the client from falling off the stretcher.

client is instructed to put all four points of the 64. Answer: (B) Gown and gloves

walker 2 feet forward flat on the floor before Rationale: Contact precautions require the use

putting weight on hand pieces. This will ensure of gloves and a gown if direct client contact is

client safety and prevent stress cracks in the anticipated. Goggles are not necessary unless

walker. The client is then instructed to move the nurse anticipates the splashes of blood,

the walker forward and walk into it. body fluids, secretions, or excretions may

62. Answer: (C) Draws one line to cross out the occur. Shoe protectors are not necessary.

incorrect information and then initials the 65. Answer: (C) Quad cane

change. Rationale: Crutches and a walker can be

Rationale: To correct an error documented in a difficult to maneuver for a client with

medical record, the nurse draws one line weakness on one side. A cane is better suited

through the incorrect information and then for client with weakness of the arm and leg on
one side. However, the quad cane would the most appropriate for this study because it

provide the most stability because of the studies the variables that could be the

structure of the cane and because a quad cane antecedents of the increased incidence of

has four legs. nosocomial infection.

66. Answer: (D) Left side-lying with the head of 71

the bed elevated 45 degrees. 70. Answer: (C) Use of laboratory data

Rationale: To facilitate removal of fluid from Rationale: Incidence of nosocomial infection is

the chest wall, the client is positioned sitting at best collected through the use of

the edge of the bed leaning over the bedside biophysiologic measures, particularly in vitro

table with the feet supported on a stool. If the measurements, hence laboratory data is

client is unable to sit up, the client is essential.

positioned lying in bed on the unaffected side 71. Answer: (B) Quasi-experiment

with the head of the bed elevated 30 to 45 Rationale: Quasi-experiment is done when

degrees. randomization and control of the variables are

67. Answer: (D) Reliability not possible.

Rationale: Reliability is consistency of the 72. Answer: (C) Primary source

research instrument. It refers to the Rationale: This refers to a primary source

repeatability of the instrument in extracting which is a direct account of the investigation

the same responses upon its repeated done by the investigator. In contrast to this is a

administration. secondary source, which is written by

68. Answer: (A) Keep the identities of the someone other than the original researcher.
subject
73. Answer: (A) Non-maleficence
secret
Rationale: Non-maleficence means do not
Rationale: Keeping the identities of the
cause harm or do any action that will cause
research subject secret will ensure anonymity
any harm to the patient/client. To do good is
because this will hinder providing link between
referred as beneficence.
the information given to whoever is its source.
74. Answer: (C) Res ipsa loquitor
69. Answer: (A) Descriptive- correlational
Rationale: Res ipsa loquitor literally means the
Rationale: Descriptive- correlational study is
thing speaks for itself. This means in
operational terms that the injury caused is the effect of an intervention done to improve the

proof that there was a negligent act. working conditions of the workers on their

75. Answer: (B) The Board can investigate productivity. It resulted to an increased

violations of the nursing law and code of ethics productivity but not due to the intervention

Rationale: Quasi-judicial power means that the but due to the psychological effects of being

Board of Nursing has the authority to observed. They performed differently because

investigate violations of the nursing law and they were under observation.

can issue summons, subpoena or subpoena 79. Answer: (B) Determines the different

duces tecum as needed. nationality of patients frequently admitted and

76. Answer: (C) May apply for re-issuance of decides to get representations samples from

his/her license based on certain conditions each.

stipulated in RA 9173 Rationale: Judgment sampling involves

Rationale: RA 9173 sec. 24 states that for including samples according to the knowledge

equity and justice, a revoked license maybe of the investigator about the participants in
reissued
the study.
provided that the following conditions
80. Answer: (B) Madeleine Leininger
are met: a) the cause for revocation of license
Rationale: Madeleine Leininger developed the
has already been corrected or removed; and,
theory on transcultural theory based on her
b) at least four years has elapsed since the
observations on the behavior of selected
license has been revoked.
people within a culture.
77. Answer: (B) Review related literature
81. Answer: (A) Random
Rationale: After formulating and delimiting the
Rationale: Random sampling gives equal
research problem, the researcher conducts a
chance for all the elements in the population
review of related literature to determine the
to be picked as part of the sample.
extent of what has been done on the study by
82. Answer: (A) Degree of agreement and
previous researchers.
disagreement
78. Answer: (B) Hawthorne effect
Rationale: Likert scale is a 5-point summated
Rationale: Hawthorne effect is based on the
scale used to determine the degree of
study of Elton Mayo and company about the
agreement or disagreement of the
respondents to a statement in a study Rationale: Meat is an excellent source of

83. Answer: (B) Sr. Callista Roy complete protein, which this client needs to

Rationale: Sr. Callista Roy developed the repair the tissue breakdown caused by

Adaptation Model which involves the pressure ulcers. Oranges and broccoli supply

physiologic mode, self-concept mode, role vitamin C but not protein. Ice cream supplies

function mode and dependence mode. only some incomplete protein, making it less

84. Answer: (A) Span of control helpful in tissue repair.

Rationale: Span of control refers to the 88. Answer: (D) Sims’ left lateral

number of workers who report directly to a Rationale: The Sims' left lateral position is the

manager. most common position used to administer a

85. Answer: (B) Autonomy cleansing enema because it allows gravity to

Rationale: Informed consent means that the aid the flow of fluid along the curve of the

patient fully understands about the surgery, sigmoid colon. If the client can't assume this

including the risks involved and the alternative position nor has poor sphincter control, the

solutions. In giving consent it is done with full dorsal recumbent or right lateral position may

knowledge and is given freely. The action of be used. The supine and prone positions are

allowing the patient to decide whether a inappropriate and uncomfortable for the

surgery is to be done or not exemplifies the client.

bioethical principle of autonomy. 89. Answer: (A) Arrange for typing and cross

86. Answer: (C) Avoid wearing canvas shoes. matching of the client’s blood.

Rationale: The client should be instructed to Rationale: The nurse first arranges for typing

avoid wearing canvas shoes. Canvas shoes and cross matching of the client's blood to

cause the feet to perspire, which may, in turn, ensure compatibility with donor blood. The

cause skin irritation and breakdown. Both other options, although appropriate when

cotton and cornstarch absorb perspiration. preparing to administer a blood transfusion,

72 come later.

The client should be instructed to cut toenails 90. Answer: (A) Independent

straight across with nail clippers. Rationale: Nursing interventions are classified

87. Answer: (D) Ground beef patties as independent, interdependent, or

dependent. Altering the drug schedule to the heart. When the stockings are in place, the

coincide with the client's daily routine leg muscles can still stretch and relax, and the

represents an independent intervention, veins can fill with blood.

whereas consulting with the physician and 93. Answer :(A) Instructing the client to report
any
pharmacist to change a client's medication
itching, swelling, or dyspnea.
because of adverse reactions represents an
Rationale: Because administration of blood or
interdependent intervention. Administering an
blood products may cause serious adverse
already-prescribed drug on time is a
effects such as allergic reactions, the nurse
dependent intervention. An intradependent
must monitor the client for these effects. Signs
nursing intervention doesn't exist.
and symptoms of life-threatening allergic
91. Answer: (D) Evaluation
reactions include itching, swelling, and
Rationale: The nursing actions described
dyspnea. Although the nurse should inform
constitute evaluation of the expected
the client of the duration of the transfusion
outcomes. The findings show that the
and should document its administration, these
expected outcomes have been achieved.
actions are less critical to the client's
Assessment consists of the client's history,
immediate health. The nurse should assess
physical examination, and laboratory studies.
vital signs at least hourly during the
Analysis consists of considering assessment
transfusion.
information to derive the appropriate nursing
94. Answer: (B) Decrease the rate of feedings
diagnosis. Implementation is the phase of the
and
nursing process where the nurse puts the plan
the concentration of the formula.
of care into action.
Rationale: Complaints of abdominal
92. Answer: (B) To observe the lower
discomfort and nausea are common in clients
extremities
receiving tube feedings. Decreasing the rate of
Rationale: Elastic stockings are used to
the feeding and the concentration of the
promote venous return. The nurse needs to
formula should decrease the client's
remove them once per day to observe the
discomfort. Feedings are normally given at
condition of the skin underneath the stockings.
room temperature to minimize abdominal
Applying the stockings increases blood flow to
cramping. To prevent aspiration during Rationale: A unit of packed RBCs may be given

feeding, the head of the client's bed should be over a period of between 1 and 4 hours. It

elevated at least 30 degrees. Also, to prevent shouldn't infuse for longer than 4 hours

bacterial growth, feeding containers should be because the risk of contamination and sepsis

routinely changed every 8 to 12 hours. increases after that time. Discard or return to

95. Answer: (D) Roll the vial gently between the the blood bank any blood not given within this

palms. time, according to facility policy.

Rationale: Rolling the vial gently between the 98. Answer: (B) Immediately before
administering
palms produces heat, which helps dissolve the
the next dose.
medication. Doing nothing or inverting the vial
Rationale: Measuring the blood drug
wouldn't help dissolve the medication. Shaking
concentration helps determine whether the
the vial vigorously could cause the medication
dosing has achieved the therapeutic goal. For
to break down, altering its action.
measurement of the trough, or lowest, blood
96. Answer: (B) Assist the client to the semi-
level of a drug, the nurse draws a blood
Fowler position if possible.
sample immediately before administering the
Rationale: By assisting the client to the semi-
next dose. Depending on the drug's duration
Fowler position, the nurse promotes easier
of action and half-life, peak blood drug levels
chest expansion, breathing, and oxygen intake.
typically are drawn after administering the
73
next dose.
The nurse should secure the elastic band so
99. Answer: (A) The nurse can implement
that the face mask fits comfortably and snugly
medication orders quickly.
rather than tightly, which could lead to
Rationale: A floor stock system enables the
irritation. The nurse should apply the face
nurse to implement medication orders quickly.
mask from the client's nose down to the chin
It doesn't allow for pharmacist input, nor does
— not vice versa. The nurse should check the
it minimize transcription errors or reinforce
connectors between the oxygen equipment
accurate calculations.
and humidifier to ensure that they're airtight;
100. Answer: (C) Shifting dullness over the
loosened connectors can cause loss of oxygen.
abdomen.
97. Answer: (B) 4 hours
Rationale: Shifting dullness over the abdomen d. History of diabetes mellitus

indicates ascites, an abnormal finding. The 3. Nurse Hazel is preparing to care for a client
who
other options are normal abdominal findings.
is newly admitted to the hospital with a possible
74
diagnosis of ectopic pregnancy. Nurse Hazel
TEST II - Community Health Nursing and Care of
the develops a plan of care for the client and

Mother and Child determines that which of the following nursing

1. May arrives at the health care clinic and tells actions is the priority?
the
a. Monitoring weight
nurse that her last menstrual period was 9
b. Assessing for edema
weeks ago. She also tells the nurse that a home
c. Monitoring apical pulse
pregnancy test was positive but she began to
d. Monitoring temperature
have mild cramps and is now having moderate
4. Nurse Oliver is teaching a diabetic pregnant
vaginal bleeding. During the physical
client about nutrition and insulin needs during
examination of the client, the nurse notes that
pregnancy. The nurse determines that the client
May has a dilated cervix. The nurse determines
understands dietary and insulin needs if the
that May is experiencing which type of
client states that the second half of pregnancy
abortion?
requires:
a. Inevitable
a. Decreased caloric intake
b. Incomplete
b. Increased caloric intake
c. Threatened
c. Decreased Insulin
d. Septic
d. Increase Insulin
2. Nurse Reese is reviewing the record of a
5. Nurse Michelle is assessing a 24 year old
pregnant client for her first prenatal visit. Which
client
of the following data, if noted on the client’s
with a diagnosis of hydatidiform mole. She is
record, would alert the nurse that the client is at
aware that one of the following is unassociated
risk for a spontaneous abortion?
with this condition?
a. Age 36 years
a. Excessive fetal activity.
b. History of syphilis
b. Larger than normal uterus for
c. History of genital herpes
gestational age. a. Contractions every 1 ½ minutes lasting

c. Vaginal bleeding 70-80 seconds.

d. Elevated levels of human chorionic b. Maternal temperature 101.2

gonadotropin. c. Early decelerations in the fetal heart

6. A pregnant client is receiving magnesium rate.

sulfate
d. Fetal heart rate baseline 140-160 bpm.
for severe pregnancy induced hypertension
9. Calcium gluconate is being administered to a
(PIH). The clinical findings that would warrant
client with pregnancy induced hypertension
use of the antidote , calcium gluconate is:
(PIH). A nursing action that must be initiated as
a. Urinary output 90 cc in 2 hours.
the plan of care throughout injection of the
b. Absent patellar reflexes. drug

c. Rapid respiratory rate above 40/min. is:

d. Rapid rise in blood pressure. a. Ventilator assistance

7. During vaginal examination of Janah who is in b. CVP readings

labor, the presenting part is at station plus two. c. EKG tracings

Nurse, correctly interprets it as: d. Continuous CPR

a. Presenting part is 2 cm above the plane 10. A trial for vaginal delivery after an earlier

of the ischial spines. caesarean, would likely to be given to a gravida,

b. Biparietal diameter is at the level of the who had:

ischial spines. 75

c. Presenting part in 2 cm below the plane a. First low transverse cesarean was for

of the ischial spines. active herpes type 2 infections; vaginal

d. Biparietal diameter is 2 cm above the culture at 39 weeks pregnancy was

ischial spines. positive.

8. A pregnant client is receiving oxytocin b. First and second caesareans were for
(Pitocin)
cephalopelvic disproportion.
for induction of labor. A condition that warrant
c. First caesarean through a classic incision
the nurse in-charge to discontinue I.V. infusion
as a result of severe fetal distress.
of Pitocin is:
d. First low transverse caesarean was for
breech position. Fetus in this pregnancy feeding.

is in a vertex presentation. 14. Nurse Hazel is teaching a mother who plans

to
11. Nurse Ryan is aware that the best initial
discontinue breast feeding after 5 months. The
approach when trying to take a crying toddler’s
nurse should advise her to include which foods
temperature is:
in her infant’s diet?
a. Talk to the mother first and then to the
a. Skim milk and baby food.
toddler.
b. Whole milk and baby food.
b. Bring extra help so it can be done
c. Iron-rich formula only.
quickly.
d. Iron-rich formula and baby food.
c. Encourage the mother to hold the child.
15. Mommy Linda is playing with her infant,
d. Ignore the crying and screaming.
who is
12. Baby Tina a 3 month old infant just had a
sitting securely alone on the floor of the clinic.
cleft lip
The mother hides a toy behind her back and the
and palate repair. What should the nurse do to
infant looks for it. The nurse is aware that
prevent trauma to operative site?
estimated age of the infant would be:
a. Avoid touching the suture line, even
a. 6 months
when cleaning.
b. 4 months
b. Place the baby in prone position.
c. 8 months
c. Give the baby a pacifier.
d. 10 months
d. Place the infant’s arms in soft elbow
16. Which of the following is the most
restraints.
prominent
13. Which action should nurse Marian include in
feature of public health nursing?
the
a. It involves providing home care to sick
care plan for a 2 month old with heart failure?
people who are not confined in the
a. Feed the infant when he cries.
hospital.
b. Allow the infant to rest before feeding.
b. Services are provided free of charge to
c. Bathe the infant and administer
people within the catchments area.
medications before feeding.
c. The public health nurse functions as part
d. Weigh and bathe the infant before
of a team providing a public health
nursing services. the RHU need?

d. Public health nursing focuses on a. 1

preventive, not curative, services. b. 2

17. When the nurse determines whether c. 3

resources
d. The RHU does not need any more
were maximized in implementing Ligtas Tigdas,
midwife item.
she is evaluating
76
a. Effectiveness
21. According to Freeman and Heinrich,
b. Efficiency community

c. Adequacy health nursing is a developmental service.

Which
d. Appropriateness
of the following best illustrates this statement?
18. Vangie is a new B.S.N. graduate. She wants
to a. The community health nurse

become a Public Health Nurse. Where should continuously develops himself

she apply? personally and professionally.

a. Department of Health b. Health education and community

b. Provincial Health Office organizing are necessary in providing

c. Regional Health Office community health services.

d. Rural Health Unit c. Community health nursing is intended

19. Tony is aware the Chairman of the Municipal primarily for health promotion and

Health Board is: prevention and treatment of disease.

a. Mayor d. The goal of community health nursing is

b. Municipal Health Officer to provide nursing services to people in

c. Public Health Nurse their own places of residence.

d. Any qualified physician 22. Nurse Tina is aware that the disease
declared
20. Myra is the public health nurse in a
municipality through Presidential Proclamation No. 4 as a

with a total population of about 20,000. There target for eradication in the Philippines is?

are 3 rural health midwives among the RHU a. Poliomyelitis

personnel. How many more midwife items will b. Measles

c. Rabies labor and delivery area. Which condition would

d. Neonatal tetanus place the client at risk for disseminated

23. May knows that the step in community intravascular coagulation (DIC)?

organizing that involves training of potential a. Intrauterine fetal death.

leaders in the community is: b. Placenta accreta.

a. Integration c. Dysfunctional labor.

b. Community organization d. Premature rupture of the membranes.

c. Community study 27. A fullterm client is in labor. Nurse Betty is

aware
d. Core group formation
that the fetal heart rate would be:
24. Beth a public health nurse takes an active
role in a. 80 to 100 beats/minute

community participation. What is the primary b. 100 to 120 beats/minute

goal of community organizing? c. 120 to 160 beats/minute

a. To educate the people regarding d. 160 to 180 beats/minute

community health problems 28. The skin in the diaper area of a 7 month old

b. To mobilize the people to resolve infant is excoriated and red. Nurse Hazel should

community health problems instruct the mother to:

c. To maximize the community’s resources a. Change the diaper more often.

in dealing with health problems. b. Apply talc powder with diaper changes.

d. To maximize the community’s resources c. Wash the area vigorously with each

in dealing with health problems. diaper change.

25. Tertiary prevention is needed in which stage d. Decrease the infant’s fluid intake to
of
decrease saturating diapers.
the natural history of disease?
29. Nurse Carla knows that the common cardiac
a. Pre-pathogenesis
anomalies in children with Down Syndrome
b. Pathogenesis (trisomy

c. Prodromal 21) is:

d. Terminal a. Atrial septal defect

26. The nurse is caring for a primigravid client in b. Pulmonic stenosis

the
c. Ventricular septal defect a. Metabolic alkalosis

d. Endocardial cushion defect b. Respiratory acidosis

30. Malou was diagnosed with severe c. Mastitis

preeclampsia
d. Physiologic anemia
is now receiving I.V. magnesium sulfate. The
34. Nurse Lynette is working in the triage area of
adverse effects associated with magnesium an

sulfate is: emergency department. She sees that several

a. Anemia pediatric clients arrive simultaneously. The

client
b. Decreased urine output
who needs to be treated first is:
c. Hyperreflexia
a. A crying 5 year old child with a
d. Increased respiratory rate
laceration on his scalp.
31. A 23 year old client is having her menstrual
b. A 4 year old child with a barking coughs
period every 2 weeks that last for 1 week. This
and flushed appearance.
type of menstrual pattern is bets defined by:
c. A 3 year old child with Down syndrome
a. Menorrhagia
who is pale and asleep in his mother’s
b. Metrorrhagia
arms.
c. Dyspareunia
d. A 2 year old infant with stridorous
d. Amenorrhea
breath sounds, sitting up in his mother’s
77
arms and drooling.
32. Jannah is admitted to the labor and delivery
35. Maureen in her third trimester arrives at the
unit. The critical laboratory result for this client
emergency room with painless vaginal bleeding.
would be:
Which of the following conditions is suspected?
a. Oxygen saturation
a. Placenta previa
b. Iron binding capacity
b. Abruptio placentae
c. Blood typing
c. Premature labor
d. Serum Calcium
d. Sexually transmitted disease
33. Nurse Gina is aware that the most common
36. A young child named Richard is suspected of
condition found during the second-trimester of
having pinworms. The community nurse collects
pregnancy is:
a stool specimen to confirm the diagnosis. The jelly most during the middle of my

nurse should schedule the collection of this menstrual cycle”.

specimen for: 39. Hypoxia is a common complication of

a. Just before bedtime laryngotracheobronchitis. Nurse Oliver should

b. After the child has been bathe frequently assess a child with

c. Any time during the day laryngotracheobronchitis for:

d. Early in the morning a. Drooling

37. In doing a child’s admission assessment, b. Muffled voice

Nurse
c. Restlessness
Betty should be alert to note which signs or
d. Low-grade fever
symptoms of chronic lead poisoning?
40. How should Nurse Michelle guide a child
a. Irritability and seizures who is

b. Dehydration and diarrhea blind to walk to the playroom?

c. Bradycardia and hypotension a. Without touching the child, talk

d. Petechiae and hematuria continuously as the child walks down the

38. To evaluate a woman’s understanding about hall.

the
b. Walk one step ahead, with the child’s
use of diaphragm for family planning, Nurse
hand on the nurse’s elbow.
Trish asks her to explain how she will use the
c. Walk slightly behind, gently guiding the
appliance. Which response indicates a need for
child forward.
further health teaching?
d. Walk next to the child, holding the
a. “I should check the diaphragm carefully
child’s hand.
for holes every time I use it”
41. When assessing a newborn diagnosed with
b. “I may need a different size of
ductus arteriosus, Nurse Olivia should expect
diaphragm if I gain or lose weight more
that the child most likely would have an:
than 20 pounds”
a. Loud, machinery-like murmur.
c. “The diaphragm must be left in place for
b. Bluish color to the lips.
atleast 6 hours after intercourse”
c. Decreased BP reading in the upper
d. “I really need to use the diaphragm and
extremities
d. Increased BP reading in the upper c. Laundry detergent

extremities. d. Powder with cornstarch

42. The reason nurse May keeps the neonate in 45. During tube feeding, how far above an
a infant’s

neutral thermal environment is that when a stomach should the nurse hold the syringe with

78 formula?

newborn becomes too cool, the neonate a. 6 inches

requires: b. 12 inches

a. Less oxygen, and the newborn’s c. 18 inches

metabolic rate increases. d. 24 inches

b. More oxygen, and the newborn’s 46. In a mothers’ class, Nurse Lhynnete
discussed
metabolic rate decreases.
childhood diseases such as chicken pox. Which
c. More oxygen, and the newborn’s
of the following statements about chicken pox is
metabolic rate increases.
correct?
d. Less oxygen, and the newborn’s
a. The older one gets, the more susceptible
metabolic rate decreases.
he becomes to the complications of
43. Before adding potassium to an infant’s I.V.
line, chicken pox.

Nurse Ron must be sure to assess whether this b. A single attack of chicken pox will

infant has: prevent future episodes, including

a. Stable blood pressure conditions such as shingles.

b. Patant fontanelles c. To prevent an outbreak in the

c. Moro’s reflex community, quarantine may be imposed

d. Voided by health authorities.

44. Nurse Carla should know that the most d. Chicken pox vaccine is best given when
common
there is an impending outbreak in the
causative factor of dermatitis in infants and
community.
younger children is:
47. Barangay Pinoy had an outbreak of German
a. Baby oil
measles. To prevent congenital rubella, what is
b. Baby lotion
the BEST advice that you can give to women in a. Hepatitis A

the first trimester of pregnancy in the barangay b. Hepatitis B

Pinoy? c. Tetanus

a. Advise them on the signs of German d. Leptospirosis

measles. 50. Mickey a 3-year old client was brought to

the
b. Avoid crowded places, such as markets
health center with the chief complaint of severe
and movie houses.
diarrhea and the passage of “rice water” stools.
c. Consult at the health center where
The client is most probably suffering from which
rubella vaccine may be given.
condition?
d. Consult a physician who may give them
a. Giardiasis
rubella immunoglobulin.
b. Cholera
48. Myrna a public health nurse knows that to
c. Amebiasis
determine possible sources of sexually
d. Dysentery
transmitted infections, the BEST method that
51. The most prevalent form of meningitis
may be undertaken is:
among
a. Contact tracing
children aged 2 months to 3 years is caused by
b. Community survey
which microorganism?
c. Mass screening tests
a. Hemophilus influenzae
d. Interview of suspects
b. Morbillivirus
49. A 33-year old female client came for
79
consultation at the health center with the chief
c. Steptococcus pneumoniae
complaint of fever for a week. Accompanying
d. Neisseria meningitidis
symptoms were muscle pains and body malaise.
52. The student nurse is aware that the
A week after the start of fever, the client noted
pathognomonic sign of measles is Koplik’s spot
yellowish discoloration of his sclera. History
and you may see Koplik’s spot by inspecting the:
showed that he waded in flood waters about 2
a. Nasal mucosa
weeks before the onset of symptoms. Based on
b. Buccal mucosa
her history, which disease condition will you
c. Skin on the abdomen
suspect?
d. Skin on neck biological used in Expanded Program on

53. Angel was diagnosed as having Dengue Immunization (EPI) should NOT be stored in the
fever.
freezer?
You will say that there is slow capillary refill
a. DPT
when the color of the nailbed that you pressed
b. Oral polio vaccine
does not return within how many seconds?
c. Measles vaccine
a. 3 seconds
d. MMR
b. 6 seconds
57. It is the most effective way of controlling
c. 9 seconds
schistosomiasis in an endemic area?
d. 10 seconds
a. Use of molluscicides
54. In Integrated Management of Childhood
b. Building of foot bridges
Illness,
c. Proper use of sanitary toilets
the nurse is aware that the severe conditions
d. Use of protective footwear, such as
generally require urgent referral to a hospital.
rubber boots
Which of the following severe conditions DOES
58. Several clients is newly admitted and
NOT always require urgent referral to a
diagnosed
hospital?
with leprosy. Which of the following clients
a. Mastoiditis
should be classified as a case of multibacillary
b. Severe dehydration
leprosy?
c. Severe pneumonia
a. 3 skin lesions, negative slit skin smear
d. Severe febrile disease
b. 3 skin lesions, positive slit skin smear
55. Myrna a public health nurse will conduct
c. 5 skin lesions, negative slit skin smear
outreach immunization in a barangay Masay
d. 5 skin lesions, positive slit skin smear
with a population of about 1500. The estimated
59. Nurses are aware that diagnosis of leprosy is
number of infants in the barangay would be:
highly dependent on recognition of symptoms.
a. 45 infants
Which of the following is an early sign of
b. 50 infants
leprosy?
c. 55 infants
a. Macular lesions
d. 65 infants
b. Inability to close eyelids
56. The community nurse is aware that the
c. Thickened painful nerves focusing on menu planning for her child.

d. Sinking of the nosebridge d. Assess and treat the child for health

60. Marie brought her 10 month old infant for problems like infections and intestinal

consultation because of fever, started 4 days parasitism.

prior to consultation. In determining malaria 80

risk, what will you do? 63. Gina is using Oresol in the management of

a. Perform a tourniquet test. diarrhea of her 3-year old child. She asked you

b. Ask where the family resides. what to do if her child vomits. As a nurse you
will
c. Get a specimen for blood smear.
tell her to:
d. Ask if the fever is present every day.
a. Bring the child to the nearest hospital
61. Susie brought her 4 years old daughter to
the for further assessment.

RHU because of cough and colds. Following the b. Bring the child to the health center for

IMCI assessment guide, which of the following is intravenous fluid therapy.

a danger sign that indicates the need for urgent c. Bring the child to the health center for

referral to a hospital? assessment by the physician.

a. Inability to drink d. Let the child rest for 10 minutes then

b. High grade fever continue giving Oresol more slowly.

c. Signs of severe dehydration 64. Nikki a 5-month old infant was brought by
his
d. Cough for more than 30 days
mother to the health center because of diarrhea
62. Jimmy a 2-year old child revealed “baggy
pants”. for 4 to 5 times a day. Her skin goes back slowly

As a nurse, using the IMCI guidelines, how will after a skin pinch and her eyes are sunken.
Using
you manage Jimmy?
the IMCI guidelines, you will classify this infant
a. Refer the child urgently to a hospital for
in
confinement.
which category?
b. Coordinate with the social worker to
a. No signs of dehydration
enroll the child in a feeding program.
b. Some dehydration
c. Make a teaching plan for the mother,
c. Severe dehydration
d. The data is insufficient. nutrient needs only up to:

65. Chris a 4-month old infant was brought by a. 5 months

her
b. 6 months
mother to the health center because of cough.
c. 1 year
His respiratory rate is 42/minute. Using the
d. 2 years
Integrated Management of Child Illness (IMCI)
69. Nurse Ron is aware that the gestational age
guidelines of assessment, his breathing is of a

considered as: conceptus that is considered viable (able to live

a. Fast outside the womb) is:

b. Slow a. 8 weeks

c. Normal b. 12 weeks

d. Insignificant c. 24 weeks

66. Maylene had just received her 4th dose of d. 32 weeks

tetanus toxoid. She is aware that her baby will 70. When teaching parents of a neonate the
proper
have protection against tetanus for
position for the neonate’s sleep, the nurse
a. 1 year
Patricia stresses the importance of placing the
b. 3 years
neonate on his back to reduce the risk of which
c. 5 years
of the following?
d. Lifetime
a. Aspiration
67. Nurse Ron is aware that unused BCG should
be b. Sudden infant death syndrome (SIDS)

discarded after how many hours of c. Suffocation

reconstitution? d. Gastroesophageal reflux (GER)

a. 2 hours 71. Which finding might be seen in baby James

a
b. 4 hours
neonate suspected of having an infection?
c. 8 hours
a. Flushed cheeks
d. At the end of the day
b. Increased temperature
68. The nurse explains to a breastfeeding
mother c. Decreased temperature

that breast milk is sufficient for all of the baby’s d. Increased activity level
72. Baby Jenny who is small-for-gestation is at 75. Which symptom would indicate the Baby

increased risk during the transitional period for Alexandra was adapting appropriately to
extrauterine
which complication?
life without difficulty?
a. Anemia probably due to chronic fetal
a. Nasal flaring
hyposia
b. Light audible grunting
b. Hyperthermia due to decreased
c. Respiratory rate 40 to 60
glycogen stores
breaths/minute
c. Hyperglycemia due to decreased
d. Respiratory rate 60 to 80
glycogen stores
breaths/minute
d. Polycythemia probably due to chronic
76. When teaching umbilical cord care for
fetal hypoxia
Jennifer a
73. Marjorie has just given birth at 42 weeks’
new mother, the nurse Jenny would include
gestation. When the nurse assessing the
which information?
neonate, which physical finding is expected?
a. Apply peroxide to the cord with each
a. A sleepy, lethargic baby
diaper change
b. Lanugo covering the body
b. Cover the cord with petroleum jelly after
c. Desquamation of the epidermis
bathing
d. Vernix caseosa covering the body
c. Keep the cord dry and open to air
81
d. Wash the cord with soap and water each
74. After reviewing the Myrna’s maternal history
day during a tub bath.
of
77. Nurse John is performing an assessment on
magnesium sulfate during labor, which
a
condition
neonate. Which of the following findings is
would nurse Richard anticipate as a potential
considered common in the healthy neonate?
problem in the neonate?
a. Simian crease
a. Hypoglycemia
b. Conjunctival hemorrhage
b. Jitteriness
c. Cystic hygroma
c. Respiratory depression
d. Bulging fontanelle
d. Tachycardia
78. Dr. Esteves decides to artificially rupture the
membranes of a mother who is on labor. c. Instructing the client on the use of sitz

Following this procedure, the nurse Hazel baths if ordered.

checks
d. Instructing the client about the
the fetal heart tones for which the following
importance of perineal (kegel) exercises.
reasons?
81. A pregnant woman accompanied by her
a. To determine fetal well-being.
husband, seeks admission to the labor and
b. To assess for prolapsed cord
delivery area. She states that she's in labor and
c. To assess fetal position
says she attended the facility clinic for prenatal
d. To prepare for an imminent delivery.
care. Which question should the nurse Oliver
79. Which of the following would be least likely ask
to
her first?
indicate anticipated bonding behaviors by new
a. “Do you have any chronic illnesses?”
parents?
b. “Do you have any allergies?”
a. The parents’ willingness to touch and
c. “What is your expected due date?”
hold the new born.
d. “Who will be with you during labor?”
b. The parent’s expression of interest
82. A neonate begins to gag and turns a dusky
about the size of the new born. color.

c. The parents’ indication that they want to What should the nurse do first?

see the newborn. a. Calm the neonate.

d. The parents’ interactions with each b. Notify the physician.

other. c. Provide oxygen via face mask as ordered

80. Following a precipitous delivery, d. Aspirate the neonate’s nose and mouth
examination of
with a bulb syringe.
the client's vagina reveals a fourth-degree
83. When a client states that her "water broke,"
laceration. Which of the following would be
which of the following actions would be
contraindicated when caring for this client?
inappropriate for the nurse to do?
a. Applying cold to limit edema during the
a. Observing the pooling of straw-colored
first 12 to 24 hours.
fluid.
b. Instructing the client to use two or more
b. Checking vaginal discharge with nitrazine
peripads to cushion the area.
paper. individual twins will grow appropriately and at

c. Conducting a bedside ultrasound for an the same rate as singletons until how many

amniotic fluid index. weeks?

d. Observing for flakes of vernix in the a. 16 to 18 weeks

vaginal discharge. b. 18 to 22 weeks

84. A baby girl is born 8 weeks premature. At c. 30 to 32 weeks

birth,
d. 38 to 40 weeks
she has no spontaneous respirations but is
87. Which of the following classifications applies
82 to

successfully resuscitated. Within several hours monozygotic twins for whom the cleavage of
the
she develops respiratory grunting, cyanosis,
fertilized ovum occurs more than 13 days after
tachypnea, nasal flaring, and retractions. She's
fertilization?
diagnosed with respiratory distress syndrome,
a. conjoined twins
intubated, and placed on a ventilator. Which
b. diamniotic dichorionic twins
nursing action should be included in the baby's
c. diamniotic monochorionic twin
plan of care to prevent retinopathy of
d. monoamniotic monochorionic twins
prematurity?
88. Tyra experienced painless vaginal bleeding
a. Cover his eyes while receiving oxygen.
has
b. Keep her body temperature low.
just been diagnosed as having a placenta previa.
c. Monitor partial pressure of oxygen
Which of the following procedures is usually
(Pao2) levels.
performed to diagnose placenta previa?
d. Humidify the oxygen.
a. Amniocentesis
85. Which of the following is normal newborn
b. Digital or speculum examination
calorie intake?
c. External fetal monitoring
a. 110 to 130 calories per kg.
d. Ultrasound
b. 30 to 40 calories per lb of body weight.
89. Nurse Arnold knows that the following
c. At least 2 ml per feeding changes

d. 90 to 100 calories per kg in respiratory functioning during pregnancy is

86. Nurse John is knowledgeable that usually considered normal:

a. Increased tidal volume magnesium toxicity?

b. Increased expiratory volume a. Calcium gluconate (Kalcinate)

c. Decreased inspiratory capacity b. Hydralazine (Apresoline)

d. Decreased oxygen consumption c. Naloxone (Narcan)

90. Emily has gestational diabetes and it is d. Rho (D) immune globulin (RhoGAM)
usually
94. Marlyn is screened for tuberculosis during
managed by which of the following therapy? her

a. Diet first prenatal visit. An intradermal injection of

b. Long-acting insulin purified protein derivative (PPD) of the

c. Oral hypoglycemic tuberculin bacilli is given. She is considered to

d. Oral hypoglycemic drug and insulin have a positive test for which of the following

91. Magnesium sulfate is given to Jemma with results?

preeclampsia to prevent which of the following a. An indurated wheal under 10 mm in

condition? diameter appears in 6 to 12 hours.

a. Hemorrhage b. An indurated wheal over 10 mm in

b. Hypertension diameter appears in 48 to 72 hours.

c. Hypomagnesemia c. A flat circumcised area under 10 mm in

d. Seizure diameter appears in 6 to 12 hours.

92. Cammile with sickle cell anemia has an d. A flat circumcised area over 10 mm in
increased
diameter appears in 48 to 72 hours.
risk for having a sickle cell crisis during
95. Dianne, 24 year-old is 27 weeks’ pregnant
pregnancy. Aggressive management of a sickle
arrives at her physician’s office with complaints
cell crisis includes which of the following
of fever, nausea, vomiting, malaise, unilateral
measures?
83
a. Antihypertensive agents
flank pain, and costovertebral angle tenderness.
b. Diuretic agents
Which of the following diagnoses is most likely?
c. I.V. fluids
a. Asymptomatic bacteriuria
d. Acetaminophen (Tylenol) for pain
b. Bacterial vaginosis
93. Which of the following drugs is the antidote
c. Pyelonephritis
for
d. Urinary tract infection (UTI) c. A flattened nose, small eyes, and thin

96. Rh isoimmunization in a pregnant client lips.

develops during which of the following d. Congenital defects such as limb

conditions? anomalies.

a. Rh-positive maternal blood crosses into 99. The uterus returns to the pelvic cavity in
which
fetal blood, stimulating fetal antibodies.
of the following time frames?
b. Rh-positive fetal blood crosses into
a. 7th to 9th day postpartum.
maternal blood, stimulating maternal
b. 2 weeks postpartum.
antibodies.
c. End of 6th week postpartum.
c. Rh-negative fetal blood crosses into
d. When the lochia changes to alba.
maternal blood, stimulating maternal
100. Maureen, a primigravida client, age 20, has
antibodies.
just completed a difficult, forceps-assisted
d. Rh-negative maternal blood crosses into
delivery of twins. Her labor was unusually
fetal blood, stimulating fetal antibodies.
long and required oxytocin (Pitocin)
97. To promote comfort during labor, the nurse
John augmentation. The nurse who's caring for her

advises a client to assume certain positions and should stay alert for:

avoid others. Which position may cause a. Uterine inversion

maternal hypotension and fetal hypoxia? b. Uterine atony

a. Lateral position c. Uterine involution

b. Squatting position d. Uterine discomfort

c. Supine position 84

d. Standing position Answers and Rationale – Community Health

98. Celeste who used heroin during her Nursing and Care of the Mother and Child
pregnancy
1. Answer: (A) Inevitable
delivers a neonate. When assessing the
Rationale: An inevitable abortion is termination
neonate,
of pregnancy that cannot be prevented.
the nurse Lhynnette expects to find:
Moderate to severe bleeding with mild
a. Lethargy 2 days after birth.
cramping and cervical dilation would be noted
b. Irritability and poor sucking.
in this type of abortion. hypertension. Fetal activity would not be noted.

2. Answer: (B) History of syphilis 6. Answer: (B) Absent patellar reflexes

Rationale: Maternal infections such as syphilis, Rationale: Absence of patellar reflexes is an

toxoplasmosis, and rubella are causes of indicator of hypermagnesemia, which requires

spontaneous abortion. administration of calcium gluconate.

3. Answer: (C) Monitoring apical pulse 7. Answer: (C) Presenting part in 2 cm below the

Rationale: Nursing care for the client with a plane of the ischial spines.

possible ectopic pregnancy is focused on Rationale: Fetus at station plus two indicates

preventing or identifying hypovolemic shock that the presenting part is 2 cm below the

and controlling pain. An elevated pulse rate is plane of the ischial spines.

an indicator of shock. 8. Answer: (A) Contractions every 1 ½ minutes

4. Answer: (B) Increased caloric intake lasting 70-80 seconds.

Rationale: Glucose crosses the placenta, but Rationale: Contractions every 1 ½ minutes

insulin does not. High fetal demands for lasting 70-80 seconds, is indicative of

glucose, combined with the insulin resistance hyperstimulation of the uterus, which could

caused by hormonal changes in the last half of result in injury to the mother and the fetus if

pregnancy can result in elevation of maternal Pitocin is not discontinued.

blood glucose levels. This increases the 9. Answer: (C) EKG tracings

mother’s demand for insulin and is referred to Rationale: A potential side effect of calcium

as the diabetogenic effect of pregnancy. gluconate administration is cardiac arrest.

5. Answer: (A) Excessive fetal activity. Continuous monitoring of cardiac activity (EKG)

Rationale: The most common signs and throught administration of calcium gluconate is

symptoms of hydatidiform mole includes an essential part of care.

elevated levels of human chorionic 10. Answer: (D) First low transverse caesarean
was
gonadotropin, vaginal bleeding, larger than
for breech position. Fetus in this pregnancy is in
normal uterus for gestational age, failure to
a vertex presentation.
detect fetal heart activity even with sensitive
Rationale: This type of client has no obstetrical
instruments, excessive nausea and vomiting,
indication for a caesarean section as she did
and early development of pregnancy-induced
with her first caesarean delivery. energy, an infant with heart failure should rest

11. Answer: (A) Talk to the mother first and then before feeding.
to
14. Answer: (C) Iron-rich formula only.
the toddler.
Rationale: The infants at age 5 months should
Rationale: When dealing with a crying toddler,
receive iron-rich formula and that they
the best approach is to talk to the mother and
shouldn’t receive solid food, even baby food
ignore the toddler first. This approach helps the
until age 6 months.
toddler get used to the nurse before she
15. Answer: (D) 10 months
attempts any procedures. It also gives the
Rationale: A 10 month old infant can sit alone
toddler an opportunity to see that the mother
and understands object permanence, so he
trusts the nurse.
would look for the hidden toy. At age 4 to 6
12. Answer: (D) Place the infant’s arms in soft
85
elbow restraints.
months, infants can’t sit securely alone. At age
Rationale: Soft restraints from the upper arm to
8 months, infants can sit securely alone but
the wrist prevent the infant from touching her
cannot understand the permanence of objects.
lip but allow him to hold a favorite item such as
16. Answer: (D) Public health nursing focuses on
a blanket. Because they could damage the
preventive, not curative, services.
operative site, such as objects as pacifiers,
Rationale: The catchments area in PHN consists
suction catheters, and small spoons shouldn’t
of a residential community, many of whom are
be placed in a baby’s mouth after cleft repair. A
well individuals who have greater need for
baby in a prone position may rub her face on
preventive rather than curative services.
the sheets and traumatize the operative site.
17. Answer: (B) Efficiency
The suture line should be cleaned gently to
Rationale: Efficiency is determining whether the
prevent infection, which could interfere with
goals were attained at the least possible cost.
healing and damage the cosmetic appearance
18. Answer: (D) Rural Health Unit
of the repair.
Rationale: R.A. 7160 devolved basic health
13. Answer: (B) Allow the infant to rest before
services to local government units (LGU’s ). The
feeding.
public health nurse is an employee of the LGU.
Rationale: Because feeding requires so much
19. Answer: (A) Mayor
Rationale: The local executive serves as the Rationale: Tertiary prevention involves

chairman of the Municipal Health Board. rehabilitation, prevention of permanent

20. Answer: (A) 1 disability and disability limitations appropriate

Rationale: Each rural health midwife is given a for convalescents, the disabled, complicated

population assignment of about 5,000. cases and the terminally ill (those in the

21. Answer: (B) Health education and terminal stage of a disease).

community
26. Answer: (A) Intrauterine fetal death.
organizing are necessary in providing
Rationale: Intrauterine fetal death, abruptio
community health services. Rationale: The
placentae, septic shock, and amniotic fluid
community health nurse develops the health
embolism may trigger normal clotting
capability of people through health education
mechanisms; if clotting factors are depleted,
and community organizing activities.
DIC may occur. Placenta accreta, dysfunctional
22. Answer: (B) Measles
labor, and premature rupture of the
Rationale: Presidential Proclamation No. 4 is on
membranes aren't associated with DIC.
the Ligtas Tigdas Program.
27. Answer: (C) 120 to 160 beats/minute
23. Answer: (D) Core group formation
Rationale: A rate of 120 to 160 beats/minute in
Rationale: In core group formation, the nurse is
the fetal heart appropriate for filling the heart
able to transfer the technology of community
with blood and pumping it out to the system.
organizing to the potential or informal
28. Answer: (A) Change the diaper more often.
community leaders through a training program.
Rationale: Decreasing the amount of time the
24. Answer: (D) To maximize the community’s
skin comes contact with wet soiled diapers will
resources in dealing with health problems.
help heal the irritation.
Rationale: Community organizing is a
29. Answer: (D) Endocardial cushion defect
developmental service, with the goal of
Rationale: Endocardial cushion defects are seen
developing the people’s self-reliance in dealing
most in children with Down syndrome,
with community health problems. A, B and C
asplenia, or polysplenia.
are objectives of contributory objectives to this
30. Answer: (B) Decreased urine output
goal.
Rationale: Decreased urine output may occur in
25. Answer: (D) Terminal
clients receiving I.V. magnesium and should be
monitored closely to keep urine output at bleeding.

greater than 30 ml/hour, because magnesium is 36. Answer: (D) Early in the morning

excreted through the kidneys and can easily 86

accumulate to toxic levels. Rationale: Based on the nurse’s knowledge of

31. Answer: (A) Menorrhagia microbiology, the specimen should be collected

Rationale: Menorrhagia is an excessive early in the morning. The rationale for this

menstrual period. timing is that, because the female worm lays

32. Answer: (C) Blood typing eggs at night around the perineal area, the first

Rationale: Blood type would be a critical value bowel movement of the day will yield the best

to have because the risk of blood loss is always results. The specific type of stool specimen

a potential complication during the labor and used in the diagnosis of pinworms is called the

delivery process. Approximately 40% of a tape test.

woman’s cardiac output is delivered to the 37. Answer: (A) Irritability and seizures

uterus, therefore, blood loss can occur quite Rationale: Lead poisoning primarily affects the

rapidly in the event of uncontrolled bleeding. CNS, causing increased intracranial pressure.

33. Answer: (D) Physiologic anemia This condition results in irritability and changes

Rationale: Hemoglobin values and hematocrit in level of consciousness, as well as seizure

decrease during pregnancy as the increase in disorders, hyperactivity, and learning

plasma volume exceeds the increase in red disabilities.

blood cell production. 38. Answer: (D) “I really need to use the
diaphragm
34. Answer: (D) A 2 year old infant with
stridorous and jelly most during the middle of my

breath sounds, sitting up in his mother’s arms menstrual cycle”.

and drooling. Rationale: The woman must understand that,

Rationale: The infant with the airway although the “fertile” period is approximately

emergency should be treated first, because of mid-cycle, hormonal variations do occur and

the risk of epiglottitis. can result in early or late ovulation. To be

35. Answer: (A) Placenta previa effective, the diaphragm should be inserted

Rationale: Placenta previa with painless vaginal before every intercourse.

39. Answer: (C) Restlessness nurse should withhold the potassium and notify

Rationale: In a child, restlessness is the earliest the physician.

sign of hypoxia. Late signs of hypoxia in a child 44. Answer: (c) Laundry detergent

are associated with a change in color, such as Rationale: Eczema or dermatitis is an allergic

pallor or cyanosis. skin reaction caused by an offending allergen.

40. Answer: (B) Walk one step ahead, with the The topical allergen that is the most common

child’s hand on the nurse’s elbow. causative factor is laundry detergent.

Rationale: This procedure is generally 45. Answer: (A) 6 inches

recommended to follow in guiding a person Rationale: This distance allows for easy flow of

who is blind. the formula by gravity, but the flow will be slow

41. Answer: (A) Loud, machinery-like murmur. enough not to overload the stomach too

Rationale: A loud, machinery-like murmur is a rapidly.

characteristic finding associated with patent 46. Answer: (A) The older one gets, the more

ductus arteriosus. susceptible he becomes to the complications of

42. Answer: (C) More oxygen, and the chicken pox.

newborn’s
Rationale: Chicken pox is usually more severe in
metabolic rate increases.
adults than in children. Complications, such as
Rationale: When cold, the infant requires more
pneumonia, are higher in incidence in adults.
oxygen and there is an increase in metabolic
47. Answer: (D) Consult a physician who may
rate. Non-shievering thermogenesis is a give

complex process that increases the metabolic them rubella immunoglobulin.

rate and rate of oxygen consumption, Rationale: Rubella vaccine is made up of

therefore, the newborn increase heat attenuated German measles viruses. This is

production. contraindicated in pregnancy. Immune globulin,

43. Answer: (D) Voided a specific prophylactic against German measles,

Rationale: Before administering potassium I.V. may be given to pregnant women.

to any client, the nurse must first check that the 48. Answer: (A) Contact tracing

client’s kidneys are functioning and that the Rationale: Contact tracing is the most practical

client is voiding. If the client is not voiding, the and reliable method of finding possible sources
of person-to-person transmitted infections, allows the return of the color of the nailbed

such as sexually transmitted diseases. within 3 seconds.

49. Answer: (D) Leptospirosis 54. Answer: (B) Severe dehydration

Rationale: Leptospirosis is transmitted through Rationale: The order of priority in the

contact with the skin or mucous membrane management of severe dehydration is as

with water or moist soil contaminated with follows: intravenous fluid therapy, referral to a

urine of infected animals, like rats. facility where IV fluids can be initiated within 30

50. Answer: (B) Cholera minutes, Oresol or nasogastric tube. When the

Rationale: Passage of profuse watery stools is foregoing measures are not possible or

the major symptom of cholera. Both amebic effective, then urgent referral to the hospital is

and bacillary dysentery are characterized by the done.

presence of blood and/or mucus in the stools. 55. Answer: (A) 45 infants

Giardiasis is characterized by fat malabsorption Rationale: To estimate the number of infants,

and, therefore, steatorrhea. multiply total population by 3%.

51. Answer: (A) Hemophilus influenzae 56. Answer: (A) DPT

Rationale: Hemophilus meningitis is unusual Rationale: DPT is sensitive to freezing. The

over the age of 5 years. In developing countries, appropriate storage temperature of DPT is 2 to

the peak incidence is in children less than 6 8° C only. OPV and measles vaccine are highly

months of age. Morbillivirus is the etiology of sensitive to heat and require freezing. MMR is

measles. Streptococcus pneumonia and not an immunization in the Expanded Program

Neisseria meningitidis may cause meningitis, on Immunization.

but age distribution is not specific in young 57. Answer: (C) Proper use of sanitary toilets

children. Rationale: The ova of the parasite get out of the

52. Answer: (B) Buccal mucosa human body together with feces. Cutting the

87 cycle at this stage is the most effective way of

Rationale: Koplik’s spot may be seen on the preventing the spread of the disease to

mucosa of the mouth or the throat. susceptible hosts.

53. Answer: (A) 3 seconds 58. Answer: (D) 5 skin lesions, positive slit skin

Rationale: Adequate blood supply to the area smear

Rationale: A multibacillary leprosy case is one marasmus. The best management is urgent

who has a positive slit skin smear and at least 5 referral to a hospital.

skin lesions. 63. Answer: (D) Let the child rest for 10 minutes

59. Answer: (C) Thickened painful nerves then continue giving Oresol more slowly.

Rationale: The lesion of leprosy is not macular. Rationale: If the child vomits persistently, that

It is characterized by a change in skin color is, he vomits everything that he takes in, he has

(either reddish or whitish) and loss of sensation, to be referred urgently to a hospital. Otherwise,

sweating and hair growth over the lesion. vomiting is managed by letting the child rest for

Inability to close the eyelids (lagophthalmos) 10 minutes and then continuing with Oresol

and sinking of the nosebridge are late administration. Teach the mother to give Oresol

symptoms. more slowly.

60. Answer: (B) Ask where the family resides. 64. Answer: (B) Some dehydration

Rationale: Because malaria is endemic, the first Rationale: Using the assessment guidelines of

question to determine malaria risk is where the IMCI, a child (2 months to 5 years old) with

client’s family resides. If the area of residence is diarrhea is classified as having SOME

not a known endemic area, ask if the child had DEHYDRATION if he shows 2 or more of the

traveled within the past 6 months, where she following signs: restless or irritable, sunken

was brought and whether she stayed overnight eyes, the skin goes back slow after a skin pinch.

in that area. 65. Answer: (C) Normal

61. Answer: (A) Inability to drink Rationale: In IMCI, a respiratory rate of

Rationale: A sick child aged 2 months to 5 years 50/minute or more is fast breathing for an

must be referred urgently to a hospital if infant aged 2 to 12 months.

he/she has one or more of the following signs: 66. Answer: (A) 1 year

not able to feed or drink, vomits everything, Rationale: The baby will have passive natural

convulsions, abnormally sleepy or difficult to immunity by placental transfer of antibodies.

awaken. The mother will have active artificial immunity

62. Answer: (A) Refer the child urgently to a lasting for about 10 years. 5 doses will give the

hospital for confinement. mother lifetime protection.

Rationale: “Baggy pants” is a sign of severe 67. Answer: (B) 4 hours

Rationale: While the unused portion of other Rationale: Temperature instability, especially

biologicals in EPI may be given until the end of when it results in a low temperature in the

the day, only BCG is discarded 4 hours after neonate, may be a sign of infection. The

reconstitution. This is why BCG immunization is neonate’s color often changes with an infection

scheduled only in the morning. process but generally becomes ashen or

68. Answer: (B) 6 months mottled. The neonate with an infection will

Rationale: After 6 months, the baby’s nutrient usually show a decrease in activity level or

needs, especially the baby’s iron requirement, lethargy.

can no longer be provided by mother’s milk 72. Answer: (D) Polycythemia probably due to

alone. chronic fetal hypoxia

69. Answer: (C) 24 weeks Rationale: The small-for-gestation neonate is at

Rationale: At approximately 23 to 24 weeks’ risk for developing polycythemia during the

gestation, the lungs are developed enough to transitional period in an attempt to decrease

sometimes maintain extrauterine life. The lungs hypoxia. The neonates are also at increased risk

are the most immature system during the for developing hypoglycemia and hypothermia

88 due to decreased glycogen stores.

gestation period. Medical care for premature 73. Answer: (C) Desquamation of the epidermis

labor begins much earlier (aggressively at 21 Rationale: Postdate fetuses lose the vernix

weeks’ gestation) caseosa, and the epidermis may become

70. Answer: (B) Sudden infant death syndrome desquamated. These neonates are usually very

(SIDS) alert. Lanugo is missing in the postdate

Rationale: Supine positioning is recommended neonate.

to reduce the risk of SIDS in infancy. The risk of 74. Answer: (C) Respiratory depression

aspiration is slightly increased with the supine Rationale: Magnesium sulfate crosses the

position. Suffocation would be less likely with placenta and adverse neonatal effects are

an infant supine than prone and the position respiratory depression, hypotonia, and

for GER requires the head of the bed to be bradycardia. The serum blood sugar isn’t

elevated. affected by magnesium sulfate. The neonate

71. Answer: (C) Decreased temperature would be floppy, not jittery.

75. Answer: (C) Respiratory rate 40 to 60 prolapsed and that the baby tolerated the

breaths/minute procedure well. The most effective way to do

Rationale: A respiratory rate 40 to 60 this is to check the fetal heart rate. Fetal
wellbeing
breaths/minute is normal for a neonate during
is assessed via a nonstress test. Fetal
the transitional period. Nasal flaring,
position is determined by vaginal examination.
respiratory rate more than 60 breaths/minute,
Artificial rupture of membranes doesn't
and audible grunting are signs of respiratory
indicate an imminent delivery.
distress.
79. Answer: (D) The parents’ interactions with
76. Answer: (C) Keep the cord dry and open to
each
air
other.
Rationale: Keeping the cord dry and open to air
Rationale: Parental interaction will provide the
helps reduce infection and hastens drying.
nurse with a good assessment of the stability of
Infants aren’t given tub bath but are sponged
the family's home life but it has no indication
off until the cord falls off. Petroleum jelly
for parental bonding. Willingness to touch and
prevents the cord from drying and encourages
hold the newborn, expressing interest about
infection. Peroxide could be painful and isn’t
the newborn's size, and indicating a desire to
recommended.
see the newborn are behaviors indicating
77. Answer: (B) Conjunctival hemorrhage
parental bonding.
Rationale: Conjunctival hemorrhages are
80. Answer: (B) Instructing the client to use two
commonly seen in neonates secondary to the
or
cranial pressure applied during the birth
more peripads to cushion the area
process. Bulging fontanelles are a sign of
Rationale: Using two or more peripads would
intracranial pressure. Simian creases are
do little to reduce the pain or promote perineal
present in 40% of the neonates with trisomy 21.
healing. Cold applications, sitz baths, and Kegel
Cystic hygroma is a neck mass that can affect
exercises are important measures when the
the airway.
client has a fourth-degree laceration.
78. Answer: (B) To assess for prolapsed cord
81. Answer: (C) “What is your expected due
Rationale: After a client has an amniotomy, the date?”

nurse should assure that the cord isn't Rationale: When obtaining the history of a
client who may be in labor, the nurse's highest determining whether a client has ruptured

priority is to determine her current status, membranes.

particularly her due date, gravidity, and parity. 84. Answer: (C) Monitor partial pressure of
oxygen
Gravidity and parity affect the duration of labor
(Pao2) levels.
and the potential for labor complications. Later,
Rationale: Monitoring PaO2 levels and reducing
the nurse should ask about chronic illnesses,
the oxygen concentration to keep PaO2 within
allergies, and support persons.
normal limits reduces the risk of retinopathy of
82. Answer: (D) Aspirate the neonate’s nose and
prematurity in a premature infant receiving
mouth with a bulb syringe.
oxygen. Covering the infant's eyes and
89
humidifying the oxygen don't reduce the risk of
Rationale: The nurse's first action should be to
retinopathy of prematurity. Because cooling
clear the neonate's airway with a bulb syringe.
increases the risk of acidosis, the infant should
After the airway is clear and the neonate's color
be kept warm so that his respiratory distress
improves, the nurse should comfort and calm
isn't aggravated.
the neonate. If the problem recurs or the
85. Answer: (A) 110 to 130 calories per kg.
neonate's color doesn't improve readily, the
Rationale: Calories per kg is the accepted way
nurse should notify the physician.
of determined appropriate nutritional intake
Administering oxygen when the airway isn't
for a newborn. The recommended calorie
clear would be ineffective.
requirement is 110 to 130 calories per kg of
83. Answer: (C) Conducting a bedside
ultrasound newborn body weight. This level will maintain a

for an amniotic fluid index. consistent blood glucose level and provide

Rationale: It isn't within a nurse's scope of enough calories for continued growth and

practice to perform and interpret a bedside development.

ultrasound under these conditions and without 86. Answer: (C) 30 to 32 weeks

specialized training. Observing for pooling of Rationale: Individual twins usually grow at the

straw-colored fluid, checking vaginal discharge same rate as singletons until 30 to 32 weeks’

with nitrazine paper, and observing for flakes of gestation, then twins don’t’ gain weight as

vernix are appropriate assessments for rapidly as singletons of the same gestational
age. The placenta can no longer keep pace with 89. Answer: (A) Increased tidal volume

the nutritional requirements of both fetuses Rationale: A pregnant client breathes deeper,

after 32 weeks, so there’s some growth which increases the tidal volume of gas moved

retardation in twins if they remain in utero at in and out of the respiratory tract with each

38 to 40 weeks. breath. The expiratory volume and residual

87. Answer: (A) conjoined twins volume decrease as the pregnancy progresses.

Rationale: The type of placenta that develops in The inspiratory capacity increases during

monozygotic twins depends on the time at pregnancy. The increased oxygen consumption

which cleavage of the ovum occurs. Cleavage in in the pregnant client is 15% to 20% greater

conjoined twins occurs more than 13 days after than in the nonpregnant state.

fertilization. Cleavage that occurs less than 3 90. Answer: (A) Diet

day after fertilization results in diamniotic Rationale: Clients with gestational diabetes are

dicchorionic twins. Cleavage that occurs usually managed by diet alone to control their

between days 3 and 8 results in diamniotic glucose intolerance. Oral hypoglycemic drugs

monochorionic twins. Cleavage that occurs are contraindicated in pregnancy. Long-acting

between days 8 to 13 result in monoamniotic insulin usually isn’t needed for blood glucose

monochorionic twins. control in the client with gestational diabetes.

88. Answer: (D) Ultrasound 91. Answer: (D) Seizure

Rationale: Once the mother and the fetus are Rationale: The anticonvulsant mechanism of

stabilized, ultrasound evaluation of the magnesium is believes to depress seizure foci in

placenta should be done to determine the the brain and peripheral neuromuscular

cause of the bleeding. Amniocentesis is blockade. Hypomagnesemia isn’t a

contraindicated in placenta previa. A digital or complication of preeclampsia. Antihypertensive

speculum examination shouldn’t be done as drug other than magnesium are preferred for

this may lead to severe bleeding or sustained hypertension. Magnesium doesn’t

hemorrhage. External fetal monitoring won’t help prevent hemorrhage in preeclamptic

detect a placenta previa, although it will detect clients.

fetal distress, which may result from blood loss 92. Answer: (C) I.V. fluids

or placenta separation. Rationale: A sickle cell crisis during pregnancy is

usually managed by exchange transfusion urgency, frequency, and suprapubic

90 tenderness. Asymptomatic bacteriuria doesn’t

oxygen, and L.V. Fluids. The client usually needs cause symptoms. Bacterial vaginosis causes

a stronger analgesic than acetaminophen to milky white vaginal discharge but no systemic

control the pain of a crisis. Antihypertensive symptoms.

drugs usually aren’t necessary. Diuretic 96. Answer: (B) Rh-positive fetal blood crosses
into
wouldn’t be used unless fluid overload resulted.
maternal blood, stimulating maternal
93. Answer: (A) Calcium gluconate (Kalcinate)
antibodies.
Rationale: Calcium gluconate is the antidote for
Rationale: Rh isoimmunization occurs when
magnesium toxicity. Ten milliliters of 10%
Rhpositive
calcium gluconate is given L.V. push over 3 to 5
fetal blood cells cross into the maternal
minutes. Hydralazine is given for sustained
circulation and stimulate maternal antibody
elevated blood pressure in preeclamptic clients.
production. In subsequent pregnancies with
Rho (D) immune globulin is given to women Rhpositive

with Rh-negative blood to prevent antibody fetuses, maternal antibodies may cross

formation from RH-positive conceptions. back into the fetal circulation and destroy the

Naloxone is used to correct narcotic toxicity. fetal blood cells.

94. Answer: (B) An indurated wheal over 10 mm 97. Answer: (C) Supine position
in
Rationale: The supine position causes
diameter appears in 48 to 72 hours.
compression of the client's aorta and inferior
Rationale: A positive PPD result would be an
vena cava by the fetus. This, in turn, inhibits
indurated wheal over 10 mm in diameter that
maternal circulation, leading to maternal
appears in 48 to 72 hours. The area must be a
hypotension and, ultimately, fetal hypoxia. The
raised wheal, not a flat circumcised area to be
other positions promote comfort and aid labor
considered positive.
progress. For instance, the lateral, or side-lying,
95. Answer: (C) Pyelonephritis
position improves maternal and fetal
Rationale The symptoms indicate acute
circulation, enhances comfort, increases
pyelonephritis, a serious condition in a
maternal relaxation, reduces muscle tension,
pregnant client. UTI symptoms include dysuria,
and eliminates pressure points. The squatting
position promotes comfort by taking advantage follow delivery and commonly results from

of gravity. The standing position also takes apparent excessive traction on the umbilical

advantage of gravity and aligns the fetus with cord and attempts to deliver the placenta

the pelvic angle. manually. Uterine involution and some uterine

98. Answer: (B) Irritability and poor sucking. discomfort are normal after delivery.

Rationale: Neonates of heroin-addicted 91

mothers are physically dependent on the drug TEST III - Care of Clients with Physiologic and

and experience withdrawal when the drug is no Psychosocial Alterations

longer supplied. Signs of heroin withdrawal 1. Nurse Michelle should know that the
drainage is
include irritability, poor sucking, and
normal 4 days after a sigmoid colostomy when
restlessness. Lethargy isn't associated with
the stool is:
neonatal heroin addiction. A flattened nose,
a. Green liquid
small eyes, and thin lips are seen in infants with
b. Solid formed
fetal alcohol syndrome. Heroin use during
c. Loose, bloody
pregnancy hasn't been linked to specific
d. Semiformed
congenital anomalies.
2. Where would nurse Kristine place the call
99. Answer: (A) 7th to 9th day postpartum
light
Rationale: The normal involutional process
for a male client with a right-sided brain attack
returns the uterus to the pelvic cavity in 7 to 9
and left homonymous hemianopsia?
days. A significant involutional complication is
a. On the client’s right side
the failure of the uterus to return to the pelvic
b. On the client’s left side
cavity within the prescribed time period. This is
c. Directly in front of the client
known as subinvolution.
d. Where the client like
100. Answer: (B) Uterine atony
3. A male client is admitted to the emergency
Rationale: Multiple fetuses, extended labor
department following an accident. What are the
stimulation with oxytocin, and traumatic
first nursing actions of the nurse?
delivery commonly are associated with uterine
a. Check respiration, circulation,
atony, which may lead to postpartum
neurological response.
hemorrhage. Uterine inversion may precede or
b. Align the spine, check pupils, and check a. Plan care so the client can receive 8

for hemorrhage. hours of uninterrupted sleep each night.

c. Check respirations, stabilize spine, and b. Monitor vital signs every 2 hours.

check circulation. c. Make sure that the client takes food and

d. Assess level of consciousness and medications at prescribed intervals.

circulation. d. Provide milk every 2 to 3 hours.

4. In evaluating the effect of nitroglycerin, Nurse 7. A male client was on warfarin (Coumadin)
before
Arthur should know that it reduces preload and
admission, and has been receiving heparin I.V.
relieves angina by:
for 2 days. The partial thromboplastin time
a. Increasing contractility and slowing
(PTT)
heart rate.
is 68 seconds. What should Nurse Carla do?
b. Increasing AV conduction and heart rate.
a. Stop the I.V. infusion of heparin and
c. Decreasing contractility and oxygen
notify the physician.
consumption.
b. Continue treatment as ordered.
d. Decreasing venous return through
c. Expect the warfarin to increase the PTT.
vasodilation.
d. Increase the dosage, because the level is
5. Nurse Patricia finds a female client who is
lower than normal.
postmyocardial
8. A client undergone ileostomy, when should
infarction (MI) slumped on the side
the
rails of the bed and unresponsive to shaking or
drainage appliance be applied to the stoma?
shouting. Which is the nurse next action?
a. 24 hours later, when edema has
a. Call for help and note the time.
subsided.
b. Clear the airway
b. In the operating room.
c. Give two sharp thumps to the
c. After the ileostomy begin to function.
precordium, and check the pulse.
d. When the client is able to begin self-care
d. Administer two quick blows.
procedures.
6. Nurse Monett is caring for a client recovering
9. A client undergone spinal anesthetic, it will be
from gastro-intestinal bleeding. The nurse
important that the nurse immediately position
should:
the client in:
a. On the side, to prevent obstruction of 12. A male client has active tuberculosis (TB).
Which
airway by tongue.
of the following symptoms will be exhibit?
b. Flat on back.
a. Chest and lower back pain
c. On the back, with knees flexed 15
b. Chills, fever, night sweats, and
degrees.
hemoptysis
d. Flat on the stomach, with the head
c. Fever of more than 104°F (40°C) and
turned to the side.
nausea
10. While monitoring a male client several hours
d. Headache and photophobia
after a motor vehicle accident, which
13. Mark, a 7-year-old client is brought to the
assessment data suggest increasing intracranial
emergency department. He’s tachypneic and
pressure?
afebrile and has a respiratory rate of 36
a. Blood pressure is decreased from
breaths/minute and has a nonproductive cough.
160/90 to 110/70.
He recently had a cold. Form this history; the
b. Pulse is increased from 87 to 95, with an
client may have which of the following
occasional skipped beat.
conditions?
c. The client is oriented when aroused
a. Acute asthma
from sleep, and goes back to sleep
b. Bronchial pneumonia
immediately.
c. Chronic obstructive pulmonary disease
92
(COPD)
d. The client refuses dinner because of
d. Emphysema
anorexia.
14. Marichu was given morphine sulfate for
11. Mrs. Cruz, 80 years old is diagnosed with
pain.
pneumonia. Which of the following symptoms
She is sleeping and her respiratory rate is 4
may appear first?
breaths/minute. If action isn’t taken quickly, she
a. Altered mental status and dehydration
might have which of the following reactions?
b. Fever and chills
a. Asthma attack
c. Hemoptysis and Dyspnea
b. Respiratory arrest
d. Pleuritic chest pain and cough
c. Seizure
d. Wake up on his own c. Use a straight razor when shaving.

15. A 77-year-old male client is admitted for d. Take aspirin to pain relief.
elective
18. Nurse Lhynnette is preparing a site for the
knee surgery. Physical examination reveals
insertion of an I.V. catheter. The nurse should
shallow respirations but no sign of respiratory
treat excess hair at the site by:
distress. Which of the following is a normal
a. Leaving the hair intact
physiologic change related to aging?
b. Shaving the area
a. Increased elastic recoil of the lungs
c. Clipping the hair in the area
b. Increased number of functional
d. Removing the hair with a depilatory.
capillaries in the alveoli
19. Nurse Michelle is caring for an elderly
c. Decreased residual volume female

d. Decreased vital capacity with osteoporosis. When teaching the client,

the
16. Nurse John is caring for a male client
receiving nurse should include information about which

lidocaine I.V. Which factor is the most relevant major complication:

to administration of this medication? a. Bone fracture

a. Decrease in arterial oxygen saturation b. Loss of estrogen

(SaO2) when measured with a pulse c. Negative calcium balance

oximeter. d. Dowager’s hump

b. Increase in systemic blood pressure. 20. Nurse Len is teaching a group of women to

c. Presence of premature ventricular perform BSE. The nurse should explain that the

contractions (PVCs) on a cardiac purpose of performing the examination is to

monitor. discover:

d. Increase in intracranial pressure (ICP). a. Cancerous lumps

17. Nurse Ron is caring for a male client taking b. Areas of thickness or fullness
an
c. Changes from previous examinations.
anticoagulant. The nurse should teach the client
d. Fibrocystic masses
to:
21. When caring for a female client who is being
a. Report incidents of diarrhea.
treated for hyperthyroidism, it is important to:
b. Avoid foods high in vitamin K
a. Provide extra blankets and clothing to giving the client discharge instructions. These

keep the client warm. instructions should include which of the

b. Monitor the client for signs of following?

restlessness, sweating, and excessive a. Avoid lifting objects weighing more than

93 5 lb (2.25 kg).

weight loss during thyroid replacement b. Lie on your abdomen when in bed

therapy. c. Keep rooms brightly lit.

c. Balance the client’s periods of activity d. Avoiding straining during bowel

and rest. movement or bending at the waist.

d. Encourage the client to be active to 25. George should be taught about testicular

prevent constipation. examinations during:

22. Nurse Kris is teaching a client with history of a. when sexual activity starts

atherosclerosis. To decrease the risk of b. After age 69

atherosclerosis, the nurse should encourage the c. After age 40

client to: d. Before age 20.

a. Avoid focusing on his weight. 26. A male client undergone a colon resection.
While
b. Increase his activity level.
turning him, wound dehiscence with
c. Follow a regular diet.
evisceration occurs. Nurse Trish first response is
d. Continue leading a high-stress lifestyle.
to:
23. Nurse Greta is working on a surgical floor.
Nurse a. Call the physician

Greta must logroll a client following a: b. Place a saline-soaked sterile dressing on

a. Laminectomy the wound.

b. Thoracotomy c. Take a blood pressure and pulse.

c. Hemorrhoidectomy d. Pull the dehiscence closed.

d. Cystectomy. 27. Nurse Audrey is caring for a client who has

24. A 55-year old client underwent cataract suffered a severe cerebrovascular accident.
removal
During routine assessment, the nurse notices
with intraocular lens implant. Nurse Oliver is
Cheyne- Strokes respirations. Cheyne-strokes
respirations are: 30. Mike with epilepsy is having a seizure.
During
a. A progressively deeper breaths followed
the active seizure phase, the nurse should:
by shallower breaths with apneic
a. Place the client on his back remove
periods.
dangerous objects, and insert a bite
b. Rapid, deep breathing with abrupt
block.
pauses between each breath.
b. Place the client on his side, remove
c. Rapid, deep breathing and irregular
dangerous objects, and insert a bite
breathing without pauses.
block.
d. Shallow breathing with an increased
c. Place the client o his back, remove
respiratory rate.
dangerous objects, and hold down his
28. Nurse Bea is assessing a male client with
heart arms.

failure. The breath sounds commonly d. Place the client on his side, remove

auscultated in clients with heart failure are: dangerous objects, and protect his head.

a. Tracheal 31. After insertion of a cheat tube for a

b. Fine crackles pneumothorax, a client becomes hypotensive

c. Coarse crackles with neck vein distention, tracheal shift, absent

d. Friction rubs breath sounds, and diaphoresis. Nurse Amanda

29. The nurse is caring for Kenneth experiencing suspects a tension pneumothorax has occurred.
an
What cause of tension pneumothorax should
acute asthma attack. The client stops wheezing the

and breath sounds aren’t audible. The reason nurse check for?
for
a. Infection of the lung.
this change is that:
94
a. The attack is over.
b. Kinked or obstructed chest tube
b. The airways are so swollen that no air
c. Excessive water in the water-seal
cannot get through.
chamber
c. The swelling has decreased.
d. Excessive chest tube drainage
d. Crackles have replaced wheezes.
32. Nurse Maureen is talking to a male client;
the
client begins choking on his lunch. He’s 35. A 77-year-old male client is admitted with a
coughing
diagnosis of dehydration and change in mental
forcefully. The nurse should:
status. He’s being hydrated with L.V. fluids.
a. Stand him up and perform the
When the nurse takes his vital signs, she notes
abdominal thrust maneuver from
he has a fever of 103°F (39.4°C) a cough
behind.
producing yellow sputum and pleuritic chest
b. Lay him down, straddle him, and
pain. The nurse suspects this client may have
perform the abdominal thrust
which of the following conditions?
maneuver.
a. Adult respiratory distress syndrome
c. Leave him to get assistance
(ARDS)
d. Stay with him but not intervene at this
b. Myocardial infarction (MI)
time.
c. Pneumonia
33. Nurse Ron is taking a health history of an 84
d. Tuberculosis
year
36. Nurse Oliver is working in an outpatient
old client. Which information will be most useful
clinic.
to the nurse for planning care?
He has been alerted that there is an outbreak of
a. General health for the last 10 years.
tuberculosis (TB). Which of the following clients
b. Current health promotion activities.
entering the clinic today most likely to have TB?
c. Family history of diseases.
a. A 16-year-old female high school
d. Marital status.
student
34. When performing oral care on a comatose
b. A 33-year-old day-care worker
client,
c. A 43-yesr-old homeless man with a
Nurse Krina should:
history of alcoholism
a. Apply lemon glycerin to the client’s lips
d. A 54-year-old businessman
at least every 2 hours.
37. Virgie with a positive Mantoux test result
b. Brush the teeth with client lying supine.
will be
c. Place the client in a side lying position,
sent for a chest X-ray. The nurse is aware that
with the head of the bed lowered.
which of the following reasons this is done?
d. Clean the client’s mouth with hydrogen
a. To confirm the diagnosis
peroxide.
b. To determine if a repeat skin test is diagnosis of Chronic Lymphocytic Leukemia.

needed 40. The treatment for patients with leukemia is

bone
c. To determine the extent of lesions
marrow transplantation. Which statement
d. To determine if this is a primary or
about
secondary infection
bone marrow transplantation is not correct?
38. Kennedy with acute asthma showing
a. The patient is under local anesthesia
inspiratory
during the procedure
and expiratory wheezes and a decreased forced
b. The aspirated bone marrow is mixed
expiratory volume should be treated with which
with heparin.
of the following classes of medication right
c. The aspiration site is the posterior or
away?
anterior iliac crest.
a. Beta-adrenergic blockers
95
b. Bronchodilators
d. The recipient receives
c. Inhaled steroids
cyclophosphamide (Cytoxan) for 4
d. Oral steroids
consecutive days before the procedure.
39. Mr. Vasquez 56-year-old client with a 40-
year 41. After several days of admission, Francis
becomes
history of smoking one to two packs of
cigarettes disoriented and complains of frequent

per day has a chronic cough producing thick headaches. The nurse in-charge first action

sputum, peripheral edema and cyanotic nail would be:

beds. Based on this information, he most likely a. Call the physician

has which of the following conditions? b. Document the patient’s status in his

a. Adult respiratory distress syndrome charts.

(ARDS) c. Prepare oxygen treatment

b. Asthma d. Raise the side rails

c. Chronic obstructive bronchitis 42. During routine care, Francis asks the nurse,

d. Emphysema “How can I be anemic if this disease causes

Situation: Francis, age 46 is admitted to the increased my white blood cell production?” The
hospital with
nurse in-charge best response would be that the
increased number of white blood cells (WBC) is: d. Recording the client’s refusal in the

a. Crowd red blood cells nurses’ notes

b. Are not responsible for the anemia. 45. During the endorsement, which of the
following
c. Uses nutrients from other cells
clients should the on-duty nurse assess first?
d. Have an abnormally short life span of
a. The 58-year-old client who was admitted
cells.
2 days ago with heart failure, blood
43. Diagnostic assessment of Francis would
probably pressure of 126/76 mm Hg, and a

not reveal: respiratory rate of 22 breaths/ minute.

a. Predominance of lymhoblasts b. The 89-year-old client with end-stage

b. Leukocytosis right-sided heart failure, blood pressure

c. Abnormal blast cells in the bone marrow of 78/50 mm Hg, and a “do not

d. Elevated thrombocyte counts resuscitate” order

44. Robert, a 57-year-old client with acute c. The 62-year-old client who was admitted
arterial
1 day ago with thrombophlebitis and is
occlusion of the left leg undergoes an
receiving L.V. heparin
emergency embolectomy. Six hours later, the
d. The 75-year-old client who was admitted
nurse isn’t able to obtain pulses in his left foot
1 hour ago with new-onset atrial
using Doppler ultrasound. The nurse
fibrillation and is receiving L.V. dilitiazem
immediately notifies the physician, and asks her
(Cardizem)
to prepare the client for surgery. As the nurse
46. Honey, a 23-year old client complains of
enters the client’s room to prepare him, he
substernal chest pain and states that her heart
states that he won’t have any more surgery.
feels like “it’s racing out of the chest”. She
Which of the following is the best initial
reports no history of cardiac disorders. The
response by the nurse?
nurse attaches her to a cardiac monitor and
a. Explain the risks of not having the
notes sinus tachycardia with a rate of
surgery
136beats/minutes. Breath sounds are clear and
b. Notifying the physician immediately
the respiratory rate is 26 breaths/minutes.
c. Notifying the nursing supervisor
Which of the following drugs should the nurse
question the client about using? 96

a. Barbiturates according to the TNM staging system as follows:

b. Opioids TIS, N0, M0. What does this classification mean?

c. Cocaine a. No evidence of primary tumor, no

d. Benzodiazepines abnormal regional lymph nodes, and no

47. A 51-year-old female client tells the nurse evidence of distant metastasis
incharge
b. Carcinoma in situ, no abnormal regional
that she has found a painless lump in her
lymph nodes, and no evidence of distant
right breast during her monthly selfexamination.
metastasis
Which assessment finding would
c. Can't assess tumor or regional lymph
strongly suggest that this client's lump is
nodes and no evidence of metastasis
cancerous?
d. Carcinoma in situ, no demonstrable
a. Eversion of the right nipple and mobile
metastasis of the regional lymph nodes,
mass
and ascending degrees of distant
b. Nonmobile mass with irregular edges
metastasis
c. Mobile mass that is soft and easily
50. Lydia undergoes a laryngectomy to treat
delineated
laryngeal cancer. When teaching the client how
d. Nonpalpable right axillary lymph nodes
to care for the neck stoma, the nurse should
48. A 35-year-old client with vaginal cancer asks
include which instruction?
the
a. "Keep the stoma uncovered."
nurse, "What is the usual treatment for this type
b. "Keep the stoma dry."
of cancer?" Which treatment should the nurse
c. "Have a family member perform stoma
name?
care initially until you get used to the
a. Surgery
procedure."
b. Chemotherapy
d. "Keep the stoma moist."
c. Radiation
51. A 37-year-old client with uterine cancer asks
d. Immunotherapy
the
49. Cristina undergoes a biopsy of a suspicious
nurse, "Which is the most common type of
lesion. The biopsy report classifies the lesion
cancer in women?" The nurse replies that it's
breast cancer. Which type of cancer causes the d. Papanicolaou-specific antigen, which is

most deaths in women? used to screen for cervical cancer.

a. Breast cancer 54. What is the most important postoperative

b. Lung cancer instruction that nurse Kate must give a client

c. Brain cancer who has just returned from the operating room

d. Colon and rectal cancer after receiving a subarachnoid block?

52. Antonio with lung cancer develops Horner's a. "Avoid drinking liquids until the gag

syndrome when the tumor invades the ribs and reflex returns."

affects the sympathetic nerve ganglia. When b. "Avoid eating milk products for 24

assessing for signs and symptoms of this hours."

syndrome, the nurse should note: c. "Notify a nurse if you experience blood

a. miosis, partial eyelid ptosis, and in your urine."

anhidrosis on the affected side of the d. "Remain supine for the time specified by

face. the physician."

b. chest pain, dyspnea, cough, weight loss, 55. A male client suspected of having colorectal

and fever. cancer will require which diagnostic study to

c. arm and shoulder pain and atrophy of confirm the diagnosis?

arm and hand muscles, both on the a. Stool Hematest

affected side. b. Carcinoembryonic antigen (CEA)

d. hoarseness and dysphagia. c. Sigmoidoscopy

53. Vic asks the nurse what PSA is. The nurse d. Abdominal computed tomography (CT)
should
scan
reply that it stands for:
56. During a breast examination, which finding
a. prostate-specific antigen, which is used most

to screen for prostate cancer. strongly suggests that the Luz has breast
cancer?
b. protein serum antigen, which is used to
a. Slight asymmetry of the breasts.
determine protein levels.
b. A fixed nodular mass with dimpling of
c. pneumococcal strep antigen, which is a
the overlying skin
bacteria that causes pneumonia.
c. Bloody discharge from the nipple a. Obtaining an X-ray of the bones every 3

d. Multiple firm, round, freely movable years is recommended to detect bone

masses that change with the menstrual loss.

cycle b. To avoid fractures, the client should

57. A female client with cancer is being avoid strenuous exercise.

evaluated
c. The recommended daily allowance of
for possible metastasis. Which of the following
calcium may be found in a wide variety
is
of foods.
one of the most common metastasis sites for
d. Obtaining the recommended daily
cancer cells?
allowance of calcium requires taking a
a. Liver
calcium supplement.
b. Colon
60. Before Jacob undergoes arthroscopy, the
c. Reproductive tract
nurse
d. White blood cells (WBCs)
reviews the assessment findings for
58. Nurse Mandy is preparing a client for
contraindications for this procedure. Which
magnetic
finding is a contraindication?
resonance imaging (MRI) to confirm or rule out
a a. Joint pain
97 b. Joint deformity
spinal cord lesion. During the MRI scan, which c. Joint flexion of less than 50%
of
d. Joint stiffness
the following would pose a threat to the client?
61. Mr. Rodriguez is admitted with severe pain
a. The client lies still. in
b. The client asks questions. the knees. Which form of arthritis is
c. The client hears thumping sounds. characterized by urate deposits and joint pain,
d. The client wears a watch and wedding usually in the feet and legs, and occurs primarily
band. in men over age 30?
59. Nurse Cecile is teaching a female client a. Septic arthritis
about
b. Traumatic arthritis
preventing osteoporosis. Which of the following
c. Intermittent arthritis
teaching points is correct?
d. Gouty arthritis joint

62. A heparin infusion at 1,500 unit/hour is c. It appears on the proximal

ordered
interphalangeal joint
for a 64-year-old client with stroke in evolution.
d. It appears on the dorsolateral aspect of
The infusion contains 25,000 units of heparin in
the interphalangeal joint.
500 ml of saline solution. How many milliliters
65. Which of the following statements explains
per hour should be given? the

a. 15 ml/hour main difference between rheumatoid arthritis

b. 30 ml/hour and osteoarthritis?

c. 45 ml/hour a. Osteoarthritis is gender-specific,

d. 50 ml/hour rheumatoid arthritis isn’t

63. A 76-year-old male client had a b. Osteoarthritis is a localized disease

thromboembolic
rheumatoid arthritis is systemic
right stroke; his left arm is swollen. Which of the
c. Osteoarthritis is a systemic disease,
following conditions may cause swelling after a
rheumatoid arthritis is localized
stroke?
d. Osteoarthritis has dislocations and
a. Elbow contracture secondary to
subluxations, rheumatoid arthritis
spasticity
doesn’t
b. Loss of muscle contraction decreasing
66. Mrs. Cruz uses a cane for assistance in
venous return walking.

c. Deep vein thrombosis (DVT) due to Which of the following statements is true about

immobility of the ipsilateral side a cane or other assistive devices?

d. Hypoalbuminemia due to protein a. A walker is a better choice than a cane.

escaping from an inflamed glomerulus b. The cane should be used on the affected

64. Heberden’s nodes are a common sign of side

osteoarthritis. Which of the following statement c. The cane should be used on the

is correct about this deformity? unaffected side

a. It appears only in men d. A client with osteoarthritis should be

b. It appears on the distal interphalangeal encouraged to ambulate without the

cane 70. For a diabetic male client with a foot ulcer,
the
67. A male client with type 1 diabetes is
scheduled doctor orders bed rest, a wet-to-dry dressing

to receive 30 U of 70/30 insulin. There is no change every shift, and blood glucose

70/30 insulin available. As a substitution, the monitoring before meals and bedtime. Why are

nurse may give the client: wet-to-dry dressings used for this client?

98 a. They contain exudate and provide a

a. 9 U regular insulin and 21 U neutral moist wound environment.

protamine Hagedorn (NPH). b. They protect the wound from

b. 21 U regular insulin and 9 U NPH. mechanical trauma and promote

c. 10 U regular insulin and 20 U NPH. healing.

d. 20 U regular insulin and 10 U NPH. c. They debride the wound and promote

68. Nurse Len should expect to administer healing by secondary intention.

which
d. They prevent the entrance of
medication to a client with gout?
microorganisms and minimize wound
a. aspirin
discomfort.
b. furosemide (Lasix)
71. Nurse Zeny is caring for a client in acute
c. colchicines
addisonian crisis. Which laboratory data would
d. calcium gluconate (Kalcinate)
the nurse expect to find?
69. Mr. Domingo with a history of hypertension
a. Hyperkalemia
is
b. Reduced blood urea nitrogen (BUN)
diagnosed with primary hyperaldosteronism.
c. Hypernatremia
This diagnosis indicates that the client's
d. Hyperglycemia
hypertension is caused by excessive hormone
72. A client is admitted for treatment of the
secretion from which of the following glands?
syndrome of inappropriate antidiuretic
a. Adrenal cortex
hormone
b. Pancreas
(SIADH). Which nursing intervention is
c. Adrenal medulla
appropriate?
d. Parathyroid
a. Infusing I.V. fluids rapidly as ordered
b. Encouraging increased oral intake d. Norepinephrine and epinephrine

c. Restricting fluids 76. On the third day after a partial

thyroidectomy,
d. Administering glucose-containing I.V.
Proserfina exhibits muscle twitching and
fluids as ordered
hyperirritability of the nervous system. When
73. A female client tells nurse Nikki that she has
questioned, the client reports numbness and
been working hard for the last 3 months to
tingling of the mouth and fingertips. Suspecting
control her type 2 diabetes mellitus with diet
a life-threatening electrolyte disturbance, the
and exercise. To determine the effectiveness of
nurse notifies the surgeon immediately. Which
the client's efforts, the nurse should check:
electrolyte disturbance most commonly follows
a. urine glucose level.
thyroid surgery?
b. fasting blood glucose level.
a. Hypocalcemia
c. serum fructosamine level.
b. Hyponatremia
d. glycosylated hemoglobin level.
c. Hyperkalemia
74. Nurse Trinity administered neutral
protamine d. Hypermagnesemia

Hagedorn (NPH) insulin to a diabetic client at 7 77. Which laboratory test value is elevated in
clients
a.m. At what time would the nurse expect the
who smoke and can't be used as a general
client to be most at risk for a hypoglycemic
indicator of cancer?
reaction?
a. Acid phosphatase level
a. 10:00 am
b. Serum calcitonin level
b. Noon
c. Alkaline phosphatase level
c. 4:00 pm
d. Carcinoembryonic antigen level
d. 10:00 pm
99
75. The adrenal cortex is responsible for
producing 78. Francis with anemia has been admitted to
the
which substances?
medical-surgical unit. Which assessment
a. Glucocorticoids and androgens
findings
b. Catecholamines and epinephrine
are characteristic of iron-deficiency anemia?
c. Mineralocorticoids and catecholamines
a. Nights sweats, weight loss, and diarrhea
b. Dyspnea, tachycardia, and pallor findings should the nurse expect when assessing

c. Nausea, vomiting, and anorexia the client?

d. Itching, rash, and jaundice a. Pallor, bradycardia, and reduced pulse

79. In teaching a female client who is HIV- pressure

positive
b. Pallor, tachycardia, and a sore tongue
about pregnancy, the nurse would know more
c. Sore tongue, dyspnea, and weight gain
teaching is necessary when the client says:
d. Angina, double vision, and anorexia
a. The baby can get the virus from my
82. After receiving a dose of penicillin, a client
placenta."
develops dyspnea and hypotension. Nurse
b. "I'm planning on starting on birth control
Celestina suspects the client is experiencing
pills."
anaphylactic shock. What should the nurse do
c. "Not everyone who has the virus gives
first?
birth to a baby who has the virus."
a. Page an anesthesiologist immediately
d. "I'll need to have a C-section if I become
and prepare to intubate the client.
pregnant and have a baby."
b. Administer epinephrine, as prescribed,
80. When preparing Judy with acquired
and prepare to intubate the client if
immunodeficiency syndrome (AIDS) for
necessary.
discharge to the home, the nurse should be sure
c. Administer the antidote for penicillin, as
to include which instruction?
prescribed, and continue to monitor the
a. "Put on disposable gloves before
client's vital signs.
bathing."
d. Insert an indwelling urinary catheter and
b. "Sterilize all plates and utensils in boiling
begin to infuse I.V. fluids as ordered.
water."
83. Mr. Marquez with rheumatoid arthritis is
c. "Avoid sharing such articles as about

toothbrushes and razors." to begin aspirin therapy to reduce

inflammation.
d. "Avoid eating foods from serving dishes
When teaching the client about aspirin, the
shared by other family members."
nurse discusses adverse reactions to prolonged
81. Nurse Marie is caring for a 32-year-old client
aspirin therapy. These include:
admitted with pernicious anemia. Which set of
a. weight gain. important for the nurse to advise the physician

b. fine motor tremors. to order:

c. respiratory acidosis. a. enzyme-linked immunosuppressant

d. bilateral hearing loss. assay (ELISA) test.

84. A 23-year-old client is diagnosed with b. electrolyte panel and hemogram.

human
c. stool for Clostridium difficile test.
immunodeficiency virus (HIV). After recovering
d. flat plate X-ray of the abdomen.
from the initial shock of the diagnosis, the client
87. A male client seeks medical evaluation for
expresses a desire to learn as much as possible
fatigue, night sweats, and a 20-lb weight loss in
about HIV and acquired immunodeficiency 6

syndrome (AIDS). When teaching the client weeks. To confirm that the client has been

about the immune system, the nurse states that infected with the human immunodeficiency
virus
adaptive immunity is provided by which type of
(HIV), the nurse expects the physician to order:
white blood cell?
100
a. Neutrophil
a. E-rosette immunofluorescence.
b. Basophil
b. quantification of T-lymphocytes.
c. Monocyte
c. enzyme-linked immunosorbent assay
d. Lymphocyte
(ELISA).
85. In an individual with Sjögren's syndrome,
nursing d. Western blot test with ELISA.

care should focus on: 88. A complete blood count is commonly

performed
a. moisture replacement.
before a Joe goes into surgery. What does this
b. electrolyte balance.
test seek to identify?
c. nutritional supplementation.
a. Potential hepatic dysfunction indicated
d. arrhythmia management.
by decreased blood urea nitrogen (BUN)
86. During chemotherapy for lymphocytic
leukemia, and creatinine levels

Mathew develops abdominal pain, fever, and b. Low levels of urine constituents normally

"horse barn" smelling diarrhea. It would be excreted in the urine

most
c. Abnormally low hematocrit (HCT) and
hemoglobin (Hb) levels arms and legs are itching.”

d. Electrolyte imbalance that could affect b. A client with cast on the right leg who

the blood's ability to coagulate properly states, “I have a funny feeling in my right

89. While monitoring a client for the leg.”

development
c. A client with osteomyelitis of the spine
of disseminated intravascular coagulation (DIC),
who states, “I am so nauseous that I
the nurse should take note of what assessment
can’t eat.”
parameters?
d. A client with rheumatoid arthritis who
a. Platelet count, prothrombin time, and
states, “I am having trouble sleeping.”
partial thromboplastin time
92. Nurse Sarah is caring for clients on the
b. Platelet count, blood glucose levels, and surgical

white blood cell (WBC) count floor and has just received report from the

c. Thrombin time, calcium levels, and previous shift. Which of the following clients

potassium levels should the nurse see first?

d. Fibrinogen level, WBC, and platelet a. A 35-year-old admitted three hours ago

count with a gunshot wound; 1.5 cm area of

90. When taking a dietary history from a newly dark drainage noted on the dressing.

admitted female client, Nurse Len should b. A 43-year-old who had a mastectomy

remember that which of the following foods is a two days ago; 23 ml of serosanguinous

common allergen? fluid noted in the Jackson-Pratt drain.

a. Bread c. A 59-year-old with a collapsed lung due

b. Carrots to an accident; no drainage noted in the

c. Orange previous eight hours.

d. Strawberries d. A 62-year-old who had an abdominalperineal

91. Nurse John is caring for clients in the resection three days ago; client
outpatient
complaints of chills.
clinic. Which of the following phone calls should
93. Nurse Eve is caring for a client who had a
the nurse return first?
thyroidectomy 12 hours ago for treatment of
a. A client with hepatitis A who states, “My
Grave’s disease. The nurse would be most
concerned if which of the following was 101

observed? d. Insert a Foley catheter

a. Blood pressure 138/82, respirations 16, 96. Nurse Jannah teaches an elderly client with

oral temperature 99 degrees Fahrenheit. right-sided weakness how to use cane. Which of

b. The client supports his head and neck the following behaviors, if demonstrated by the

when turning his head to the right. client to the nurse, indicates that the teaching

c. The client spontaneously flexes his wrist was effective?

when the blood pressure is obtained. a. The client holds the cane with his right

d. The client is drowsy and complains of hand, moves the can forward followed

sore throat. by the right leg, and then moves the left

94. Julius is admitted with complaints of severe leg.

pain
b. The client holds the cane with his right
in the lower right quadrant of the abdomen. To
hand, moves the cane forward followed
assist with pain relief, the nurse should take
by his left leg, and then moves the right
which of the following actions?
leg.
a. Encourage the client to change positions
c. The client holds the cane with his left
frequently in bed.
hand, moves the cane forward followed
b. Administer Demerol 50 mg IM q 4 hours
by the right leg, and then moves the left
and PRN.
leg.
c. Apply warmth to the abdomen with a
d. The client holds the cane with his left
heating pad.
hand, moves the cane forward followed
d. Use comfort measures and pillows to
by his left leg, and then moves the right
position the client.
leg.
95. Nurse Tina prepares a client for peritoneal
97. An elderly client is admitted to the nursing
dialysis. Which of the following actions should home

the nurse take first? setting. The client is occasionally confused and

a. Assess for a bruit and a thrill. her gait is often unsteady. Which of the

b. Warm the dialysate solution. following actions, if taken by the nurse, is most

c. Position the client on the left side. appropriate?

a. Ask the woman’s family to provide 99. Nurse Deric is supervising a group of elderly

personal items such as photos or clients in a residential home setting. The nurse

mementos. knows that the elderly are at greater risk of

b. Select a room with a bed by the door so developing sensory deprivation for what
reason?
the woman can look down the hall.
a. Increased sensitivity to the side effects
c. Suggest the woman eat her meals in the
of medications.
room with her roommate.
b. Decreased visual, auditory, and
d. Encourage the woman to ambulate in
gustatory abilities.
the halls twice a day.
c. Isolation from their families and familiar
98. Nurse Evangeline teaches an elderly client
how surroundings.

to use a standard aluminum walker. Which of d. Decrease musculoskeletal function and

the following behaviors, if demonstrated by the mobility.

client, indicates that the nurse’s teaching was 100. A male client with emphysema becomes

effective? restless and confused. What step should

a. The client slowly pushes the walker nurse Jasmine take next?

forward 12 inches, then takes small a. Encourage the client to perform pursed

steps forward while leaning on the lip breathing.

walker. b. Check the client’s temperature.

b. The client lifts the walker, moves it c. Assess the client’s potassium level.

forward 10 inches, and then takes d. Increase the client’s oxygen flow rate.

several small steps forward. 102

c. The client supports his weight on the Answers and Rationale – Care of Clients with

walker while advancing it forward, then Physiologic and Psychosocial Alterations

takes small steps while balancing on the 1. Answer: (C) Loose, bloody

walker. Rationale: Normal bowel function and

softformed
d. The client slides the walker 18 inches
stool usually do not occur until around
forward, then takes small steps while
the seventh day following surgery. The stool
holding onto the walker for balance.
consistency is related to how much water is important baseline information for cardiac

being absorbed. arrest procedure

2. Answer: (A) On the client’s right side 6. Answer: (C) Make sure that the client takes

Rationale: The client has left visual field food and medications at prescribed intervals.

blindness. The client will see only from the Rationale: Food and drug therapy will prevent

right side. the accumulation of hydrochloric acid, or will

3. Answer: (C) Check respirations, stabilize neutralize and buffer the acid that does
spine,
accumulate.
and check circulation
7. Answer: (B) Continue treatment as ordered.
Rationale: Checking the airway would be
Rationale: The effects of heparin are
priority, and a neck injury should be
monitored by the PTT is normally 30 to 45
suspected.
seconds; the therapeutic level is 1.5 to 2 times
4. Answer: (D) Decreasing venous return
the normal level.
through
8. Answer: (B) In the operating room.
vasodilation.
Rationale: The stoma drainage bag is applied
Rationale: The significant effect of
in the operating room. Drainage from the
nitroglycerin is vasodilation and decreased
ileostomy contains secretions that are rich in
venous return, so the heart does not have to
digestive enzymes and highly irritating to the
work hard.
skin. Protection of the skin from the effects of
5. Answer: (A) Call for help and note the time.
these enzymes is begun at once. Skin exposed
Rationale: Having established, by stimulating
to these enzymes even for a short time
the client, that the client is unconscious rather
becomes reddened, painful, and excoriated.
than sleep, the nurse should immediately call
9. Answer: (B) Flat on back.
for help. This may be done by dialing the
Rationale: To avoid the complication of a
operator from the client’s phone and giving
painful spinal headache that can last for
the hospital code for cardiac arrest and the
several days, the client is kept in flat in a
client’s room number to the operator, of if the
supine position for approximately 4 to 12
phone is not available, by pulling the
hours postoperatively. Headaches are
emergency call button. Noting the time is
believed to be causes by the seepage of
cerebral spinal fluid from the puncture site. By symptoms, acute asthma is the most likely

keeping the client flat, cerebral spinal fluid diagnosis. He’s unlikely to have bronchial

pressures are equalized, which avoids trauma pneumonia without a productive cough and

to the neurons. fever and he’s too young to have developed

10. Answer: (C) The client is oriented when (COPD) and emphysema.

aroused from sleep, and goes back to sleep 14. Answer: (B) Respiratory arrest

immediately. Rationale: Narcotics can cause respiratory

Rationale: This finding suggest that the level arrest if given in large quantities. It’s unlikely

of consciousness is decreasing. the client will have asthma attack or a seizure

11. Answer: (A) Altered mental status and or wake up on his own.

dehydration 15. Answer: (D) Decreased vital capacity

Rationale: Fever, chills, hemortysis, dyspnea, Rationale: Reduction in vital capacity is a

cough, and pleuritic chest pain are the normal physiologic change includes decreased

common symptoms of pneumonia, but elderly 103

clients may first appear with only an altered elastic recoil of the lungs, fewer functional

lentil status and dehydration due to a blunted capillaries in the alveoli, and an increased in

immune response. residual volume.

12. Answer: (B) Chills, fever, night sweats, and 16. Answer: (C) Presence of premature
ventricular
hemoptysis
contractions (PVCs) on a cardiac monitor.
Rationale: Typical signs and symptoms are
Rationale: Lidocaine drips are commonly used
chills, fever, night sweats, and hemoptysis.
to treat clients whose arrhythmias haven’t
Chest pain may be present from coughing, but
been controlled with oral medication and who
isn’t usual. Clients with TB typically have
lowgrade are having PVCs that are visible on the cardiac

fevers, not higher than 102°F (38.9°C). monitor. SaO2, blood pressure, and ICP are

Nausea, headache, and photophobia aren’t important factors but aren’t as significant as

usual TB symptoms. PVCs in the situation.

13. Answer:(A) Acute asthma 17. Answer: (B) Avoid foods high in vitamin K

Rationale: Based on the client’s history and Rationale: The client should avoid consuming
large amounts of vitamin K because vitamin K themselves to discover changes that have

can interfere with anticoagulation. The client occurred in the breast. Only a physician can

may need to report diarrhea, but isn’t effect diagnose lumps that are cancerous, areas of

of taking an anticoagulant. An electric razornot thickness or fullness that signal the presence

a straight razor-should be used to prevent of a malignancy, or masses that are fibrocystic

cuts that cause bleeding. Aspirin may increase as opposed to malignant.

the risk of bleeding; acetaminophen should be 21. Answer: (C) Balance the client’s periods of

used to pain relief. activity and rest.

18. Answer: (C) Clipping the hair in the area Rationale: A client with hyperthyroidism

Rationale: Hair can be a source of infection needs to be encouraged to balance periods of

and should be removed by clipping. Shaving activity and rest. Many clients with

the area can cause skin abrasions and hyperthyroidism are hyperactive and complain

depilatories can irritate the skin. of feeling very warm.

19. Answer: (A) Bone fracture 22. Answer: (B) Increase his activity level.

Rationale: Bone fracture is a major Rationale: The client should be encouraged to

complication of osteoporosis that results increase his activity level. aintaining an ideal

when loss of calcium and phosphate increased weight; following a low-cholesterol, low

the fragility of bones. Estrogen deficiencies sodium diet; and avoiding stress are all

result from menopause-not osteoporosis. important factors in decreasing the risk of

Calcium and vitamin D supplements may be atherosclerosis.

used to support normal bone metabolism, But 23. Answer: (A) Laminectomy

a negative calcium balance isn’t a Rationale: The client who has had spinal

complication of osteoporosis. Dowager’s surgery, such as laminectomy, must be log

hump results from bone fractures. It develops rolled to keep the spinal column straight when

when repeated vertebral fractures increase turning. Thoracotomy and cystectomy may

spinal curvature. turn themselves or may be assisted into a

20. Answer: (C) Changes from previous comfortable position. Under normal

examinations. circumstances, hemorrhoidectomy is an

Rationale: Women are instructed to examine outpatient procedure, and the client may
resume normal activities immediately after 27. Answer: (A) A progressively deeper breaths

surgery. followed by shallower breaths with apneic

24. Answer: (D) Avoiding straining during bowel periods.

movement or bending at the waist. Rationale: Cheyne-Strokes respirations are

Rationale: The client should avoid straining, breaths that become progressively deeper

lifting heavy objects, and coughing harshly fallowed by shallower respirations with

because these activities increase intraocular 104

pressure. Typically, the client is instructed to apneas periods. Biot’s respirations are rapid,

avoid lifting objects weighing more than 15 lb deep breathing with abrupt pauses between

(7kg) – not 5lb. instruct the client when lying each breath, and equal depth between each

in bed to lie on either the side or back. The breath. Kussmaul’s respirationa are rapid,

client should avoid bright light by wearing deep breathing without pauses. Tachypnea is

sunglasses. shallow breathing with increased respiratory

25. Answer: (D) Before age 20. rate.

Rationale: Testicular cancer commonly occurs 28. Answer: (B) Fine crackles

in men between ages 20 and 30. A male client Rationale: Fine crackles are caused by fluid in

should be taught how to perform testicular the alveoli and commonly occur in clients with

self- examination before age 20, preferably heart failure. Tracheal breath sounds are

when he enters his teens. auscultated over the trachea. Coarse crackles

26. Answer: (B) Place a saline-soaked sterile are caused by secretion accumulation in the

dressing on the wound. airways. Friction rubs occur with pleural

Rationale: The nurse should first place inflammation.

salinesoaked
29. Answer: (B) The airways are so swollen that
sterile dressings on the open wound to no

prevent tissue drying and possible infection. air cannot get through

Then the nurse should call the physician and Rationale: During an acute attack, wheezing

take the client’s vital signs. The dehiscence may stop and breath sounds become

needs to be surgically closed, so the nurse inaudible because the airways are so swollen

should never try to close it. that air can’t get through. If the attack is over
and swelling has decreased, there would be standing. If the client is unconscious, she

no more wheezing and less emergent concern. should lay him down. A nurse should never

Crackles do not replace wheezes during an leave a choking client alone.

acute asthma attack. 33. Answer: (B) Current health promotion

30. Answer: (D) Place the client on his side, activities

remove dangerous objects, and protect his Rationale: Recognizing an individual’s positive

head. health measures is very useful. General health

Rationale: During the active seizure phase, in the previous 10 years is important,

initiate precautions by placing the client on his however, the current activities of an 84 year

side, removing dangerous objects, and old client are most significant in planning care.

protecting his head from injury. A bite block Family history of disease for a client in later

should never be inserted during the active years is of minor significance. Marital status

seizure phase. Insertion can break the teeth information may be important for discharge

and lead to aspiration. planning but is not as significant for

31. Answer: (B) Kinked or obstructed chest tube addressing the immediate medical problem.

Rationales: Kinking and blockage of the chest 34. Answer: (C) Place the client in a side lying

tube is a common cause of a tension position, with the head of the bed lowered.

pneumothorax. Infection and excessive Rationale: The client should be positioned in a

drainage won’t cause a tension side-lying position with the head of the bed

pneumothorax. Excessive water won’t affect lowered to prevent aspiration. A small amount

the chest tube drainage. of toothpaste should be used and the mouth

32. Answer: (D) Stay with him but not intervene swabbed or suctioned to remove pooled
at
secretions. Lemon glycerin can be drying if
this time.
used for extended periods. Brushing the teeth
Rationale: If the client is coughing, he should
with the client lying supine may lead to
be able to dislodge the object or cause a
aspiration. Hydrogen peroxide is caustic to
complete obstruction. If complete obstruction
tissues and should not be used.
occurs, the nurse should perform the
35. Answer: (C) Pneumonia
abdominal thrust maneuver with the client
Rationale: Fever productive cough and
pleuritic chest pain are common signs and if this is a primary or secondary infection.

symptoms of pneumonia. The client with 38. Answer: (B) Bronchodilators

ARDS has dyspnea and hypoxia with Rationale: Bronchodilators are the first line of

worsening hypoxia over time, if not treated treatment for asthma because
bronchoconstriction
aggressively. Pleuritic chest pain varies with
is the cause of reduced airflow.
respiration, unlike the constant chest pain
Beta- adrenergic blockers aren’t used to treat
during an MI; so this client most likely isn’t
asthma and can cause broncho- constriction.
having an MI. the client with TB typically has a
Inhaled oral steroids may be given to reduce
cough producing blood-tinged sputum. A
the inflammation but aren’t used for
sputum culture should be obtained to confirm
emergency relief.
the nurse’s suspicions.
39. Answer: (C) Chronic obstructive bronchitis
36. Answer: (C) A 43-yesr-old homeless man
with Rationale: Because of this extensive smoking

a history of alcoholism history and symptoms the client most likely

Rationale: Clients who are economically has chronic obstructive bronchitis. Client with

disadvantaged, malnourished, and have ARDS have acute symptoms of hypoxia and

reduced immunity, such as a client with a typically need large amounts of oxygen.

history of alcoholism, are at extremely high Clients with asthma and emphysema tend not

risk for developing TB. A high school student, to have chronic cough or peripheral edema.

day- care worker, and businessman probably 40. Answer: (A) The patient is under local

have a much low risk of contracting TB. anesthesia during the procedure Rationale:

37. Answer: (C ) To determine the extent of Before the procedure, the patient is

lesions administered with drugs that would help to

Rationale: If the lesions are large enough, the prevent infection and rejection of the

chest X-ray will show their presence in the transplanted cells such as antibiotics,

lungs. Sputum culture confirms the diagnosis. cytotoxic, and corticosteroids. During the

There can be false-positive and false-negative transplant, the patient is placed under general

105 anesthesia.

skin test results. A chest X-ray can’t determine 41. Answer: (D) Raise the side rails
Rationale: A patient who is disoriented is at is on L.V. medication that requires close

risk of falling out of bed. The initial action of monitoring. After assessing this client, the

the nurse should be raising the side rails to nurse should assess the client with

ensure patients safety. thrombophlebitis who is receiving a heparin

42. Answer: (A) Crowd red blood cells infusion, and then the 58- year-old client

Rationale: The excessive production of white admitted 2 days ago with heart failure (his

blood cells crowd out red blood cells signs and symptoms are resolving and don’t

production which causes anemia to occur. require immediate attention). The lowest

43. Answer: (B) Leukocytosis priority is the 89-year-old with end-stage

Rationale: Chronic Lymphocytic leukemia (CLL) right-sided heart failure, who requires
timeconsuming
is characterized by increased production of
supportive measures.
leukocytes and lymphocytes resulting in
46. Answer: (C) Cocaine
leukocytosis, and proliferation of these cells
Rationale: Because of the client’s age and
within the bone marrow, spleen and liver.
negative medical history, the nurse should
44. Answer: (A) Explain the risks of not having
the question her about cocaine use. Cocaine

surgery increases myocardial oxygen consumption and

Rationale: The best initial response is to can cause coronary artery spasm, leading to

explain the risks of not having the surgery. If tachycardia, ventricular fibrillation, myocardial

the client understands the risks but still ischemia, and myocardial infarction.

refuses the nurse should notify the physician Barbiturate overdose may trigger respiratory

and the nurse supervisor and then record the depression and slow pulse. Opioids can cause

client’s refusal in the nurses’ notes. marked respiratory depression, while

45. Answer: (D) The 75-year-old client who was benzodiazepines can cause drowsiness and

admitted 1 hour ago with new-onset atrial confusion.

fibrillation and is receiving L.V. dilitiazem 47. Answer: (B) Nonmobile mass with irregular

(Cardizem) edges

Rationale: The client with atrial fibrillation has Rationale: Breast cancer tumors are fixed,

the greatest potential to become unstable and hard, and poorly delineated with irregular
edges. A mobile mass that is soft and easily lymph nodes, and ascending degrees of

delineated is most often a fluid-filled benign distant metastasis is classified as T1, T2, T3, or

cyst. Axillary lymph nodes may or may not be T4; N0; and M1, M2, or M3.

palpable on initial detection of a cancerous 50. Answer: (D) "Keep the stoma moist."

mass. Nipple retraction — not eversion — Rationale: The nurse should instruct the client

may be a sign of cancer. to keep the stoma moist, such as by applying a

48. Answer: (C) Radiation thin layer of petroleum jelly around the edges,

Rationale: The usual treatment for vaginal because a dry stoma may become irritated.

cancer is external or intravaginal radiation The nurse should recommend placing a stoma

therapy. Less often, surgery is performed. bib over the stoma to filter and warm air

Chemotherapy typically is prescribed only if before it enters the stoma. The client should

vaginal cancer is diagnosed in an early stage, begin performing stoma care without

which is rare. Immunotherapy isn't used to assistance as soon as possible to gain

treat vaginal cancer. independence in self-care activities.

49. Answer: (B) Carcinoma in situ, no abnormal 51. Answer: (B) Lung cancer

regional lymph nodes, and no evidence of Rationale: Lung cancer is the most deadly type

distant metastasis of cancer in both women and men. Breast

Rationale: TIS, N0, M0 denotes carcinoma in cancer ranks second in women, followed (in

situ, no abnormal regional lymph nodes, and descending order) by colon and rectal cancer,

no evidence of distant metastasis. No pancreatic cancer, ovarian cancer, uterine

evidence of primary tumor, no abnormal cancer, lymphoma, leukemia, liver cancer,

106 brain cancer, stomach cancer, and multiple

regional lymph nodes, and no evidence of myeloma.

distant metastasis is classified as T0, N0, M0. If 52. Answer: (A) miosis, partial eyelid ptosis, and

the tumor and regional lymph nodes can't be anhidrosis on the affected side of the face.

assessed and no evidence of metastasis exists, Rationale: Horner's syndrome, which occurs

the lesion is classified as TX, NX, M0. A when a lung tumor invades the ribs and

progressive increase in tumor size, no affects the sympathetic nerve ganglia, is

demonstrable metastasis of the regional characterized by miosis, partial eyelid ptosis,

and anhidrosis on the affected side of the cancers. Stool Hematest detects blood, which

face. Chest pain, dyspnea, cough, weight loss, is a sign of colorectal cancer; however, the

and fever are associated with pleural tumors. test doesn't confirm the diagnosis. CEA may

Arm and shoulder pain and atrophy of the arm be elevated in colorectal cancer but isn't

and hand muscles on the affected side suggest considered a confirming test. An abdominal CT

Pancoast's tumor, a lung tumor involving the scan is used to stage the presence of

first thoracic and eighth cervical nerves within colorectal cancer.

the brachial plexus. Hoarseness in a client 56. Answer: (B) A fixed nodular mass with

with lung cancer suggests that the tumor has dimpling of the overlying skin

extended to the recurrent laryngeal nerve; Rationale: A fixed nodular mass with dimpling

dysphagia suggests that the lung tumor is of the overlying skin is common during late

compressing the esophagus. stages of breast cancer. Many women have

53. 53. Answer: (A) prostate-specific antigen, slightly asymmetrical breasts. Bloody nipple

which is used to screen for prostate cancer. discharge is a sign of intraductal papilloma, a

Rationale: PSA stands for prostate-specific benign condition. Multiple firm, round, freely

antigen, which is used to screen for prostate movable masses that change with the

cancer. The other answers are incorrect. menstrual cycle indicate fibrocystic breasts, a

54. Answer: (D) "Remain supine for the time benign condition.

specified by the physician." Rationale: The 57. Answer: (A) Liver

nurse should instruct the client to remain Rationale: The liver is one of the five most

supine for the time specified by the physician. common cancer metastasis sites. The others

Local anesthetics used in a subarachnoid block are the lymph nodes, lung, bone, and brain.

don't alter the gag reflex. No interactions The colon, reproductive tract, and WBCs are

between local anesthetics and food occur. occasional metastasis sites.

Local anesthetics don't cause hematuria. 58. Answer: (D) The client wears a watch and

55. Answer: (C) Sigmoidoscopy wedding band.

Rationale: Used to visualize the lower GI tract, Rationale: During an MRI, the client should

sigmoidoscopy and proctoscopy aid in the wear no metal objects, such as jewelry,

detection of two-thirds of all colorectal because the strong magnetic field can pull on
them, causing injury to the client and (if they instrument into the joint to see it clearly.

fly off) to others. The client must lie still Other contraindications for this procedure

during the MRI but can talk to those include skin and wound infections. Joint pain

performing the test by way of the microphone may be an indication, not a contraindication,

inside the scanner tunnel. The client should for arthroscopy. Joint deformity and joint

hear thumping sounds, which are caused by stiffness aren't contraindications for this

the sound waves thumping on the magnetic procedure.

field. 61. Answer: (D) Gouty arthritis

59. Answer: (C) The recommended daily Rationale: Gouty arthritis, a metabolic disease,

allowance of calcium may be found in a wide is characterized by urate deposits and pain in

variety of foods. the joints, especially those in the feet and

107 legs. Urate deposits don't occur in septic or

Rationale: Premenopausal women require traumatic arthritis. Septic arthritis results from

1,000 mg of calcium per day. Postmenopausal bacterial invasion of a joint and leads to

women require 1,500 mg per day. It's often, inflammation of the synovial lining. Traumatic

though not always, possible to get the arthritis results from blunt trauma to a joint or

recommended daily requirement in the foods ligament. Intermittent arthritis is a rare,

we eat. Supplements are available but not benign condition marked by regular, recurrent

always necessary. Osteoporosis doesn't show joint effusions, especially in the knees.

up on ordinary X-rays until 30% of the bone 62. Answer: (B) 30 ml/hou

loss has occurred. Bone densitometry can Rationale: An infusion prepared with 25,000

detect bone loss of 3% or less. This test is units of heparin in 500 ml of saline solution

sometimes recommended routinely for yields 50 units of heparin per milliliter of

women over 35 who are at risk. Strenuous solution. The equation is set up as 50 units

exercise won't cause fractures. times X (the unknown quantity) equals 1,500

60. Answer: (C) Joint flexion of less than 50% units/hour, X equals 30 ml/hour.

Rationale: Arthroscopy is contraindicated in 63. Answer: (B) Loss of muscle contraction

clients with joint flexion of less than 50% decreasing venous return

because of technical problems in inserting the Rationale: In clients with hemiplegia or

hemiparesis loss of muscle contraction joints.

decreases venous return and may cause 67. Answer: (A) a. 9 U regular insulin and 21 U

swelling of the affected extremity. neutral protamine Hagedorn (NPH).

Contractures, or bony calcifications may occur Rationale: A 70/30 insulin preparation is 70%

with a stroke, but don’t appear with swelling. NPH and 30% regular insulin. Therefore, a

DVT may develop in clients with a stroke but is correct substitution requires mixing 21 U of

more likely to occur in the lower extremities. NPH and 9 U of regular insulin. The other

A stroke isn’t linked to protein loss. choices are incorrect dosages for the

64. Answer: (B) It appears on the distal prescribed insulin.

interphalangeal joint 68. Answer: (C) colchicines

Rationale: Heberden’s nodes appear on the Rationale: A disease characterized by joint

distal interphalageal joint on both men and inflammation (especially in the great toe),

women. Bouchard’s node appears on the gout is caused by urate crystal deposits in the

dorsolateral aspect of the proximal joints. The physician prescribes colchicine to

interphalangeal joint. reduce these deposits and thus ease joint

65. Answer: (B) Osteoarthritis is a localized inflammation. Although aspirin is used to

disease rheumatoid arthritis is systemic reduce joint inflammation and pain in clients

Rationale: Osteoarthritis is a localized disease, with osteoarthritis and rheumatoid arthritis, it

rheumatoid arthritis is systemic. Osteoarthritis isn't indicated for gout because it has no

isn’t gender-specific, but rheumatoid arthritis effect on urate crystal formation. Furosemide,

is. Clients have dislocations and subluxations a diuretic, doesn't relieve gout. Calcium

in both disorders. gluconate is used to reverse a negative

66. Answer: (C) The cane should be used on the calcium balance and relieve muscle cramps,

unaffected side not to treat gout.

Rationale: A cane should be used on the 69. Answer: (A) Adrenal cortex

unaffected side. A client with osteoarthritis Rationale: Excessive secretion of aldosterone

should be encouraged to ambulate with a in the adrenal cortex is responsible for the

cane, walker, or other assistive device as client's hypertension. This hormone acts on

needed; their use takes weight and stress off the renal tubule, where it promotes
reabsorption of sodium and excretion of in the liver and muscle, causing hypoglycemia.

108 72. Answer: (C) Restricting fluids

potassium and hydrogen ions. The pancreas Rationale: To reduce water retention in a

mainly secretes hormones involved in fuel client with the SIADH, the nurse should

metabolism. The adrenal medulla secretes the restrict fluids. Administering fluids by any

catecholamines — epinephrine and route would further increase the client's

norepinephrine. The parathyroids secrete already heightened fluid load.

parathyroid hormone. 73. Answer: (D) glycosylated hemoglobin level.

70. Answer: (C) They debride the wound and Rationale: Because some of the glucose in the

promote healing by secondary intention bloodstream attaches to some of the

Rationale: For this client, wet-to-dry dressings hemoglobin and stays attached during the

are most appropriate because they clean the 120-day life span of red blood cells,

foot ulcer by debriding exudate and necrotic glycosylated hemoglobin levels provide

tissue, thus promoting healing by secondary information about blood glucose levels during

intention. Moist, transparent dressings the previous 3 months. Fasting blood glucose

contain exudate and provide a moist wound and urine glucose levels only give information

environment. Hydrocolloid dressings prevent about glucose levels at the point in time when

the entrance of microorganisms and minimize they were obtained. Serum fructosamine

wound discomfort. Dry sterile dressings levels provide information about blood

protect the wound from mechanical trauma glucose control over the past 2 to 3 weeks.

and promote healing. 74. Answer: (C) 4:00 pm

71. Answer: (A) Hyperkalemia Rationale: NPH is an intermediate-acting

Rationale: In adrenal insufficiency, the client insulin that peaks 8 to 12 hours after

has hyperkalemia due to reduced aldosterone administration. Because the nurse

secretion. BUN increases as the glomerular administered NPH insulin at 7 a.m., the client

filtration rate is reduced. Hyponatremia is is at greatest risk for hypoglycemia from 3

caused by reduced aldosterone secretion. p.m. to 7 p.m.

Reduced cortisol secretion leads to impaired 75. Answer: (A) Glucocorticoids and androgens

glyconeogenesis and a reduction of glycogen Rationale: The adrenal glands have two
divisions, the cortex and medulla. The cortex treatment is successful. An elevated acid

produces three types of hormones: phosphatase level may indicate prostate

glucocorticoids, mineralocorticoids, and cancer. An elevated alkaline phosphatase level

androgens. The medulla produces may reflect bone metastasis. An elevated

catecholamines— epinephrine and serum calcitonin level usually signals thyroid

norepinephrine. cancer.

76. Answer: (A) Hypocalcemia 78. Answer: (B) Dyspnea, tachycardia, and pallor

Rationale: Hypocalcemia may follow thyroid Rationale: Signs of iron-deficiency anemia

surgery if the parathyroid glands were include dyspnea, tachycardia, and pallor as

removed accidentally. Signs and symptoms of well as fatigue, listlessness, irritability, and

hypocalcemia may be delayed for up to 7 days headache. Night sweats, weight loss, and

after surgery. Thyroid surgery doesn't directly diarrhea may signal acquired

cause serum sodium, potassium, or immunodeficiency syndrome (AIDS). Nausea,

magnesium abnormalities. Hyponatremia may vomiting, and anorexia may be signs of

occur if the client inadvertently received too hepatitis B. Itching, rash, and jaundice may

much fluid; however, this can happen to any result from an allergic or hemolytic reaction.

surgical client receiving I.V. fluid therapy, not 79. Answer: (D) "I'll need to have a C-section if I

just one recovering from thyroid surgery. become pregnant and have a baby."

Hyperkalemia and hypermagnesemia usually Rationale: The human immunodeficiency virus

are associated with reduced renal excretion of (HIV) is transmitted from mother to child via

potassium and magnesium, not thyroid 109

surgery. the transplacental route, but a Cesarean

77. Answer: (D) Carcinoembryonic antigen level section delivery isn't necessary when the

Rationale: In clients who smoke, the level of mother is HIV-positive. The use of birth

carcinoembryonic antigen is elevated. control will prevent the conception of a child

Therefore, it can't be used as a general who might have HIV. It's true that a mother

indicator of cancer. However, it is helpful in who's HIV positive can give birth to a baby

monitoring cancer treatment because the who's HIV negative.

level usually falls to normal within 1 month if 80. Answer: (C) "Avoid sharing such articles as
toothbrushes and razors." medications, such as antihistamines and

Rationale: The human immunodeficiency virus corticosteroids; if these medications don't

(HIV), which causes AIDS, is most relieve the respiratory compromise associated

concentrated in the blood. For this reason, the with anaphylaxis, the nurse should prepare to

client shouldn't share personal articles that intubate the client. No antidote for penicillin

may be blood-contaminated, such as exists; however, the nurse should continue to

toothbrushes and razors, with other family monitor the client's vital signs. A client who

members. HIV isn't transmitted by bathing or remains hypotensive may need fluid

by eating from plates, utensils, or serving resuscitation and fluid intake and output

dishes used by a person with AIDS. monitoring; however, administering

81. Answer: (B) Pallor, tachycardia, and a sore epinephrine is the first priority.

tongue 83. Answer: (D) bilateral hearing loss.

Rationale: Pallor, tachycardia, and a sore Rationale: Prolonged use of aspirin and other

tongue are all characteristic findings in salicylates sometimes causes bilateral hearing

pernicious anemia. Other clinical loss of 30 to 40 decibels. Usually, this adverse

manifestations include anorexia; weight loss; a effect resolves within 2 weeks after the

smooth, beefy red tongue; a wide pulse therapy is discontinued. Aspirin doesn't lead

pressure; palpitations; angina; weakness; to weight gain or fine motor tremors. Large or

fatigue; and paresthesia of the hands and feet. toxic salicylate doses may cause respiratory

Bradycardia, reduced pulse pressure, weight alkalosis, not respiratory acidosis.

gain, and double vision aren't characteristic 84. Answer: (D) Lymphocyte

findings in pernicious anemia. Rationale: The lymphocyte provides adaptive

82. Answer: (B) Administer epinephrine, as immunity — recognition of a foreign antigen

prescribed, and prepare to intubate the client and formation of memory cells against the

if necessary. antigen. Adaptive immunity is mediated by B

Rationale: To reverse anaphylactic shock, the and T lymphocytes and can be acquired

nurse first should administer epinephrine, a actively or passively. The neutrophil is crucial

potent bronchodilator as prescribed. The to phagocytosis. The basophil plays an

physician is likely to order additional important role in the release of inflammatory

mediators. The monocyte functions in case of "horse barn" smelling diarrhea.

phagocytosis and monokine production. 87. Answer: (D) Western blot test with ELISA.

85. Answer: (A) moisture replacement. Rationale: HIV infection is detected by

Rationale: Sjogren's syndrome is an analyzing blood for antibodies to HIV, which

autoimmune disorder leading to progressive form approximately 2 to 12 weeks after

loss of lubrication of the skin, GI tract, ears, exposure to HIV and denote infection. The

nose, and vagina. Moisture replacement is the Western blot test — electrophoresis of

mainstay of therapy. Though malnutrition and antibody proteins — is more than 98%

electrolyte imbalance may occur as a result of accurate in detecting HIV antibodies when

Sjogren's syndrome's effect on the GI tract, it used in conjunction with the ELISA. It isn't

isn't the predominant problem. Arrhythmias specific when used alone. E-rosette

aren't a problem associated with Sjogren's immunofluorescence is used to detect viruses

syndrome. 110

86. Answer: (C) stool for Clostridium difficile in general; it doesn't confirm HIV infection.
test.
Quantification of T-lymphocytes is a useful
Rationale: Immunosuppressed clients — for
monitoring test but isn't diagnostic for HIV.
example, clients receiving chemotherapy, —
The ELISA test detects HIV antibody particles
are at risk for infection with C. difficile, which
but may yield inaccurate results; a positive
causes "horse barn" smelling diarrhea.
ELISA result must be confirmed by the
Successful treatment begins with an accurate
Western blot test.
diagnosis, which includes a stool test. The
88. Answer: (C) Abnormally low hematocrit
ELISA test is diagnostic for human (HCT)

immunodeficiency virus (HIV) and isn't and hemoglobin (Hb) levels

indicated in this case. An electrolyte panel and Rationale: Low preoperative HCT and Hb

hemogram may be useful in the overall levels indicate the client may require a blood

evaluation of a client but aren't diagnostic for transfusion before surgery. If the HCT and Hb

specific causes of diarrhea. A flat plate of the levels decrease during surgery because of

abdomen may provide useful information blood loss, the potential need for a

about bowel function but isn't indicated in the transfusion increases. Possible renal failure is
indicated by elevated BUN or creatinine levels. Rationale: The client is at risk for peritonitis;

Urine constituents aren't found in the blood. should be assessed for further symptoms and

Coagulation is determined by the presence of infection.

appropriate clotting factors, not electrolytes. 93. Answer: (C) The client spontaneously flexes

89. Answer: (A) Platelet count, prothrombin his wrist when the blood pressure is obtained.
time,
Rationale: Carpal spasms indicate
and partial thromboplastin time
hypocalcemia.
Rationale: The diagnosis of DIC is based on the
94. Answer: (D) Use comfort measures and
results of laboratory studies of prothrombin
pillows to position the client.
time, platelet count, thrombin time, partial
Rationale: Using comfort measures and
thromboplastin time, and fibrinogen level as
pillows to position the client is a
well as client history and other assessment nonpharmacological

factors. Blood glucose levels, WBC count, methods of pain relief.

calcium levels, and potassium levels aren't 95. Answer: (B) Warm the dialysate solution.

used to confirm a diagnosis of DIC. Rationale: Cold dialysate increases discomfort.

90. Answer: (D) Strawberries The solution should be warmed to body

Rationale: Common food allergens include temperature in warmer or heating pad; don’t

berries, peanuts, Brazil nuts, cashews, use microwave oven.

shellfish, and eggs. Bread, carrots, and 96. Answer: (C) The client holds the cane with
his
oranges rarely cause allergic reactions.
left hand, moves the cane forward followed
91. Answer: (B) A client with cast on the right
leg by the right leg, and then moves the left leg.

who states, “I have a funny feeling in my right Rationale: The cane acts as a support and aids

leg.” in weight bearing for the weaker right leg.

Rationale: It may indicate neurovascular 97. Answer: (A) Ask the woman’s family to

compromise, requires immediate assessment. provide personal items such as photos or

92. Answer: (D) A 62-year-old who had an mementos.

abdominal-perineal resection three days ago; Rationale: Photos and mementos provide

client complaints of chills. visual stimulation to reduce sensory

deprivation. ureteral colic and hematuria is to decrease:

98. Answer: (B) The client lifts the walker, moves a. Pain

it forward 10 inches, and then takes several b. Weight

small steps forward. c. Hematuria

Rationale: A walker needs to be picked up, d. Hypertension

placed down on all legs. 3. Matilda, with hyperthyroidism is to receive

99. Answer: (C) Isolation from their families and Lugol’s iodine solution before a subtotal

familiar surroundings. thyroidectomy is performed. The nurse is aware

Rationale: Gradual loss of sight, hearing, and that this medication is given to:

taste interferes with normal functioning. a. Decrease the total basal metabolic rate.

100. Answer: (A) Encourage the client to b. Maintain the function of the parathyroid
perform
glands.
pursed lip breathing.
c. Block the formation of thyroxine by the
Rationale: Purse lip breathing prevents the
thyroid gland.
collapse of lung unit and helps client control
d. Decrease the size and vascularity of the
rate and depth of breathing.
thyroid gland.
111
4. Ricardo, was diagnosed with type I diabetes.
TEST IV - Care of Clients with Physiologic and The

Psychosocial Alterations nurse is aware that acute hypoglycemia also can

1. Randy has undergone kidney transplant, what develop in the client who is diagnosed with:

assessment would prompt Nurse Katrina to a. Liver disease

suspect organ rejection? b. Hypertension

a. Sudden weight loss c. Type 2 diabetes

b. Polyuria d. Hyperthyroidism

c. Hypertension 5. Tracy is receiving combination chemotherapy

for
d. Shock
treatment of metastatic carcinoma. Nurse Ruby
2. The immediate objective of nursing care for
an should monitor the client for the systemic side

overweight, mildly hypertensive male client effect of:

with
a. Ascites 8. Patrick is in the oliguric phase of acute
tubular
b. Nystagmus
necrosis and is experiencing fluid and
c. Leukopenia
electrolyte
d. Polycythemia
imbalances. The client is somewhat confused
6. Norma, with recent colostomy expresses
and complains of nausea and muscle weakness.
concern about the inability to control the
As part of the prescribed therapy to correct this
passage of gas. Nurse Oliver should suggest that
electrolyte imbalance, the nurse would expect
the client plan to:
to:
a. Eliminate foods high in cellulose.
a. Administer Kayexalate
b. Decrease fluid intake at meal times.
b. Restrict foods high in protein
c. Avoid foods that in the past caused
c. Increase oral intake of cheese and milk.
flatus.
d. Administer large amounts of normal
d. Adhere to a bland diet prior to social
saline via I.V.
events.
9. Mario has burn injury. After Forty48 hours,
7. Nurse Ron begins to teach a male client how the
to
physician orders for Mario 2 liters of IV fluid to
perform colostomy irrigations. The nurse would
be administered q12 h. The drop factor of the
evaluate that the instructions were understood
tubing is 10 gtt/ml. The nurse should set the
when the client states, “I should:
flow to provide:
a. Lie on my left side while instilling the
a. 18 gtt/min
irrigating solution.”
b. 28 gtt/min
b. Keep the irrigating container less than
c. 32 gtt/min
18 inches above the stoma.”
d. 36 gtt/min
c. Instill a minimum of 1200 ml of irrigating
10. Terence suffered from burn injury. Using the
solution to stimulate evacuation of the rule

bowel.” of nines, which has the largest percent of

burns?
d. Insert the irrigating catheter deeper into
a. Face and neck
the stoma if cramping occurs during the
b. Right upper arm and penis
procedure.”
c. Right thigh and penis the hypoxic stimulus for breathing.

d. Upper trunk b. Hypoxia stimulates the central

11. Herbert, a 45 year old construction engineer chemoreceptors in the medulla that
is
makes the client breath.
brought to the hospital unconscious after falling
c. Oxygen is administered best using a
112 nonrebreathing

from a 2-story building. When assessing the mask

client, the nurse would be most concerned if d. Blood gases are monitored using a pulse
the
oximeter.
assessment revealed:
14. Tonny has undergoes a left thoracotomy and
a. Reactive pupils a

b. A depressed fontanel partial pneumonectomy. Chest tubes are

c. Bleeding from ears inserted, and one-bottle water-seal drainage is

d. An elevated temperature instituted in the operating room. In the

12. Nurse Sherry is teaching male client postanesthesia care unit Tonny is placed in
regarding
Fowler's position on either his right side or on
his permanent artificial pacemaker. Which
his back. The nurse is aware that this position:
information given by the nurse shows her
a. Reduce incisional pain.
knowledge deficit about the artificial cardiac
b. Facilitate ventilation of the left lung.
pacemaker?
c. Equalize pressure in the pleural space.
a. take the pulse rate once a day, in the
d. Increase venous return
morning upon awakening
15. Kristine is scheduled for a bronchoscopy.
b. May be allowed to use electrical When

appliances teaching Kristine what to expect afterward, the

c. Have regular follow up care nurse's highest priority of information would be:

d. May engage in contact sports a. Food and fluids will be withheld for at

13. The nurse is ware that the most relevant least 2 hours.

knowledge about oxygen administration to a b. Warm saline gargles will be done q 2h.

male client with COPD is c. Coughing and deep-breathing exercises

a. Oxygen at 1-2L/min is given to maintain will be done q2h.

d. Only ice chips and cold liquids will be transmitted during oral sex.

allowed initially. 18. Maritess was recently diagnosed with a

16. Nurse Tristan is caring for a male client in genitourinary problem and is being examined in
acute
the emergency department. When palpating
renal failure. The nurse should expect her
hypertonic
kidneys, the nurse should keep which
glucose, insulin infusions, and sodium anatomical

bicarbonate to be used to treat: fact in mind?

a. hypernatremia. a. The left kidney usually is slightly higher

b. hypokalemia. than the right one.

c. hyperkalemia. b. The kidneys are situated just above the

d. hypercalcemia. adrenal glands.

17. Ms. X has just been diagnosed with c. The average kidney is approximately 5
condylomata
cm (2") long and 2 to 3 cm (¾" to 1-1/8")
acuminata (genital warts). What information is
wide.
appropriate to tell this client?
d. The kidneys lie between the 10th and
a. This condition puts her at a higher risk
12th thoracic vertebrae.
for cervical cancer; therefore, she should
19. Jestoni with chronic renal failure (CRF) is
have a Papanicolaou (Pap) smear
admitted to the urology unit. The nurse is aware
annually.
that the diagnostic test are consistent with CRF
b. The most common treatment is if

metronidazole (Flagyl), which should the result is:

eradicate the problem within 7 to 10 a. Increased pH with decreased hydrogen

days. ions.

c. The potential for transmission to her 113

sexual partner will be eliminated if b. Increased serum levels of potassium,

condoms are used every time they have magnesium, and calcium.

sexual intercourse. c. Blood urea nitrogen (BUN) 100 mg/dl

d. The human papillomavirus (HPV), which and serum creatinine 6.5 mg/ dl.

causes condylomata acuminata, can't be d. Uric acid analysis 3.5 mg/dl and
phenolsulfonphthalein (PSP) excretion 22. Ricardo is scheduled for a prostatectomy,
and
75%.
the anesthesiologist plans to use a spinal
20. Katrina has an abnormal result on a
(subarachnoid) block during surgery. In the
Papanicolaou test. After admitting that she read
operating room, the nurse positions the client
her chart while the nurse was out of the room,
according to the anesthesiologist's instructions.
Katrina asks what dysplasia means. Which
Why does the client require special positioning
definition should the nurse provide?
for this type of anesthesia?
a. Presence of completely undifferentiated
a. To prevent confusion
tumor cells that don't resemble cells of
b. To prevent seizures
the tissues of their origin.
c. To prevent cerebrospinal fluid (CSF)
b. Increase in the number of normal cells in
leakage
a normal arrangement in a tissue or an
d. To prevent cardiac arrhythmias
organ.
23. A male client had a nephrectomy 2 days ago
c. Replacement of one type of fully
and
differentiated cell by another in tissues
is now complaining of abdominal pressure and
where the second type normally isn't
nausea. The first nursing action should be to:
found.
a. Auscultate bowel sounds.
d. Alteration in the size, shape, and
b. Palpate the abdomen.
organization of differentiated cells.
c. Change the client's position.
21. During a routine checkup, Nurse Mariane
d. Insert a rectal tube.
assesses a male client with acquired
24. Wilfredo with a recent history of rectal
immunodeficiency syndrome (AIDS) for signs bleeding
and
is being prepared for a colonoscopy. How should
symptoms of cancer. What is the most common
the nurse Patricia position the client for this test
AIDS-related cancer?
initially?
a. Squamous cell carcinoma
a. Lying on the right side with legs straight
b. Multiple myeloma
b. Lying on the left side with knees bent
c. Leukemia
c. Prone with the torso elevated
d. Kaposi's sarcoma
d. Bent over with hands touching the floor
25. A male client with inflammatory bowel 28. Mr. Mendoza who has suffered a
disease
cerebrovascular accident (CVA) is too weak to
undergoes an ileostomy. On the first day after
move on his own. To help the client avoid
surgery, Nurse Oliver notes that the client's
pressure ulcers, Nurse Celia should:
stoma appears dusky. How should the nurse
a. Turn him frequently.
interpret this finding?
b. Perform passive range-of-motion (ROM)
a. Blood supply to the stoma has been
exercises.
interrupted.
c. Reduce the client's fluid intake.
b. This is a normal finding 1 day after
d. Encourage the client to use a footboard.
surgery.
114
c. The ostomy bag should be adjusted.
29. Nurse Maria plans to administer
d. An intestinal obstruction has occurred. dexamethasone

26. Anthony suffers burns on the legs, which cream to a female client who has dermatitis
nursing over

intervention helps prevent contractures? the anterior chest. How should the nurse apply

a. Applying knee splints this topical agent?

b. Elevating the foot of the bed a. With a circular motion, to enhance

c. Hyperextending the client's palms absorption.

d. Performing shoulder range-of-motion b. With an upward motion, to increase

exercises blood supply to the affected area

27. Nurse Ron is assessing a client admitted with c. In long, even, outward, and downward

second- and third-degree burns on the face, strokes in the direction of hair growth

arms, and chest. Which finding indicates a d. In long, even, outward, and upward

potential problem? strokes in the direction opposite hair

a. Partial pressure of arterial oxygen growth

(PaO2) value of 80 mm Hg. 30. Nurse Kate is aware that one of the
following
b. Urine output of 20 ml/hour.
classes of medication protects the ischemic
c. White pulmonary secretions.
myocardium by blocking catecholamines and
d. Rectal temperature of 100.6° F (38° C).
sympathetic nerve stimulation is:
a. Beta -adrenergic blockers c. Cholesterol intake of less than 300 mg

b. Calcium channel blocker daily

c. Narcotics d. Less than 10% of calories from saturated

d. Nitrates fat

31. A male client has jugular distention. On 34. A 37-year-old male client was admitted to
what the

position should the nurse place the head of the coronary care unit (CCU) 2 days ago with an

bed to obtain the most accurate reading of acute myocardial infarction. Which of the

jugular vein distention? following actions would breach the client

a. High Fowler’s confidentiality?

b. Raised 10 degrees a. The CCU nurse gives a verbal report to

c. Raised 30 degrees the nurse on the telemetry unit before

d. Supine position transferring the client to that unit

32. The nurse is aware that one of the following b. The CCU nurse notifies the on-call

classes of medications maximizes cardiac physician about a change in the client’s

performance in clients with heart failure by condition

increasing ventricular contractility? c. The emergency department nurse calls

a. Beta-adrenergic blockers up the latest electrocardiogram results

b. Calcium channel blocker to check the client’s progress.

c. Diuretics d. At the client’s request, the CCU nurse

d. Inotropic agents updates the client’s wife on his condition

33. A male client has a reduced serum high- 35. A male client arriving in the emergency
density
department is receiving cardiopulmonary
lipoprotein (HDL) level and an elevated
resuscitation from paramedics who are giving
lowdensity
ventilations through an endotracheal (ET) tube
lipoprotein (LDL) level. Which of the
that they placed in the client’s home. During a
following dietary modifications is not
pause in compressions, the cardiac monitor
appropriate for this client?
shows narrow QRS complexes and a heart rate
a. Fiber intake of 25 to 30 g daily
of beats/minute with a palpable pulse. Which of
b. Less than 30% of calories from fat
the following actions should the nurse take c. Electrocardiogram, complete blood
first?
count, testing for occult blood,
a. Start an L.V. line and administer
comprehensive serum metabolic panel.
amiodarone (Cardarone), 300 mg L.V.
d. Electroencephalogram, alkaline
over 10 minutes.
phosphatase and aspartate
b. Check endotracheal tube placement.
aminotransferase levels, basic serum
c. Obtain an arterial blood gas (ABG)
metabolic panel
sample.
38. Macario had coronary artery bypass graft
d. Administer atropine, 1 mg L.V. (CABG)

36. After cardiac surgery, a client’s blood surgery 3 days ago. Which of the following
pressure
conditions is suspected by the nurse when a
measures 126/80 mm Hg. Nurse Katrina
decrease in platelet count from 230,000 ul to
determines that mean arterial pressure (MAP) is
5,000 ul is noted?
which of the following?
a. Pancytopenia
a. 46 mm Hg
b. Idiopathic thrombocytopemic purpura
b. 80 mm Hg
(ITP)
c. 95 mm Hg
c. Disseminated intravascular coagulation
d. 90 mm Hg
(DIC)
37. A female client arrives at the emergency
d. Heparin-associated thrombosis and
department with chest and stomach pain and a
thrombocytopenia (HATT)
report of black tarry stool for several months.
39. Which of the following drugs would be
Which of the following order should the nurse ordered

Oliver anticipate? by the physician to improve the platelet count in

a. Cardiac monitor, oxygen, creatine kinase a male client with idiopathic thrombocytopenic

and lactate dehydrogenase levels purpura (ITP)?

b. Prothrombin time, partial a. Acetylsalicylic acid (ASA)

thromboplastin time, fibrinogen and b. Corticosteroids

fibrin split product values. c. Methotrezate

115 d. Vitamin K
40. A female client is scheduled to receive a d. Persistent hypothermia
heart
44. Francis with leukemia has neutropenia.
valve replacement with a porcine valve. Which Which of

of the following types of transplant is this? the following functions must frequently

a. Allogeneic assessed?

b. Autologous a. Blood pressure

c. Syngeneic b. Bowel sounds

d. Xenogeneic c. Heart sounds

41. Marco falls off his bicycle and injuries his d. Breath sounds
ankle.
45. The nurse knows that neurologic
Which of the following actions shows the initial complications

response to the injury in the extrinsic pathway? of multiple myeloma (MM) usually involve
which
a. Release of Calcium
of the following body system?
b. Release of tissue thromboplastin
a. Brain
c. Conversion of factors XII to factor XIIa
b. Muscle spasm
d. Conversion of factor VIII to factor VIIIa
c. Renal dysfunction
42. Instructions for a client with systemic lupus
d. Myocardial irritability
erythematosus (SLE) would include information
46. Nurse Patricia is aware that the average
about which of the following blood dyscrasias?
length
a. Dressler’s syndrome
of time from human immunodeficiency virus
b. Polycythemia
(HIV) infection to the development of acquired
c. Essential thrombocytopenia
immunodeficiency syndrome (AIDS)?
d. Von Willebrand’s disease
a. Less than 5 years
43. The nurse is aware that the following
b. 5 to 7 years
symptom
c. 10 years
is most commonly an early indication of stage 1
d. More than 10 years
Hodgkin’s disease?
47. An 18-year-old male client admitted with
a. Pericarditis
heat
b. Night sweat
stroke begins to show signs of disseminated
c. Splenomegaly
intravascular coagulation (DIC). Which of the leukemia (ALL) and beginning chemotherapy.

following laboratory findings is most consistent 50. Stacy is discharged from the hospital
following
with DIC?
her chemotherapy treatments. Which
a. Low platelet count
statement
b. Elevated fibrinogen levels
of Stacy’s mother indicated that she
c. Low levels of fibrin degradation products understands

d. Reduced prothrombin time when she will contact the physician?

48. Mario comes to the clinic complaining of a. “I should contact the physician if Stacy
fever,
has difficulty in sleeping”.
drenching night sweats, and unexplained weight
b. “I will call my doctor if Stacy has
loss over the past 3 months. Physical
persistent vomiting and diarrhea”.
examination reveals a single enlarged
c. “My physician should be called if Stacy is
supraclavicular lymph node. Which of the
irritable and unhappy”.
following is the most probable diagnosis?
d. “Should Stacy have continued hair loss, I
a. Influenza
need to call the doctor”.
b. Sickle cell anemia
51. Stacy’s mother states to the nurse that it is
c. Leukemia hard

d. Hodgkin’s disease to see Stacy with no hair. The best response for

116 the nurse is:

49. A male client with a gunshot wound requires a. “Stacy looks very nice wearing a hat”.
an
b. “You should not worry about her hair,
emergency blood transfusion. His blood type is
just be glad that she is alive”.
AB negative. Which blood type would be the
c. “Yes it is upsetting. But try to cover up
safest for him to receive?
your feelings when you are with her or
a. AB Rh-positive
else she may be upset”.
b. A Rh-positive
d. “This is only temporary; Stacy will regrow
c. A Rh-negative
new hair in 3-6 months, but may
d. O Rh-positive
be different in texture”.
Situation: Stacy is diagnosed with acute
lymphoid
52. Stacy has beginning stomatitis. To promote client with which of the following conditions?
oral
a. Adult respiratory distress syndrome
hygiene and comfort, the nurse in-charge
(ARDS)
should:
b. Asthma
a. Provide frequent mouthwash with
c. Chronic obstructive bronchitis
normal saline.
d. Emphysema
b. Apply viscous Lidocaine to oral ulcers as
56. Jose is in danger of respiratory arrest
needed. following

c. Use lemon glycerine swabs every 2 the administration of a narcotic analgesic. An

hours. arterial blood gas value is obtained. Nurse Oliver

d. Rinse mouth with Hydrogen Peroxide. would expect the paco2 to be which of the

53. During the administration of chemotherapy following values?

agents, Nurse Oliver observed that the IV site is a. 15 mm Hg

red and swollen, when the IV is touched Stacy b. 30 mm Hg

shouts in pain. The first nursing action to take is: c. 40 mm Hg

a. Notify the physician d. 80 mm Hg

b. Flush the IV line with saline solution 57. Timothy’s arterial blood gas (ABG) results
are as
c. Immediately discontinue the infusion
follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm
d. Apply an ice pack to the site, followed by
Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result
warm compress.
represents which of the following conditions?
54. The term “blue bloater” refers to a male
client a. Metabolic acidosis

which of the following conditions? b. Metabolic alkalosis

a. Adult respiratory distress syndrome c. Respiratory acidosis

(ARDS) d. Respiratory alkalosis

b. Asthma 58. Norma has started a new drug for

hypertension.
c. Chronic obstructive bronchitis
Thirty minutes after she takes the drug, she
d. Emphysema
develops chest tightness and becomes short of
55. The term “pink puffer” refers to the female
breath and tachypneic. She has a decreased Which clinical manifestation is most common
level
with this condition?
of consciousness. These signs indicate which of
a. Increased urine output
the following conditions?
b. Altered level of consciousness
a. Asthma attack
c. Decreased tendon reflex
b. Pulmonary embolism
d. Hypotension
c. Respiratory failure
62. When Mr. Gonzales regained consciousness,
d. Rheumatoid arthritis the

117 physician orders 50 ml of Lactose p.o. every 2

Situation: Mr. Gonzales was admitted to the hours. Mr. Gozales develops diarrhea. The nurse
hospital
best action would be:
with ascites and jaundice. To rule out cirrhosis
a. “I’ll see if your physician is in the
of the
hospital”.
liver:
b. “Maybe you’re reacting to the drug; I
59. Which laboratory test indicates liver
cirrhosis? will withhold the next dose”.
a. Decreased red blood cell count c. “I’ll lower the dosage as ordered so the
b. Decreased serum acid phosphate level drug causes only 2 to 4 stools a day”.
c. Elevated white blood cell count d. “Frequently, bowel movements are
d. Elevated serum aminotransferase needed to reduce sodium level”.
60. 60.The biopsy of Mr. Gonzales confirms the 63. Which of the following groups of symptoms
diagnosis of cirrhosis. Mr. Gonzales is at indicates a ruptured abdominal aortic
increased risk for excessive bleeding primarily aneurysm?
because of: a. Lower back pain, increased blood
a. Impaired clotting mechanism pressure, decreased red blood cell (RBC)
b. Varix formation count, increased white blood (WBC)
c. Inadequate nutrition count.
d. Trauma of invasive procedure b. Severe lower back pain, decreased blood
61. Mr. Gonzales develops hepatic pressure, decreased RBC count,
encephalopathy.
increased WBC count.
c. Severe lower back pain, decreased blood a. Anaphylactic shock

pressure, decreased RBC count, b. Cardiogenic shock

decreased RBC count, decreased WBC c. Distributive shock

count. d. Myocardial infarction (MI)

d. Intermitted lower back pain, decreased 67. A client with hypertension asks the nurse
which
blood pressure, decreased RBC count,
factors can cause blood pressure to drop to
increased WBC count.
normal levels?
64. After undergoing a cardiac catheterization,
Tracy a. Kidneys’ excretion to sodium only.

has a large puddle of blood under his buttocks. b. Kidneys’ retention of sodium and water

Which of the following steps should the nurse c. Kidneys’ excretion of sodium and water

take first? d. Kidneys’ retention of sodium and

a. Call for help. excretion of water

b. Obtain vital signs 68. Nurse Rose is aware that the statement that

c. Ask the client to “lift up” best explains why furosemide (Lasix) is

d. Apply gloves and assess the groin site administered to treat hypertension is:

65. Which of the following treatment is a a. It dilates peripheral blood vessels.

suitable
b. It decreases sympathetic
surgical intervention for a client with unstable
cardioacceleration.
angina?
c. It inhibits the angiotensin-coverting
a. Cardiac catheterization
enzymes
b. Echocardiogram
d. It inhibits reabsorption of sodium and
c. Nitroglycerin
water in the loop of Henle.
d. Percutaneous transluminal coronary
118
angioplasty (PTCA)
69. Nurse Nikki knows that laboratory results
66. The nurse is aware that the following terms
supports the diagnosis of systemic lupus
used
erythematosus (SLE) is:
to describe reduced cardiac output and
a. Elavated serum complement level
perfusion impairment due to ineffective
b. Thrombocytosis, elevated sedimentation
pumping of the heart is:
rate the following responses best describes the

c. Pancytopenia, elevated antinuclear result?

antibody (ANA) titer a. Appropriate; lowering carbon dioxide

d. Leukocysis, elevated blood urea nitrogen (CO2) reduces intracranial pressure (ICP)

(BUN) and creatinine levels b. Emergent; the client is poorly

70. Arnold, a 19-year-old client with a mild oxygenated

concussion is discharged from the emergency c. Normal

department. Before discharge, he complains of d. Significant; the client has alveolar

a
hypoventilation
headache. When offered acetaminophen, his
72. When prioritizing care, which of the
mother tells the nurse the headache is severe following

and she would like her son to have something clients should the nurse Olivia assess first?

stronger. Which of the following responses by a. A 17-year-old client’s 24-hours

the nurse is appropriate? postappendectomy

a. “Your son had a mild concussion, b. A 33-year-old client with a recent

acetaminophen is strong enough.” diagnosis of Guillain-Barre syndrome

b. “Aspirin is avoided because of the c. A 50-year-old client 3 days

danger of Reye’s syndrome in children or postmyocardial infarction

young adults.” d. A 50-year-old client with diverticulitis

c. “Narcotics are avoided after a head 73. JP has been diagnosed with gout and wants
to
injury because they may hide a
know why colchicine is used in the treatment of
worsening condition.”
gout. Which of the following actions of
d. Stronger medications may lead to
colchicines explains why it’s effective for gout?
vomiting, which increases the
a. Replaces estrogen
intracarnial pressure (ICP).”
b. Decreases infection
71. When evaluating an arterial blood gas from
a c. Decreases inflammation

male client with a subdural hematoma, the d. Decreases bone demineralization

nurse notes the Paco2 is 30 mm Hg. Which of 74. Norma asks for information about
osteoarthritis.
Which of the following statements about Thirty-six hours later, the client's urine output

osteoarthritis is correct? suddenly rises above 200 ml/hour, leading the

a. Osteoarthritis is rarely debilitating nurse to suspect diabetes insipidus. Which

b. Osteoarthritis is a rare form of arthritis laboratory findings support the nurse's

suspicion
c. Osteoarthritis is the most common form
of diabetes insipidus?
of arthritis
a. Above-normal urine and serum
d. Osteoarthritis afflicts people over 60
osmolality levels
75. Ruby is receiving thyroid replacement
therapy b. Below-normal urine and serum

develops the flu and forgets to take her thyroid osmolality levels

replacement medicine. The nurse understands c. Above-normal urine osmolality level,

that skipping this medication will put the client below-normal serum osmolality level

at risk for developing which of the following d. Below-normal urine osmolality level,
lifethreatening
above-normal serum osmolality level
complications?
119
a. Exophthalmos
78. Jomari is diagnosed with hyperosmolar
b. Thyroid storm
hyperglycemic nonketotic syndrome (HHNS) is
c. Myxedema coma
stabilized and prepared for discharge. When
d. Tibial myxedema
preparing the client for discharge and home
76. Nurse Sugar is assessing a client with
management, which of the following statements
Cushing's
indicates that the client understands her
syndrome. Which observation should the nurse
condition and how to control it?
report to the physician immediately?
a. "I can avoid getting sick by not becoming
a. Pitting edema of the legs
dehydrated and by paying attention to
b. An irregular apical pulse
my need to urinate, drink, or eat more
c. Dry mucous membranes
than usual."
d. Frequent urination
b. "If I experience trembling, weakness,
77. Cyrill with severe head trauma sustained in a
car and headache, I should drink a glass of
accident is admitted to the intensive care unit. soda that contains sugar."
c. "I will have to monitor my blood glucose 81. Which of the following laboratory test
results
level closely and notify the physician if
would suggest to the nurse Len that a client has
it's constantly elevated."
a corticotropin-secreting pituitary adenoma?
d. "If I begin to feel especially hungry and
a. High corticotropin and low cortisol levels
thirsty, I'll eat a snack high in
b. Low corticotropin and high cortisol levels
carbohydrates."
c. High corticotropin and high cortisol
79. A 66-year-old client has been complaining of
levels
sleeping more, increased urination, anorexia,
d. Low corticotropin and low cortisol levels
weakness, irritability, depression, and bone pain
82. A male client is scheduled for a
that interferes with her going outdoors. Based
transsphenoidal
on these assessment findings, the nurse would
hypophysectomy to remove a pituitary tumor.
suspect which of the following disorders?
Preoperatively, the nurse should assess for
a. Diabetes mellitus
potential complications by doing which of the
b. Diabetes insipidus
following?
c. Hypoparathyroidism
a. Testing for ketones in the urine
d. Hyperparathyroidism
b. Testing urine specific gravity
80. Nurse Lourdes is teaching a client recovering
c. Checking temperature every 4 hours
from addisonian crisis about the need to take
d. Performing capillary glucose testing
fludrocortisone acetate and hydrocortisone at
every 4 hours
home. Which statement by the client indicates
83. Capillary glucose monitoring is being
an understanding of the instructions? performed

a. "I'll take my hydrocortisone in the late every 4 hours for a client diagnosed with

afternoon, before dinner." diabetic ketoacidosis. Insulin is administered

b. "I'll take all of my hydrocortisone in the using a scale of regular insulin according to

morning, right after I wake up." glucose results. At 2 p.m., the client has a

c. "I'll take two-thirds of the dose when I capillary glucose level of 250 mg/dl for which he

wake up and one-third in the late receives 8 U of regular insulin. Nurse Mariner

afternoon." should expect the dose's:

d. "I'll take the entire dose at bedtime." a. onset to be at 2 p.m. and its peak to be
at 3 p.m. sites, the nurse should provide which

b. onset to be at 2:15 p.m. and its peak to instruction?

be at 3 p.m. 120

c. onset to be at 2:30 p.m. and its peak to a. "Inject insulin into healthy tissue with

be at 4 p.m. large blood vessels and nerves."

d. onset to be at 4 p.m. and its peak to be b. "Rotate injection sites within the same

at 6 p.m. anatomic region, not among different

84. The physician orders laboratory tests to regions."

confirm
c. "Administer insulin into areas of scar
hyperthyroidism in a female client with classic
tissue or hypotrophy whenever
signs and symptoms of this disorder. Which test
possible."
result would confirm the diagnosis?
d. "Administer insulin into sites above
a. No increase in the thyroid-stimulating
muscles that you plan to exercise heavily
hormone (TSH) level after 30 minutes
later that day."
during the TSH stimulation test
86. Nurse Sarah expects to note an elevated
b. A decreased TSH level serum

c. An increase in the TSH level after 30 glucose level in a client with hyperosmolar

minutes during the TSH stimulation test hyperglycemic nonketotic syndrome (HHNS).

d. Below-normal levels of serum Which other laboratory finding should the nurse

triiodothyronine (T3) and serum anticipate?

thyroxine (T4) as detected by a. Elevated serum acetone level

radioimmunoassay b. Serum ketone bodies

85. Rico with diabetes mellitus must learn how c. Serum alkalosis
to
d. Below-normal serum potassium level
self-administer insulin. The physician has
87. For a client with Graves' disease, which
prescribed 10 U of U-100 regular insulin and 35 nursing

U of U-100 isophane insulin suspension (NPH) to intervention promotes comfort?

be taken before breakfast. When teaching the a. Restricting intake of oral fluids

client how to select and rotate insulin injection b. Placing extra blankets on the client's bed
c. Limiting intake of high-carbohydrate c. Bronchitis

foods d. Pneumonia

d. Maintaining room temperature in the 91. A 67-year-old client develops acute

shortness of
low-normal range
breath and progressive hypoxia requiring right
88. Patrick is treated in the emergency
department femur. The hypoxia was probably caused by

for a Colles' fracture sustained during a fall. which of the following conditions?

What is a Colles' fracture? a. Asthma attack

a. Fracture of the distal radius b. Atelectasis

b. Fracture of the olecranon c. Bronchitis

c. Fracture of the humerus d. Fat embolism

d. Fracture of the carpal scaphoid 92. A client with shortness of breath has
decreased
89. Cleo is diagnosed with osteoporosis. Which
to absent breath sounds on the right side, from
electrolytes are involved in the development of
the apex to the base. Which of the following
this disorder?
conditions would best explain this?
a. Calcium and sodium
a. Acute asthma
b. Calcium and phosphorous
b. Chronic bronchitis
c. Phosphorous and potassium
c. Pneumonia
d. Potassium and sodium
d. Spontaneous pneumothorax
90. Johnny a firefighter was involved in
93. A 62-year-old male client was in a motor
extinguishing a house fire and is being treated
vehicle
to
accident as an unrestrained driver. He’s now in
smoke inhalation. He develops severe hypoxia
the emergency department complaining of
48 hours after the incident, requiring intubation
difficulty of breathing and chest pain. On
and mechanical ventilation. He most likely has
auscultation of his lung field, no breath sounds
developed which of the following conditions?
are present in the upper lobe. This client may
a. Adult respiratory distress syndrome
have which of the following conditions?
(ARDS)
a. Bronchitis
b. Atelectasis
b. Pneumonia
c. Pneumothorax 97. After a motor vehicle accident, Armand an
22-
d. Tuberculosis (TB)
year-old client is admitted with a
94. If a client requires a pneumonectomy, what
pneumothorax.
fills
The surgeon inserts a chest tube and attaches it
the area of the thoracic cavity?
to a chest drainage system. Bubbling soon
a. The space remains filled with air only
appears in the water seal chamber. Which of the
b. The surgeon fills the space with a gel
following is the most likely cause of the
c. Serous fluids fills the space and
bubbling?
consolidates the region
a. Air leak
d. The tissue from the other lung grows
b. Adequate suction
over to the other side
c. Inadequate suction
95. Hemoptysis may be present in the client
with a d. Kinked chest tube

pulmonary embolism because of which of the 98. Nurse Michelle calculates the IV flow rate for
a
following reasons?
postoperative client. The client receives 3,000
a. Alveolar damage in the infracted area
ml
b. Involvement of major blood vessels in
of Ringer’s lactate solution IV to run over 24
the occluded area
hours. The IV infusion set has a drop factor of 10
c. Loss of lung parenchyma
drops per milliliter. The nurse should regulate
d. Loss of lung tissue
the client’s IV to deliver how many drops per
121
minute?
96. Aldo with a massive pulmonary embolism
a. 18
will
b. 21
have an arterial blood gas analysis performed to
c. 35
determine the extent of hypoxia. The acid-base
d. 40
disorder that may be present is?
99. Mickey, a 6-year-old child with a congenital
a. Metabolic acidosis
heart disorder is admitted with congestive heart
b. Metabolic alkalosis
failure. Digoxin (lanoxin) 0.12 mg is ordered for
c. Respiratory acidosis
the child. The bottle of Lanoxin contains .05 mg
d. Respiratory alkalosis
of Lanoxin in 1 ml of solution. What amount caused by uretheral distention and

should the nurse administer to the child? smooth muscle spasm; relief form pain is

a. 1.2 ml the priority.

b. 2.4 ml 3. Answer: (D) Decrease the size and

c. 3.5 ml vascularity of the thyroid gland.

d. 4.2 ml Rationale: Lugol’s solution provides

100. Nurse Alexandra teaches a client about iodine, which aids in decreasing the
elastic
vascularity of the thyroid gland, which
stockings. Which of the following statements,
limits the risk of hemorrhage when
if made by the client, indicates to the nurse
surgery is performed.
that the teaching was successful?
4. Answer: (A) Liver Disease
a. “I will wear the stockings until the
Rationale: The client with liver disease has
physician tells me to remove them.”
a decreased ability to metabolize
b. “I should wear the stockings even when I
carbohydrates because of a decreased
am sleep.”
ability to form glycogen (glycogenesis) and
c. “Every four hours I should remove the
to form glucose from glycogen.
stockings for a half hour.”
5. Answer: (C) Leukopenia
d. “I should put on the stockings before
Rationale: Leukopenia, a reduction in
getting out of bed in the morning.”
WBCs, is a systemic effect of
122
chemotherapy as a result of
Answers and Rationale – Care of Clients with
myelosuppression.
Physiologic and Psychosocial Alterations
6. Answer: (C) Avoid foods that in the past
1. Answer: (C) Hypertension
caused flatus.
Rationale: Hypertension, along with fever,
Rationale: Foods that bothered a person
and tenderness over the grafted kidney,
preoperatively will continue to do so after
reflects acute rejection.
a colostomy.
2. Answer: (A) Pain
7. Answer: (B) Keep the irrigating container
Rationale: Sharp, severe pain (renal colic)
less than 18 inches above the stoma.”
radiating toward the genitalia and thigh is
Rationale: This height permits the solution
to flow slowly with little force so that easily contribute to increased intracranial

excessive peristalsis is not immediately pressure and brain herniation.

precipitated. 12. Answer: (D) may engage in contact sports

8. Answer: (A) Administer Kayexalate Rationale: The client should be advised by

Rationale: Kayexalate,a potassium the nurse to avoid contact sports. This will

exchange resin, permits sodium to be prevent trauma to the area of the

exchanged for potassium in the intestine, pacemaker generator.

reducing the serum potassium level. 13. Answer: (A) Oxygen at 1-2L/min is given to

9. Answer:(B) 28 gtt/min maintain the hypoxic stimulus for

Rationale: This is the correct flow rate; breathing.

multiply the amount to be infused (2000 Rationale: COPD causes a chronic CO2

ml) by the drop factor (10) and divide the retention that renders the medulla

result by the amount of time in minutes insensitive to the CO2 stimulation for

(12 hours x 60 minutes) breathing. The hypoxic state of the client

10. Answer: (D) Upper trunk then becomes the stimulus for breathing.

Rationale: The percentage designated for Giving the client oxygen in low

each burned part of the body using the concentrations will maintain the client’s

rule of nines: Head and neck 9%; Right hypoxic drive.

upper extremity 9%; Left upper extremity 14. Answer: (B) Facilitate ventilation of the

9%; Anterior trunk 18%; Posterior trunk left lung.

18%; Right lower extremity 18%; Left Rationale: Since only a partial

lower extremity 18%; Perineum 1%. pneumonectomy is done, there is a need

11. Answer: (C) Bleeding from ears to promote expansion of this remaining

Rationale: The nurse needs to perform a Left lung by positioning the client on the

thorough assessment that could indicate opposite unoperated side.

alterations in cerebral function, increased 15. Answer: (A) Food and fluids will be

intracranial pressures, fractures and withheld for at least 2 hours.

bleeding. Bleeding from the ears occurs Rationale: Prior to bronchoscopy, the

only with basal skull fractures that can doctors sprays the back of the throat with
anesthetic to minimize the gag reflex and very important for early detection.

thus facilitate the insertion of the Because condylomata acuminata is a

bronchoscope. Giving the client food and virus, there is no permanent cure.

drink after the procedure without Because condylomata acuminata can

checking on the return of the gag reflex occur on the vulva, a condom won't

can cause the client to aspirate. The gag protect sexual partners. HPV can be

reflex usually returns after two hours. transmitted to other parts of the body,

16. Answer: (C) hyperkalemia. such as the mouth, oropharynx, and

123 larynx.

Rationale: Hyperkalemia is a common 18. Answer: (A) The left kidney usually is

complication of acute renal failure. It's slightly higher than the right one.

life-threatening if immediate action isn't Rationale: The left kidney usually is

taken to reverse it. The administration of slightly higher than the right one. An

glucose and regular insulin, with sodium adrenal gland lies atop each kidney. The

bicarbonate if necessary, can temporarily average kidney measures approximately

prevent cardiac arrest by moving 11 cm (4-3/8") long, 5 to 5.8 cm (2" to

potassium into the cells and temporarily 2¼") wide, and 2.5 cm (1") thick. The

reducing serum potassium levels. kidneys are located retroperitoneally, in

Hypernatremia, hypokalemia, and the posterior aspect of the abdomen, on

hypercalcemia don't usually occur with either side of the vertebral column. They

acute renal failure and aren't treated with lie between the 12th thoracic and 3rd

glucose, insulin, or sodium bicarbonate. lumbar vertebrae.

17. Answer: (A) This condition puts her at a 19. Answer: (C) Blood urea nitrogen (BUN)

higher risk for cervical cancer; therefore, 100 mg/dl and serum creatinine 6.5mg/dl.

she should have a Papanicolaou (Pap) Rationale: The normal BUN level ranges 8

smear annually. to 23 mg/dl; the normal serum creatinine

Rationale: Women with condylomata level ranges from 0.7 to 1.5 mg/dl. The

acuminata are at risk for cancer of the test results in option C are abnormally

cervix and vulva. Yearly Pap smears are elevated, reflecting CRF and the kidneys'
decreased ability to remove nonprotein myeloma, and leukemia may occur in

nitrogen waste from the blood. CRF anyone and aren't associated specifically

causes decreased pH and increased with AIDS.

hydrogen ions — not vice versa. CRF also 22. Answer: (C) To prevent cerebrospinal fluid

increases serum levels of potassium, (CSF) leakage

magnesium, and phosphorous, and Rationale: The client receiving a

decreases serum levels of calcium. A uric subarachnoid block requires special

acid analysis of 3.5 mg/dl falls within the positioning to prevent CSF leakage and

normal range of 2.7 to 7.7 mg/dl; PSP headache and to ensure proper anesthetic

excretion of 75% also falls with the normal distribution. Proper positioning doesn't

range of 60% to 75%. help prevent confusion, seizures, or

20. Answer: (D) Alteration in the size, shape, cardiac arrhythmias.

and organization of differentiated cells 23. Answer: (A) Auscultate bowel sounds.

Rationale: Dysplasia refers to an alteration Rationale: If abdominal distention is

in the size, shape, and organization of accompanied by nausea, the nurse must

differentiated cells. The presence of first auscultate bowel sounds. If bowel

completely undifferentiated tumor cells sounds are absent, the nurse should

that don't resemble cells of the tissues of suspect gastric or small intestine dilation

their origin is called anaplasia. An increase and these findings must be reported to

in the number of normal cells in a normal the physician. Palpation should be

arrangement in a tissue or an organ is avoided postoperatively with abdominal

called hyperplasia. Replacement of one distention. If peristalsis is absent,

type of fully differentiated cell by another changing positions and inserting a rectal

in tissues where the second type normally tube won't relieve the client's discomfort.

isn't found is called metaplasia. 24. Answer: (B) Lying on the left side with

21. Answer: (D) Kaposi's sarcoma knees bent

Rationale: Kaposi's sarcoma is the most Rationale: For a colonoscopy, the nurse

common cancer associated with AIDS. initially should position the client on the

Squamous cell carcinoma, multiple 124

left side with knees bent. Placing the because this action doesn't hold the joints

client on the right side with legs straight, in a position of function. Hyperextending a

prone with the torso elevated, or bent body part for an extended time is

over with hands touching the floor inappropriate because it can cause

wouldn't allow proper visualization of the contractures. Performing shoulder rangeof-

large intestine. motion exercises can prevent

25. Answer: (A) Blood supply to the stoma has contractures in the shoulders, but not in

been interrupted the legs.

Rationale: An ileostomy stoma forms as 27. Answer: (B) Urine output of 20 ml/hour.

the ileum is brought through the Rationale: A urine output of less than 40

abdominal wall to the surface skin, ml/hour in a client with burns indicates a

creating an artificial opening for waste fluid volume deficit. This client's PaO2

elimination. The stoma should appear value falls within the normal range (80 to

cherry red, indicating adequate arterial 100 mm Hg). White pulmonary secretions

perfusion. A dusky stoma suggests also are normal. The client's rectal

decreased perfusion, which may result temperature isn't significantly elevated

from interruption of the stoma's blood and probably results from the fluid

supply and may lead to tissue damage or volume deficit.

necrosis. A dusky stoma isn't a normal 28. Answer: (A) Turn him frequently.

finding. Adjusting the ostomy bag Rationale: The most important

wouldn't affect stoma color, which intervention to prevent pressure ulcers is

depends on blood supply to the area. An frequent position changes, which relieve

intestinal obstruction also wouldn't pressure on the skin and underlying

change stoma color. tissues. If pressure isn't relieved,

26. Answer: (A) Applying knee splints capillaries become occluded, reducing

Rationale: Applying knee splints prevents circulation and oxygenation of the tissues

leg contractures by holding the joints in a and resulting in cell death and ulcer

position of function. Elevating the foot of formation. During passive ROM exercises,

the bed can't prevent contractures the nurse moves each joint through its
range of movement, which improves joint demand, promote vasodilation, and

mobility and circulation to the affected decrease anxiety. Nitrates reduce

area but doesn't prevent pressure ulcers. myocardial oxygen consumption bt

Adequate hydration is necessary to decreasing left ventricular end diastolic

maintain healthy skin and ensure tissue pressure (preload) and systemic vascular

repair. A footboard prevents plantar resistance (afterload).

flexion and footdrop by maintaining the 31. Answer: (C) Raised 30 degrees

foot in a dorsiflexed position. Rationale: Jugular venous pressure is

29. Answer: (C) In long, even, outward, and measured with a centimeter ruler to

downward strokes in the direction of hair obtain the vertical distance between the

growth sternal angle and the point of highest

Rationale: When applying a topical agent, pulsation with the head of the bed

the nurse should begin at the midline and inclined between 15 to 30 degrees.

use long, even, outward, and downward Increased pressure can’t be seen when

strokes in the direction of hair growth. the client is supine or when the head of

This application pattern reduces the risk the bed is raised 10 degrees because the

of follicle irritation and skin inflammation. point that marks the pressure level is

30. Answer: (A) Beta -adrenergic blockers above the jaw (therefore, not visible). In

Rationale: Beta-adrenergic blockers work 125

by blocking beta receptors in the high Fowler’s position, the veins would be

myocardium, reducing the response to barely discernible above the clavicle.

catecholamines and sympathetic nerve 32. Answer: (D) Inotropic agents

stimulation. They protect the Rationale: Inotropic agents are

myocardium, helping to reduce the risk of administered to increase the force of the

another infraction by decreasing heart’s contractions, thereby increasing

myocardial oxygen demand. Calcium ventricular contractility and ultimately

channel blockers reduce the workload of increasing cardiac output. Beta-adrenergic

the heart by decreasing the heart rate. blockers and calcium channel blockers

Narcotics reduce myocardial oxygen decrease the heart rate and ultimately
decreased the workload of the heart. the emergency department. Once the

Diuretics are administered to decrease the airways is secured, oxygenation and

overall vascular volume, also decreasing ventilation should be confirmed using an

the workload of the heart. end-tidal carbon dioxide monitor and

33. Answer: (B) Less than 30% of calories from pulse oximetry. Next, the nurse should

fat make sure L.V. access is established. If the

Rationale: A client with low serum HDL client experiences symptomatic

and high serum LDL levels should get less bradycardia, atropine is administered as

than 30% of daily calories from fat. The ordered 0.5 to 1 mg every 3 to 5 minutes

other modifications are appropriate for to a total of 3 mg. Then the nurse should

this client. try to find the cause of the client’s arrest

34. Answer: (C) The emergency department by obtaining an ABG sample. Amiodarone

nurse calls up the latest electrocardiogram is indicated for ventricular tachycardia,

results to check the client’s progress ventricular fibrillation and atrial flutter –

Rationale: The emergency department not symptomatic bradycardia.

nurse is no longer directly involved with 36. Answer: (C) 95 mm Hg

the client’s care and thus has no legal Rationale: Use the following formula to

right to information about his present calculate MAP

condition. Anyone directly involved in his MAP = systolic + 2 (diastolic)

care (such as the telemetry nurse and the 3

on-call physician) has the right to MAP=126 mm Hg + 2 (80 mm Hg)

information about his condition. Because 3

the client requested that the nurse update MAP=286 mm HG

his wife on his condition, doing so doesn’t 3

breach confidentiality. MAP=95 mm Hg

35. Answer: (B) Check endotracheal tube 37. Answer: (C) Electrocardiogram, complete

placement. blood count, testing for occult blood,

Rationale: ET tube placement should be comprehensive serum metabolic panel.

confirmed as soon as the client arrives in Rationale: An electrocardiogram evaluates

the complaints of chest pain, laboratory platelets. Methotrexate can cause

tests determines anemia, and the stool thrombocytopenia. Vitamin K is used to

test for occult blood determines blood in treat an excessive anticoagulate state

the stool. Cardiac monitoring, oxygen, and from warfarin overload, and ASA

creatine kinase and lactate decreases platelet aggregation.

dehydrogenase levels are appropriate for 40. Answer: (D) Xenogeneic

a cardiac primary problem. A basic Rationale: An xenogeneic transplant is

metabolic panel and alkaline phosphatase between is between human and another

and aspartate aminotransferase levels 126

assess liver function. Prothrombin time, species. A syngeneic transplant is between

partial thromboplastin time, fibrinogen identical twins, allogeneic transplant is

and fibrin split products are measured to between two humans, and autologous is a

verify bleeding dyscrasias; an transplant from the same individual.

electroencephalogram evaluates brain 41. Answer: (B)

electrical activity. Rationale: Tissue thromboplastin is

38. Answer: (D) Heparin-associated released when damaged tissue comes in

thrombosis and thrombocytopenia (HATT) contact with clotting factors. Calcium is

Rationale: HATT may occur after CABG released to assist the conversion of

surgery due to heparin use during surgery. factors X to Xa. Conversion of factors XII to

Although DIC and ITP cause platelet XIIa and VIII to IIIa are part of the intrinsic

aggregation and bleeding, neither is pathway.

common in a client after revascularization 42. Answer: (C) Essential thrombocytopenia

surgery. Pancytopenia is a reduction in all Rationale: Essential thrombocytopenia is

blood cells. linked to immunologic disorders, such as

39. Answer: (B) Corticosteroids SLE and human immunodeficiency virus.

Rationale: Corticosteroid therapy can The disorder known as von Willebrand’s

decrease antibody production and disease is a type of hemophilia and isn’t

phagocytosis of the antibody-coated linked to SLE. Moderate to severe anemia

platelets, retaining more functioning is associated with SLE, not polycythemia.

Dressler’s syndrome is pericarditis that spinal cord compression from a spinal

occurs after a myocardial infarction and tumor. This should be recognized and

isn’t linked to SLE. treated promptly as progression of the

43. Answer: (B) Night sweat tumor may result in paraplegia. The other

Rationale: In stage 1, symptoms include a options, which reflect parts of the nervous

single enlarged lymph node (usually), system, aren’t usually affected by MM.

unexplained fever, night sweats, malaise, 46. Answer: (C) 10 years

and generalized pruritis. Although Rationale: Epidermiologic studies show

splenomegaly may be present in some the average time from initial contact with

clients, night sweats are generally more HIV to the development of AIDS is 10

prevalent. Pericarditis isn’t associated years.

with Hodgkin’s disease, nor is 47. Answer: (A) Low platelet count

hypothermia. Moreover, splenomegaly Rationale: In DIC, platelets and clotting

and pericarditis aren’t symptoms. factors are consumed, resulting in

Persistent hypothermia is associated with microthrombi and excessive bleeding. As

Hodgkin’s but isn’t an early sign of the clots form, fibrinogen levels decrease and

disease. the prothrombin time increases. Fibrin

44. Answer: (D) Breath sounds degeneration products increase as

Rationale: Pneumonia, both viral and fibrinolysis takes places.

fungal, is a common cause of death in 48. Answer: (D) Hodgkin’s disease

clients with neutropenia, so frequent Rationale: Hodgkin’s disease typically

assessment of respiratory rate and breath causes fever night sweats, weight loss,

sounds is required. Although assessing and lymph mode enlargement. Influenza

blood pressure, bowel sounds, and heart doesn’t last for months. Clients with sickle

sounds is important, it won’t help detect cell anemia manifest signs and symptoms

pneumonia. of chronic anemia with pallor of the

45. Answer: (B) Muscle spasm mucous membrane, fatigue, and

Rationale: Back pain or paresthesia in the decreased tolerance for exercise; they

lower extremities may indicate impending don’t show fever, night sweats, weight
loss or lymph node enlargement. Rationale: This is the appropriate

Leukemia doesn’t cause lymph node response. The nurse should help the

enlargement. mother how to cope with her own feelings

49. Answer: (C) A Rh-negative regarding the child’s disease so as not to

Rationale: Human blood can sometimes affect the child negatively. When the hair

contain an inherited D antigen. Persons grows back, it is still of the same color and

with the D antigen have Rh-positive blood texture.

type; those lacking the antigen have Rhnegative 52. Answer: (B) Apply viscous Lidocaine to

blood. It’s important that a oral ulcers as needed.

person with Rh- negative blood receives Rationale: Stomatitis can cause pain and

Rh-negative blood. If Rh-positive blood is this can be relieved by applying topical

administered to an Rh-negative person, anesthetics such as lidocaine before

the recipient develops anti-Rh agglutinins, mouth care. When the patient is already

and sub sequent transfusions with Rhpositive comfortable, the nurse can proceed with

blood may cause serious providing the patient with oral rinses of

reactions with clumping and hemolysis of saline solution mixed with equal part of

red blood cells. water or hydrogen peroxide mixed water

50. Answer: (B) “I will call my doctor if Stacy in 1:3 concentrations to promote oral

has persistent vomiting and diarrhea”. hygiene. Every 2-4 hours.

Rationale: Persistent (more than 24 hours) 53. Answer: (C) Immediately discontinue the

vomiting, anorexia, and diarrhea are signs infusion

of toxicity and the patient should stop the Rationale: Edema or swelling at the IV site

medication and notify the health care is a sign that the needle has been

provider. The other manifestations are dislodged and the IV solution is leaking

expected side effects of chemotherapy. into the tissues causing the edema. The

51. Answer: (D) “This is only temporary; Stacy patient feels pain as the nerves are

will re-grow new hair in 3-6 months, but irritated by pressure and the IV solution.

may be different in texture”. The first action of the nurse would be to

127 discontinue the infusion right away to

prevent further edema and other dioxide. The value expected would be

complication. around 80 mm Hg. All other values are

54. Answer: (C) Chronic obstructive bronchitis lower than expected.

Rationale: Clients with chronic obstructive 57. Answer: (C) Respiratory acidosis

bronchitis appear bloated; they have large Rationale: Because Paco2 is high at 80 mm

barrel chest and peripheral edema, Hg and the metabolic measure, HCO3- is

cyanotic nail beds, and at times, normal, the client has respiratory acidosis.

circumoral cyanosis. Clients with ARDS are The pH is less than 7.35, academic, which

acutely short of breath and frequently eliminates metabolic and respiratory

need intubation for mechanical ventilation alkalosis as possibilities. If the HCO3- was

and large amount of oxygen. Clients with below 22 mEq/L the client would have

asthma don’t exhibit characteristics of metabolic acidosis.

chronic disease, and clients with 58. Answer: (C) Respiratory failure

emphysema appear pink and cachectic. Rationale: The client was reacting to the

55. Answer: (D) Emphysema drug with respiratory signs of impending

Rationale: Because of the large amount of anaphylaxis, which could lead to

energy it takes to breathe, clients with eventually respiratory failure. Although

emphysema are usually cachectic. They’re the signs are also related to an asthma

pink and usually breathe through pursed attack or a pulmonary embolism, consider

lips, hence the term “puffer.” Clients with the new drug first. Rheumatoid arthritis

ARDS are usually acutely short of breath. doesn’t manifest these signs.

Clients with asthma don’t have any 59. Answer: (D) Elevated serum

particular characteristics, and clients with aminotransferase

chronic obstructive bronchitis are bloated Rationale: Hepatic cell death causes

and cyanotic in appearance. release of liver enzymes alanine

56. Answer: D 80 mm Hg aminotransferase (ALT), aspartate

Rationale: A client about to go into aminotransferase (AST) and lactate

respiratory arrest will have inefficient dehydrogenase (LDH) into the circulation.

ventilation and will be retaining carbon Liver cirrhosis is a chronic and irreversible
disease of the liver characterized by the amount of medication given to the

generalized inflammation and fibrosis of patient. The stool will be mashy or soft.

the liver tissues. Lactulose is also very sweet and may

60. Answer: (A) Impaired clotting mechanism cause cramping and bloating.

Rationale: Cirrhosis of the liver results in 63. Answer: (B) Severe lower back pain,

decreased Vitamin K absorption and decreased blood pressure, decreased RBC

formation of clotting factors resulting in count, increased WBC count.

impaired clotting mechanism. Rationale: Severe lower back pain

61. Answer: (B) Altered level of consciousness indicates an aneurysm rupture, secondary

Rationale: Changes in behavior and level to pressure being applied within the

of consciousness are the first sins of abdominal cavity. When ruptured occurs,

hepatic encephalopathy. Hepatic the pain is constant because it can’t be

encephalopathy is caused by liver failure alleviated until the aneurysm is repaired.

and develops when the liver is unable to Blood pressure decreases due to the loss

convert protein metabolic product of blood. After the aneurysm ruptures, the

ammonia to urea. This results in vasculature is interrupted and blood

accumulation of ammonia and other toxic volume is lost, so blood pressure wouldn’t

in the blood that damages the cells. increase. For the same reason, the RBC

128 count is decreased – not increased. The

62. Answer: (C) “I’ll lower the dosage as WBC count increases as cell migrate to the

ordered so the drug causes only 2 to 4 site of injury.

stools a day”. 64. Answer: (D) Apply gloves and assess the

Rationale: Lactulose is given to a patients groin site

with hepatic encephalopathy to reduce Rationale: Observing standard precautions

absorption of ammonia in the intestines is the first priority when dealing with any

by binding with ammonia and promoting blood fluid. Assessment of the groin site is

more frequent bowel movements. If the the second priority. This establishes where

patient experience diarrhea, it indicates the blood is coming from and determines

over dosage and the nurse must reduce how much blood has been lost. The goal in
this situation is to stop the bleeding. The and water

nurse would call for help if it were Rationale: The kidneys respond to rise in

warranted after the assessment of the blood pressure by excreting sodium and

situation. After determining the extent of excess water. This response ultimately

the bleeding, vital signs assessment is affects sysmolic blood pressure by

important. The nurse should never move regulating blood volume. Sodium or water

the client, in case a clot has formed. retention would only further increase

Moving can disturb the clot and cause blood pressure. Sodium and water travel

rebleeding. together across the membrane in the

65. Answer: (D) Percutaneous transluminal kidneys; one can’t travel without the

coronary angioplasty (PTCA) other.

Rationale: PTCA can alleviate the blockage 68. Answer: (D) It inhibits reabsorption of

and restore blood flow and oxygenation. sodium and water in the loop of Henle.

An echocardiogram is a noninvasive Rationale: Furosemide is a loop diuretic

diagnosis test. Nitroglycerin is an oral that inhibits sodium and water

sublingual medication. Cardiac reabsorption in the loop Henle, thereby

catheterization is a diagnostic tool – not a causing a decrease in blood pressure.

treatment. Vasodilators cause dilation of peripheral

66. Answer: (B) Cardiogenic shock blood vessels, directly relaxing vascular

Rationale: Cardiogenic shock is shock smooth muscle and decreasing blood

related to ineffective pumping of the pressure. Adrenergic blockers decrease

heart. Anaphylactic shock results from an sympathetic cardioacceleration and

allergic reaction. Distributive shock results decrease blood pressure. Angiotensinconverting

from changes in the intravascular volume enzyme inhibitors decrease

distribution and is usually associated with blood pressure due to their action on

increased cardiac output. MI isn’t a shock angiotensin.

state, though a severe MI can lead to 69. Answer: (C) Pancytopenia, elevated

shock. antinuclear antibody (ANA) titer

67. Answer: (C) Kidneys’ excretion of sodium Rationale: Laboratory findings for clients
with SLE usually show pancytopenia, properties; therefore, lowering Paco2

elevated ANA titer, and decreased serum through hyperventilation will lower ICP

complement levels. Clients may have caused by dilated cerebral vessels.

elevated BUN and creatinine levels from Oxygenation is evaluated through Pao2

nephritis, but the increase does not and oxygen saturation. Alveolar

indicate SLE. hypoventilation would be reflected in an

70. Answer: (C) Narcotics are avoided after a increased Paco2.

head injury because they may hide a 72. Answer: (B) A 33-year-old client with a

worsening condition. recent diagnosis of Guillain-Barre

129 syndrome

Rationale: Narcotics may mask changes in Rationale: Guillain-Barre syndrome is

the level of consciousness that indicate characterized by ascending paralysis and

increased ICP and shouldn’t potential respiratory failure. The order of

acetaminophen is strong enough ignores client assessment should follow client

the mother’s question and therefore isn’t priorities, with disorder of airways,

appropriate. Aspirin is contraindicated in breathing, and then circulation. There’s no

conditions that may have bleeding, such information to suggest the postmyocardial

as trauma, and for children or young infarction client has an arrhythmia or

adults with viral illnesses due to the other complication. There’s no evidence

danger of Reye’s syndrome. Stronger to suggest hemorrhage or perforation for

medications may not necessarily lead to the remaining clients as a priority of care.

vomiting but will sedate the client, 73. Answer: (C) Decreases inflammation

thereby masking changes in his level of Rationale: Then action of colchicines is to

consciousness. decrease inflammation by reducing the

71. Answer: (A) Appropriate; lowering carbon migration of leukocytes to synovial fluid.

dioxide (CO2) reduces intracranial Colchicine doesn’t replace estrogen,

pressure (ICP) decrease infection, or decrease bone

Rationale: A normal Paco2 value is 35 to demineralization.

45 mm Hg CO2 has vasodilating 74. Answer: (C) Osteoarthritis is the most

common form of arthritis frequent urination signal dehydration,

Rationale: Osteoarthritis is the most which isn't associated with Cushing's

common form of arthritis and can be syndrome.

extremely debilitating. It can afflict people 77. Answer: (D) Below-normal urine

of any age, although most are elderly. osmolality level, above-normal serum

75. Answer: (C) Myxedema coma osmolality level

Rationale: Myxedema coma, severe Rationale: In diabetes insipidus, excessive

hypothyroidism, is a life-threatening polyuria causes dilute urine, resulting in a

condition that may develop if thyroid below-normal urine osmolality level. At

replacement medication isn't taken. the same time, polyuria depletes the body

Exophthalmos, protrusion of the eyeballs, of water, causing dehydration that leads

is seen with hyperthyroidism. Thyroid to an above-normal serum osmolality

storm is life-threatening but is caused by level. For the same reasons, diabetes

severe hyperthyroidism. Tibial myxedema, insipidus doesn't cause above-normal

peripheral mucinous edema involving the urine osmolality or below-normal serum

lower leg, is associated with osmolality levels.

hypothyroidism but isn't life-threatening. 78. Answer: (A) "I can avoid getting sick by not

76. Answer: (B) An irregular apical pulse becoming dehydrated and by paying

Rationale: Because Cushing's syndrome attention to my need to urinate, drink, or

causes aldosterone overproduction, which eat more than usual."

increases urinary potassium loss, the Rationale: Inadequate fluid intake during

disorder may lead to hypokalemia. hyperglycemic episodes often leads to

Therefore, the nurse should immediately HHNS. By recognizing the signs of

report signs and symptoms of hyperglycemia (polyuria, polydipsia, and

hypokalemia, such as an irregular apical polyphagia) and increasing fluid intake,

pulse, to the physician. Edema is an the client may prevent HHNS. Drinking a

expected finding because aldosterone glass of nondiet soda would be

overproduction causes sodium and fluid appropriate for hypoglycemia. A client

retention. Dry mucous membranes and whose diabetes is controlled with oral
130 afternoon. This dosage schedule reduces

antidiabetic agents usually doesn't need adverse effects.

to monitor blood glucose levels. A 81. Answer: (C) High corticotropin and high
highcarbohydrate
cortisol levels
diet would exacerbate the
Rationale: A corticotropin-secreting
client's condition, particularly if fluid
pituitary tumor would cause high
intake is low.
corticotropin and high cortisol levels. A
79. Answer: (D) Hyperparathyroidism
high corticotropin level with a low cortisol
Rationale: Hyperparathyroidism is most
level and a low corticotropin level with a
common in older women and is
low cortisol level would be associated
characterized by bone pain and weakness
with hypocortisolism. Low corticotropin
from excess parathyroid hormone (PTH).
and high cortisol levels would be seen if
Clients also exhibit hypercaliuria-causing
there was a primary defect in the adrenal
polyuria. While clients with diabetes
glands.
mellitus and diabetes insipidus also have
82. Answer: (D) Performing capillary glucose
polyuria, they don't have bone pain and
testing every 4 hours
increased sleeping. Hypoparathyroidism is
Rationale: The nurse should perform
characterized by urinary frequency rather
capillary glucose testing every 4 hours
than polyuria.
because excess cortisol may cause insulin
80. Answer: (C) "I'll take two-thirds of the
resistance, placing the client at risk for
dose when I wake up and one-third in the
hyperglycemia. Urine ketone testing isn't
late afternoon."
indicated because the client does secrete
Rationale: Hydrocortisone, a
insulin and, therefore, isn't at risk for
glucocorticoid, should be administered
ketosis. Urine specific gravity isn't
according to a schedule that closely
indicated because although fluid balance
reflects the bodies own secretion of this
can be compromised, it usually isn't
hormone; therefore, two-thirds of the
dangerously imbalanced. Temperature
dose of hydrocortisone should be taken in
regulation may be affected by excess
the morning and one-third in the late
cortisol and isn't an accurate indicator of
infection. client to rotate injection sites within the

83. Answer: (C) onset to be at 2:30 p.m. and same anatomic region. Rotating sites

its peak to be at 4 p.m. among different regions may cause

Rationale: Regular insulin, which is a excessive day-to-day variations in the

short-acting insulin, has an onset of 15 to blood glucose level; also, insulin

30 minutes and a peak of 2 to 4 hours. absorption differs from one region to the

Because the nurse gave the insulin at 2 next. Insulin should be injected only into

p.m., the expected onset would be from healthy tissue lacking large blood vessels,

2:15 p.m. to 2:30 p.m. and the peak from nerves, or scar tissue or other deviations.

4 p.m. to 6 p.m. Injecting insulin into areas of hypertrophy

84. Answer: (A) No increase in the may delay absorption. The client shouldn't
thyroidstimulating
inject insulin into areas of lipodystrophy
hormone (TSH) level after 30
(such as hypertrophy or atrophy); to
minutes during the TSH stimulation test
prevent lipodystrophy, the client should
Rationale: In the TSH test, failure of the
rotate injection sites systematically.
TSH level to rise after 30 minutes confirms
Exercise speeds drug absorption, so the
hyperthyroidism. A decreased TSH level
client shouldn't inject insulin into sites
indicates a pituitary deficiency of this
above muscles that will be exercised
hormone. Below-normal levels of T3 and
heavily.
T4, as detected by radioimmunoassay,
86. Answer: (D) Below-normal serum
signal hypothyroidism. A below-normal T4
potassium level
level also occurs in malnutrition and liver
131
disease and may result from
Rationale: A client with HHNS has an
administration of phenytoin and certain
overall body deficit of potassium resulting
other drugs.
from diuresis, which occurs secondary to
85. Answer: (B) "Rotate injection sites within
the hyperosmolar, hyperglycemic state
the same anatomic region, not among
caused by the relative insulin deficiency.
different regions."
An elevated serum acetone level and
Rationale: The nurse should instruct the
serum ketone bodies are characteristic of
diabetic ketoacidosis. Metabolic acidosis, porous, brittle, and abnormally vulnerable

not serum alkalosis, may occur in HHNS. to fracture. Sodium and potassium aren't

87. Answer: (D) Maintaining room involved in the development of

temperature in the low-normal range steoporosis.

Rationale: Graves' disease causes signs 90. Answer: (A) Adult respiratory distress

and symptoms of hypermetabolism, such syndrome (ARDS)

as heat intolerance, diaphoresis, excessive Rationale: Severe hypoxia after smoke

thirst and appetite, and weight loss. To inhalation is typically related to ARDS. The

reduce heat intolerance and diaphoresis, other conditions listed aren’t typically

the nurse should keep the client's room associated with smoke inhalation and

temperature in the low-normal range. To severe hypoxia.

replace fluids lost via diaphoresis, the 91. Answer: (D) Fat embolism

nurse should encourage, not restrict, Rationale: Long bone fractures are

intake of oral fluids. Placing extra blankets correlated with fat emboli, which cause

on the bed of a client with heat shortness of breath and hypoxia. It’s

intolerance would cause discomfort. To unlikely the client has developed asthma

provide needed energy and calories, the or bronchitis without a previous history.

nurse should encourage the client to eat He could develop atelectasis but it

high-carbohydrate foods. typically doesn’t produce progressive

88. Answer: (A) Fracture of the distal radius hypoxia.

Rationale: Colles' fracture is a fracture of 92. Answer: (D) Spontaneous pneumothorax

the distal radius, such as from a fall on an Rationale: A spontaneous pneumothorax

outstretched hand. It's most common in occurs when the client’s lung collapses,

women. Colles' fracture doesn't refer to a causing an acute decreased in the amount

fracture of the olecranon, humerus, or of functional lung used in oxygenation.

carpal scaphoid. The sudden collapse was the cause of his

89. Answer: (B) Calcium and phosphorous chest pain and shortness of breath. An

Rationale: In osteoporosis, bones lose asthma attack would show wheezing

calcium and phosphate salts, becoming breath sounds, and bronchitis would have
rhonchi. Pneumonia would have bronchial 96. Answer: (D) Respiratory alkalosis

breath sounds over the area of Rationale: A client with massive

consolidation. pulmonary embolism will have a large

93. Answer: (C) Pneumothorax region and blow off large amount of

Rationale: From the trauma the client carbon dioxide, which crosses the

experienced, it’s unlikely he has unaffected alveolar-capillary membrane

bronchitis, pneumonia, or TB; rhonchi more readily than does oxygen and results

with bronchitis, bronchial breath sounds in respiratory alkalosis.

with TB would be heard. 97. Answer: (A) Air leak

94. Answer: (C) Serous fluids fills the space Rationale: Bubbling in the water seal

and consolidates the region chamber of a chest drainage system stems

Rationale: Serous fluid fills the space and from an air leak. In pneumothorax an air

eventually consolidates, preventing 132

extensive mediastinal shift of the heart leak can occur as air is pulled from the

and remaining lung. Air can’t be left in the pleural space. Bubbling doesn’t normally

space. There’s no gel that can be placed in occur with either adequate or inadequate

the pleural space. The tissue from the suction or any preexisting bubbling in the

other lung can’t cross the mediastinum, water seal chamber.

although a temporary mediastinal shift 98. Answer: (B) 21

exits until the space is filled. Rationale: 3000 x 10 divided by 24 x 60.

95. Answer: (A) Alveolar damage in the 99. Answer: (B) 2.4 ml

infracted area Rationale: .05 mg/ 1 ml = .12mg/ x ml,

Rationale: The infracted area produces .05x = .12, x = 2.4 ml.

alveolar damage that can lead to the 100. Answer: (D) “I should put on the stockings

production of bloody sputum, sometimes before getting out of bed in the morning.

in massive amounts. Clot formation Rationale: Promote venous return by

usually occurs in the legs. There’s a loss of applying external pressure on veins.

lung parenchyma and subsequent scar 133

tissue formation. TEST V - Care of Clients with Physiologic and

Psychosocial Alterations because:

1. Mr. Marquez reports of losing his job, not a. The client is disruptive.
being
b. The client is harmful to self.
able to sleep at night, and feeling upset with his
c. The client is harmful to others.
wife. Nurse John responds to the client, “You
d. The client needs to be on medication
may want to talk about your employment
first.
situation in group today.” The Nurse is using
4. Dervid, an adolescent boy was admitted for
which therapeutic technique?
substance abuse and hallucinations. The client’s
a. Observations
mother asks Nurse Armando to talk with his
b. Restating
husband when he arrives at the hospital. The
c. Exploring
mother says that she is afraid of what the father
d. Focusing
might say to the boy. The most appropriate
2. Tony refuses his evening dose of Haloperidol
nursing intervention would be to:
(Haldol), then becomes extremely agitated in
a. Inform the mother that she and the
the
father can work through this problem
dayroom while other clients are watching
themselves.
television. He begins cursing and throwing
b. Refer the mother to the hospital social
furniture. Nurse Oliver first action is to:
worker.
a. Check the client’s medical record for an
c. Agree to talk with the mother and the
order for an as-needed I.M. dose of
father together.
medication for agitation.
d. Suggest that the father and son work
b. Place the client in full leather restraints.
things out.
c. Call the attending physician and report
5. What is Nurse John likely to note in a male
the behavior.
client
d. Remove all other clients from the
being admitted for alcohol withdrawal?
dayroom.
a. Perceptual disorders.
3. Tina who is manic, but not yet on medication,
b. Impending coma.
comes to the drug treatment center. The nurse
c. Recent alcohol intake.
would not let this client join the group session
d. Depression with mutism.
6. Aira has taken amitriptyline HCL (Elavil) for 3 a. Short-acting anesthesia

days, but now complains that it “doesn’t help” b. Decreased oral and respiratory

and refuses to take it. What should the nurse secretions.

say
c. Skeletal muscle paralysis.
or do?
d. Analgesia.
a. Withhold the drug.
9. Nurse Gina is aware that the dietary
b. Record the client’s response. implications

c. Encourage the client to tell the doctor. for a client in manic phase of bipolar disorder is:

d. Suggest that it takes a while before a. Serve the client a bowl of soup, buttered

seeing the results. French bread, and apple slices.

7. Dervid, an adolescent has a history of truancy b. Increase calories, decrease fat, and

from school, running away from home and decrease protein.

“barrowing” other people’s things without their c. Give the client pieces of cut-up steak,

permission. The adolescent denies stealing, carrots, and an apple.

rationalizing instead that as long as no one was 134

using the items, it was all right to borrow them. d. Increase calories, carbohydrates, and

It is important for the nurse to understand the protein.

psychodynamically, this behavior may be largely 10. What parental behavior toward a child
during an
attributed to a developmental defect related to
admission procedure should cause Nurse Ron to
the:
suspect child abuse?
a. Id
a. Flat affect
b. Ego
b. Expressing guilt
c. Superego
c. Acting overly solicitous toward the child.
d. Oedipal complex
d. Ignoring the child.
8. In preparing a female client for
electroconvulsive 11. Nurse Lynnette notices that a female client
with
therapy (ECT), Nurse Michelle knows that
obsessive-compulsive disorder washes her
succinylcoline (Anectine) will be administered
hands
for which therapeutic effect?
for long periods each day. How should the nurse
respond to this compulsive behavior? physical examination rules out a physical cause

a. By designating times during which the for her paralysis, the physician admits her to the

client can focus on the behavior. psychiatric unit where she is diagnosed with

b. By urging the client to reduce the conversion disorder. Meryl asks the nurse, "Why

frequency of the behavior as rapidly as has this happened to me?" What is the nurse's

possible. best response?

c. By calling attention to or attempting to a. "You've developed this paralysis so you

prevent the behavior. can stay with your parents. You must

d. By discouraging the client from deal with this conflict if you want to walk

verbalizing anxieties. again."

12. After seeking help at an outpatient mental b. "It must be awful not to be able to move

health clinic, Ruby who was raped while walking your legs. You may feel better if you

her dog is diagnosed with posttraumatic stress realize the problem is psychological, not

disorder (PTSD). Three months later, Ruby physical."

returns to the clinic, complaining of fear, loss of c. "Your problem is real but there is no

control, and helpless feelings. Which nursing physical basis for it. We'll work on what

intervention is most appropriate for Ruby? is going on in your life to find out why

a. Recommending a high-protein, low-fat it's happened."

diet. d. "It isn't uncommon for someone with

b. Giving sleep medication, as prescribed, your personality to develop a conversion

to restore a normal sleep- wake cycle. disorder during times of stress."

c. Allowing the client time to heal. 14. Nurse Krina knows that the following drugs
have
d. Exploring the meaning of the traumatic
been known to be effective in treating
event with the client.
obsessive-compulsive disorder (OCD):
13. Meryl, age 19, is highly dependent on her
a. benztropine (Cogentin) and
parents and fears leaving home to go away to
diphenhydramine (Benadryl).
college. Shortly before the semester starts, she
b. chlordiazepoxide (Librium) and
complains that her legs are paralyzed and is
diazepam (Valium)
rushed to the emergency department. When
c. fluvoxamine (Luvox) and clomipramine reduce or eliminate panic attacks?

(Anafranil) 135

d. divalproex (Depakote) and lithium a. Antidepressants

(Lithobid) b. Anticholinergics

15. Alfred was newly diagnosed with anxiety c. Antipsychotics

disorder. The physician prescribed buspirone d. Mood stabilizers

(BuSpar). The nurse is aware that the teaching 18. A client seeks care because she feels
depressed
instructions for newly prescribed buspirone
and has gained weight. To treat her atypical
should include which of the following?
depression, the physician prescribes
a. A warning about the drugs delayed
tranylcypromine sulfate (Parnate), 10 mg by
therapeutic effect, which is from 14 to
mouth twice per day. When this drug is used to
30 days.
treat atypical depression, what is its onset of
b. A warning about the incidence of
action?
neuroleptic malignant syndrome (NMS).
a. 1 to 2 days
c. A reminder of the need to schedule
b. 3 to 5 days
blood work in 1 week to check blood
c. 6 to 8 days
levels of the drug.
d. 10 to 14 days
d. A warning that immediate sedation can
19. A 65 years old client is in the first stage of
occur with a resultant drop in pulse.
Alzheimer's disease. Nurse Patricia should plan
16. Richard with agoraphobia has been
symptomfree to focus this client's care on:

for 4 months. Classic signs and symptoms of a. Offering nourishing finger foods to help

phobias include: maintain the client's nutritional status.

a. Insomnia and an inability to concentrate. b. Providing emotional support and

b. Severe anxiety and fear. individual counseling.

c. Depression and weight loss. c. Monitoring the client to prevent minor

d. Withdrawal and failure to distinguish illnesses from turning into major

reality from fantasy. problems.

17. Which medications have been found to help d. Suggesting new activities for the client
and family to do together. and can be life-threatening. To minimize these

20. The nurse is assessing a client who has just effects, opiate users are commonly detoxified
been
with:
admitted to the emergency department. Which
a. Barbiturates
signs would suggest an overdose of an
b. Amphetamines
antianxiety agent?
c. Methadone
a. Combativeness, sweating, and confusion
d. Benzodiazepines
b. Agitation, hyperactivity, and grandiose
23. Nurse Cristina is caring for a client who
ideation
experiences false sensory perceptions with no
c. Emotional lability, euphoria, and
basis in reality. These perceptions are known as:
impaired memory
a. Delusions
d. Suspiciousness, dilated pupils, and
b. Hallucinations
increased blood pressure
c. Loose associations
21. The nurse is caring for a client diagnosed
d. Neologisms
with
24. Nurse Marco is developing a plan of care for
antisocial personality disorder. The client has a
a
history of fighting, cruelty to animals, and
client with anorexia nervosa. Which action
stealing. Which of the following traits would the
should the nurse include in the plan?
nurse be most likely to uncover during
a. Restricts visits with the family and
assessment?
friends until the client begins to eat.
a. History of gainful employment
b. Provide privacy during meals.
b. Frequent expression of guilt regarding
c. Set up a strict eating plan for the client.
antisocial behavior
d. Encourage the client to exercise, which
c. Demonstrated ability to maintain close,
will reduce her anxiety.
stable relationships
25. Tim is admitted with a diagnosis of delusions
d. A low tolerance for frustration of

22. Nurse Amy is providing care for a male client grandeur. The nurse is aware that this diagnosis

undergoing opiate withdrawal. Opiate reflects a belief that one is:

withdrawal causes severe physical discomfort a. Highly important or famous.

b. Being persecuted 28. Richard is admitted with a diagnosis of

c. Connected to events unrelated to schizotypal personality disorder. hich signs

oneself would this client exhibit during social situations?

d. Responsible for the evil in the world. a. Aggressive behavior

26. Nurse Jen is caring for a male client with b. Paranoid thoughts
manic
c. Emotional affect
depression. The plan of care for a client in a
d. Independence needs
manic state would include:
29. Nurse Mickey is caring for a client diagnosed
a. Offering a high-calorie meals and
with bulimia. The most appropriate initial goal
strongly encouraging the client to finish
for a client diagnosed with bulimia is to:
all food.
a. Avoid shopping for large amounts of
b. Insisting that the client remain active
food.
through the day so that he’ll sleep at
b. Control eating impulses.
night.
c. Identify anxiety-causing situations
c. Allowing the client to exhibit
d. Eat only three meals per day.
hyperactive, demanding, manipulative
30. Rudolf is admitted for an overdose of
behavior without setting limits.
amphetamines. When assessing the client, the
136
nurse should expect to see:
d. Listening attentively with a neutral
a. Tension and irritability
attitude and avoiding power struggles.
b. Slow pulse
27. Ramon is admitted for detoxification after a
c. Hypotension
cocaine overdose. The client tells the nurse that
d. Constipation
he frequently uses cocaine but that he can
31. Nicolas is experiencing hallucinations tells
control his use if he chooses. Which coping the

mechanism is he using? nurse, “The voices are telling me I’m no good.”

a. Withdrawal The client asks if the nurse hears the voices. The

b. Logical thinking most appropriate response by the nurse would

c. Repression be:

d. Denial a. “It is the voice of your conscience, which

only you can control.” c. Adaptation and a return to a prior level

b. “No, I do not hear your voices, but I of functioning.

believe you can hear them”. d. A higher level of anxiety continuing for

c. “The voices are coming from within you more than 3 months.

and only you can hear them.” 35. Miranda a psychiatric client is to be
discharged
d. “Oh, the voices are a symptom of your
with orders for haloperidol (haldol) therapy.
illness; don’t pay any attention to them.”
When developing a teaching plan for discharge,
32. The nurse is aware that the side effect of
the nurse should include cautioning the client
electroconvulsive therapy that a client may
against:
experience:
a. Driving at night
a. Loss of appetite
b. Staying in the sun
b. Postural hypotension
c. Ingesting wines and cheeses
c. Confusion for a time after treatment
d. Taking medications containing aspirin
d. Complete loss of memory for a time
36. Jen a nursing student is anxious about the
33. A dying male client gradually moves toward
upcoming board examination but is able to
resolution of feelings regarding impending
study
death. Basing care on the theory of Kubler-Ross,
intently and does not become distracted by a
Nurse Trish plans to use nonverbal interventions
roommate’s talking and loud music. The
when assessment reveals that the client is in
student’s ability to ignore distractions and to
the:
focus on studying demonstrates:
a. Anger stage
a. Mild-level anxiety
b. Denial stage
b. Panic-level anxiety
c. Bargaining stage
c. Severe-level anxiety
d. Acceptance stage
d. Moderate-level anxiety
34. The outcome that is unrelated to a crisis
state is: 37. When assessing a premorbid personality

a. Learning more constructive coping skills characteristic of a client with a major

b. Decompensation to a lower level of depression, it would be unusual for the nurse to

functioning. find that this client demonstrated:

a. Rigidity c. Reminding the client that a CBC must be

b. Stubbornness done once a month.

137 d. Encouraging the client to have blood

c. Diverse interest levels checked as ordered.

d. Over meticulousness 41. The psychiatrist orders lithium carbonate

600
38. Nurse Krina recognizes that the suicidal risk
for mg p.o t.i.d for a female client. Nurse Katrina

depressed client is greatest: would be aware that the teachings about the

a. As their depression begins to improve side effects of this drug were understood when

b. When their depression is most severe the client state, “I will call my doctor

c. Before any type of treatment is started immediately if I notice any:

d. As they lose interest in the environment a. Sensitivity to bright light or sun

39. Nurse Kate would expect that a client with b. Fine hand tremors or slurred speech

vascular dementis would experience: c. Sexual dysfunction or breast

a. Loss of remote memory related to enlargement

anoxia d. Inability to urinate or difficulty when

b. Loss of abstract thinking related to urinating

emotional state 42. Nurse Mylene recognizes that the most

c. Inability to concentrate related to important factor necessary for the

establishment
decreased stimuli
of trust in a critical care area is:
d. Disturbance in recalling recent events
a. Privacy
related to cerebral hypoxia.
b. Respect
40. Josefina is to be discharged on a regimen of
c. Empathy
lithium carbonate. In the teaching plan for
d. Presence
discharge the nurse should include:
43. When establishing an initial nurse-client
a. Advising the client to watch the diet
relationship, Nurse Hazel should explore with
carefully
the client the:
b. Suggesting that the client take the pills
a. Client’s perception of the presenting
with milk
problem. 46. Nurse Judy knows that statistics show that in

b. Occurrence of fantasies the client may adolescent suicide behavior:

experience. a. Females use more dramatic methods

c. Details of any ritualistic acts carried out than males

by the client b. Males account for more attempts than

d. Client’s feelings when external; controls do females

are instituted. c. Females talk more about suicide before

44. Tranylcypromine sulfate (Parnate) is attempting it

prescribed
d. Males are more likely to use lethal
for a depressed client who has not responded to
methods than are females
the tricyclic antidepressants. After teaching the
47. Dervid with paranoid schizophrenia
client about the medication, Nurse Marian repeatedly

evaluates that learning has occurred when the uses profanity during an activity therapy
session.
client states, “I will avoid:
Which response by the nurse would be most
a. Citrus fruit, tuna, and yellow
appropriate?
vegetables.”
a. "Your behavior won't be tolerated. Go to
b. Chocolate milk, aged cheese, and
your room immediately."
yogurt’”
138
c. Green leafy vegetables, chicken, and
b. "You're just doing this to get back at me
milk.”
for making you come to therapy."
d. Whole grains, red meats, and
c. "Your cursing is interrupting the activity.
carbonated soda.”
Take time out in your room for 10
45. Nurse John is a aware that most crisis
situations minutes."

should resolve in about: d. "I'm disappointed in you. You can't

a. 1 to 2 weeks control yourself even for a few minutes."

b. 4 to 6 weeks 48. Nurse Maureen knows that the

nonantipsychotic
c. 4 to 6 months
medication used to treat some clients with
d. 6 to 12 months
schizoaffective disorder is:
a. phenelzine (Nardil) substituting a different type of

b. chlordiazepoxide (Librium) antidepressant.

c. lithium carbonate (Lithane) b. Advising the client to sit up for 1 minute

d. imipramine (Tofranil) before getting out of bed.

49. Which information is most important for the c. Instructing the client to double the

nurse Trinity to include in a teaching plan for a dosage until the problem resolves.

male schizophrenic client taking clozapine d. Informing the client that this adverse

(Clozaril)? reaction should disappear within 1

a. Monthly blood tests will be necessary. week.

b. Report a sore throat or fever to the 52. Mr. Cruz visits the physician's office to seek

physician immediately. treatment for depression, feelings of

c. Blood pressure must be monitored for hopelessness, poor appetite, insomnia, fatigue,

hypertension. low self- esteem, poor concentration, and

d. Stop the medication when symptoms difficulty making decisions. The client states that

subside. these symptoms began at least 2 years ago.

50. Ricky with chronic schizophrenia takes Based on this report, the nurse Tyfany suspects:

neuroleptic medication is admitted to the a. Cyclothymic disorder.

psychiatric unit. Nursing assessment reveals b. Atypical affective disorder.

rigidity, fever, hypertension, and diaphoresis. c. Major depression.

These findings suggest which life- threatening d. Dysthymic disorder.

reaction: 53. After taking an overdose of phenobarbital

a. Tardive dyskinesia. (Barbita), Mario is admitted to the emergency

b. Dystonia. department. Dr. Trinidad prescribes activated

c. Neuroleptic malignant syndrome. charcoal (Charcocaps) to be administered by

d. Akathisia. mouth immediately. Before administering the

51. Which nursing intervention would be most dose, the nurse verifies the dosage ordered.

appropriate if a male client develop orthostatic What is the usual minimum dose of activated

hypotension while taking amitriptyline (Elavil)? charcoal?

a. Consulting with the physician about a. 5 g mixed in 250 ml of water

b. 15 g mixed in 500 ml of water lasts hours to a number of days.

c. 30 g mixed in 250 ml of water 139

d. 60 g mixed in 500 ml of water 57. Edward, a 66 year old client with slight
memory
54. What herbal medication for depression,
widely impairment and poor concentration is
diagnosed
used in Europe, is now being prescribed in the
with primary degenerative dementia of the
United States?
Alzheimer's type. Early signs of this dementia
a. Ginkgo biloba
include subtle personality changes and
b. Echinacea
withdrawal from social interactions. To assess
c. St. John's wort
for progression to the middle stage of
d. Ephedra
Alzheimer's disease, the nurse should observe
55. Cely with manic episodes is taking lithium.
the client for:
Which electrolyte level should the nurse check
a. Occasional irritable outbursts.
before administering this medication?
b. Impaired communication.
a. Clcium
c. Lack of spontaneity.
b. Sodium
d. Inability to perform self-care activities.
c. Chloride
58. Isabel with a diagnosis of depression is
d. Potassium
started
56. Nurse Josefina is caring for a client who has
on imipramine (Tofranil), 75 mg by mouth at
been
bedtime. The nurse should tell the client that:
diagnosed with delirium. Which statement
about a. This medication may be habit forming

delirium is true? and will be discontinued as soon as the

a. It's characterized by an acute onset and client feels better.

lasts about 1 month. b. This medication has no serious adverse

b. It's characterized by a slowly evolving effects.

onset and lasts about 1 week. c. The client should avoid eating such

c. It's characterized by a slowly evolving foods as aged cheeses, yogurt, and

onset and lasts about 1 month. chicken livers while taking the

d. It's characterized by an acute onset and medication.

d. This medication may initially cause 61. Mr. Garcia, an attorney who throws books
and
tiredness, which should become less
furniture around the office after losing a case is
bothersome over time.
referred to the psychiatric nurse in the law
59. Kathleen is admitted to the psychiatric clinic
firm's
for
employee assistance program. Nurse Beatriz
treatment of anorexia nervosa. To promote the
knows that the client's behavior most likely
client's physical health, the nurse should plan
to: represents the use of which defense

a. Severely restrict the client's physical mechanism?

activities. a. Regression

b. Weigh the client daily, after the evening b. Projection

meal. c. Reaction-formation

c. Monitor vital signs, serum electrolyte d. Intellectualization

levels, and acid-base balance. 62. Nurse Anne is caring for a client who has
been
d. Instruct the client to keep an accurate
treated long term with antipsychotic
record of food and fluid intake.
medication.
60. Celia with a history of polysubstance abuse
During the assessment, Nurse Anne checks the
is
client for tardive dyskinesia. If tardive dyskinesia
admitted to the facility. She complains of nausea
is present, Nurse Anne would most likely
and vomiting 24 hours after admission. The
observe:
nurse assesses the client and notes piloerection,
a. Abnormal movements and involuntary
pupillary dilation, and lacrimation. The nurse
movements of the mouth, tongue, and
suspects that the client is going through which
of face.

the following withdrawals? b. Abnormal breathing through the nostrils

a. Alcohol withdrawal accompanied by a “thrill.”

b. Cannibis withdrawal c. Severe headache, flushing, tremors, and

c. Cocaine withdrawal ataxia.

d. Opioid withdrawal d. Severe hypertension, migraine

headache,
63. Dennis has a lithium level of 2.4 mEq/L. The c. Sleepiness and lethargy

nurse immediately would assess the client for d. Bradycardia and diarrhea

which of the following signs or symptoms? 66. Kitty, a 9 year old child has very limited

a. Weakness vocabulary and interaction skills. She has an I.Q.

b. Diarrhea of 45. She is diagnosed to have Mental

c. Blurred vision retardation of this classification:

d. Fecal incontinence a. Profound

64. Nurse Jannah is monitoring a male client b. Mild

who
c. Moderate
has been placed inrestraints because of violent
d. Severe
behavior. Nurse determines that it will be safe
67. The therapeutic approach in the care of
to
Armand
remove the restraints when:
an autistic child include the following EXCEPT:
a. The client verbalizes the reasons for the
a. Engage in diversionary activities when
violent behavior.
acting -out
b. The client apologizes and tells the nurse
b. Provide an atmosphere of acceptance
that it will never happen again.
c. Provide safety measures
c. No acts of aggression have been
d. Rearrange the environment to activate
observed within 1 hour after the release
the child
of two of the extremity restraints.
68. Jeremy is brought to the emergency room
d. The administered medication has taken by

effect. friends who state that he took something an

140 hour ago. He is actively hallucinating, agitated,

65. Nurse Irish is aware that Ritalin is the drug with irritated nasal septum.
of
a. Heroin
choice for a child with ADHD. The side effects of
b. Cocaine
the following may be noted by the nurse:
c. LSD
a. Increased attention span and
d. Marijuana
concentration
69. Nurse Pauline is aware that Dementia unlike
b. Increase in appetite
delirium is characterized by: c. Reassure the client that these are

a. Slurred speech common side effects of lithium therapy

b. Insidious onset d. Hold the next dose and obtain an order

c. Clouding of consciousness for a stat serum lithium level

d. Sensory perceptual change 73. Nurse Sarah ensures a therapeutic

environment
70. A 35 year old female has intense fear of
riding an for all the client. Which of the following best

elevator. She claims “ As if I will die inside.” The describes a therapeutic milieu?

client is suffering from: a. A therapy that rewards adaptive

a. Agoraphobia behavior

b. Social phobia b. A cognitive approach to change behavior

c. Claustrophobia c. A living, learning or working

d. Xenophobia environment.

71. Nurse Myrna develops a counter- d. A permissive and congenial environment

transference
74. Anthony is very hostile toward one of the
reaction. This is evidenced by: staff

a. Revealing personal information to the for no apparent reason. He is manifesting:

client a. Splitting

b. Focusing on the feelings of the client. b. Transference

c. Confronting the client about c. Countertransference

discrepancies in verbal or non-verbal d. Resistance

behavior 75. Marielle, 17 years old was sexually attacked

d. The client feels angry towards the nurse while on her way home from school. She is

who resembles his mother. brought to the hospital by her mother. Rape is

72. Tristan is on Lithium has suffered from an example of which type of crisis:
diarrhea
a. Situational
and vomiting. What should the nurse in-charge
b. Adventitious
do first:
c. Developmental
a. Recognize this as a drug interaction
d. Internal
b. Give the client Cogentin
76. Nurse Greta is aware that the following is c. Severe anxiety

classified as an Axis I disorder by the Diagnosis d. Sublimation

and Statistical Manual of Mental Disorders, Text 79. Charina, a college student who frequently
visited
Revision (DSM-IV-TR) is:
the health center during the past year with
a. Obesity
multiple vague complaints of GI symptoms
b. Borderline personality disorder
before course examinations. Although physical
c. Major depression
causes have been eliminated, the student
d. Hypertension
continues to express her belief that she has a
141
serious illness. These symptoms are typically of
77. Katrina, a newly admitted is extremely
hostile which of the following disorders?

toward a staff member she has just met, a. Conversion disorder

without
b. Depersonalization
apparent reason. According to Freudian theory,
c. Hypochondriasis
the nurse should suspect that the client is
d. Somatization disorder
experiencing which of the following
80. Nurse Daisy is aware that the following
phenomena?
pharmacologic agents are sedative- hypnotic
a. Intellectualization
medication is used to induce sleep for a client
b. Transference
experiencing a sleep disorder is:
c. Triangulation
a. Triazolam (Halcion)
d. Splitting
b. Paroxetine (Paxil)\
78. An 83year-old male client is in extended
c. Fluoxetine (Prozac)
care
d. Risperidone (Risperdal)
facility is anxious most of the time and
81. Aldo, with a somatoform pain disorder may
frequently complains of a number of vague
obtain secondary gain. Which of the following
symptoms that interfere with his ability to eat.
statement refers to a secondary gain?
These symptoms indicate which of the following
a. It brings some stability to the family
disorders?
b. It decreases the preoccupation with the
a. Conversion disorder
physical illness
b. Hypochondriasis
c. It enables the client to avoid some 84. Mark, with a diagnosis of generalized
anxiety
unpleasant activity
disorder wants to stop taking his lorazepam
d. It promotes emotional support or
(Ativan). Which of the following important facts
attention for the client
should nurse Betty discuss with the client about
82. Dervid is diagnosed with panic disorder with
discontinuing the medication?
agoraphobia is talking with the nurse in-charge
a. Stopping the drug may cause depression
about the progress made in treatment. Which of
b. Stopping the drug increases cognitive
the following statements indicates a positive
abilities
client response?
c. Stopping the drug decreases sleeping
a. “I went to the mall with my friends last
difficulties
Saturday”
d. Stopping the drug can cause withdrawal
b. “I’m hyperventilating only when I have a
symptoms
panic attack”
85. Jennifer, an adolescent who is depressed
c. “Today I decided that I can stop taking
and
my medication”
reported by his parents as having difficulty in
d. “Last night I decided to eat more than a
school is brought to the community mental
bowl of cereal”
health center to be evaluated. Which of the
83. The effectiveness of monoamine oxidase
following other health problems would the
(MAO)
nurse
inhibitor drug therapy in a client with
suspect?
posttraumatic stress disorder can be
a. Anxiety disorder
demonstrated by which of the following client
b. Behavioral difficulties
self –reports?
c. Cognitive impairment
a. “I’m sleeping better and don’t have
d. Labile moods
nightmares”
142
b. “I’m not losing my temper as much”
86. Ricardo, an outpatient in psychiatric facility
c. “I’ve lost my craving for alcohol” is

d. I’ve lost my phobia for water” diagnosed with dysthymic disorder. Which of
the
following statement about dysthymic disorder is a. Infection

true? b. Metabolic acidosis

a. It involves a mood range from moderate c. Drug intoxication

depression to hypomania d. Hepatic encephalopathy

b. It involves a single manic depression 89. Nurse Ron enters a client’s room, the client
says,
c. It’s a form of depression that occurs in
“They’re crawling on my sheets! Get them off
the fall and winter
my bed!” Which of the following assessment is
d. It’s a mood disorder similar to major
the most accurate?
depression but of mild to moderate
a. The client is experiencing aphasia
severity
b. The client is experiencing dysarthria
87. The nurse is aware that the following ways
in c. The client is experiencing a flight of ideas

vascular dementia different from Alzheimer’s d. The client is experiencing visual

disease is: hallucination

a. Vascular dementia has more abrupt 90. Which of the following descriptions of a
client’s
onset
experience and behavior can be assessed as an
b. The duration of vascular dementia is
illusion?
usually brief
a. The client tries to hit the nurse when
c. Personality change is common in
vital signs must be taken
vascular dementia
b. The client says, “I keep hearing a voice
d. The inability to perform motor activities
telling me to run away”
occurs in vascular dementia
c. The client becomes anxious whenever
88. Loretta, a newly admitted client was
diagnosed the nurse leaves the bedside

with delirium and has history of hypertension d. The client looks at the shadow on a wall

and anxiety. She had been taking digoxin, and tells the nurse she sees frightening

furosemide (Lasix), and diazepam (Valium) for faces on the wall.

anxiety. This client’s impairment may be related 91. During conversation of Nurse John with a
client,
to which of the following conditions?
he observes that the client shift from one topic
to the next on a regular basis. Which of the 94. Nurse Alexandra notices other clients on the
unit
following terms describes this disorder?
avoiding a client diagnosed with antisocial
a. Flight of ideas
personality disorder. When discussing
b. Concrete thinking
appropriate behavior in group therapy, which of
c. Ideas of reference
the following comments is expected about this
d. Loose association
client by his peers?
92. Francis tells the nurse that her coworkers
are a. Lack of honesty

sabotaging the computer. When the nurse asks b. Belief in superstition

questions, the client becomes argumentative. c. Show of temper tantrums

This behavior shows personality traits d. Constant need for attention

associated
95. Tommy, with dependent personality
with which of the following personality disorder is
disorder?
working to increase his self- esteem. Which of
a. Antisocial
the following statements by the Tommy shows
b. Histrionic
teaching was successful?
c. Paranoid
143
d. Schizotypal
a. “I’m not going to look just at the
93. Which of the following interventions is
negative things about myself”
important for a Cely experiencing with paranoid
b. “I’m most concerned about my level of
personality disorder taking olanzapine
competence and progress”
(Zyprexa)?
c. “I’m not as envious of the things other
a. Explain effects of serotonin syndrome
people have as I used to be”
b. Teach the client to watch for
d. “I find I can’t stop myself from taking
extrapyramidal adverse reaction
over things other should be doing”
c. Explain that the drug is less affective if
96. Norma, a 42-year-old client with a diagnosis
the client smokes of

d. Discuss the need to report paradoxical chronic undifferentiated schizophrenia lives in a

effects such as euphoria 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 99. Mike is admitted to a psychiatric unit with a

following interventions should be done first? diagnosis of undifferentiated schizophrenia.

a. Talk about his hallucinations and fears Which of the following defense mechanisms is

b. Refer him for anticholinergic adverse probably used by mike?

reactions a. Projection

c. Assess for possible physical problems b. Rationalization

such as rash c. Regression

d. Call his physician to get his medication d. Repression

increased to control his psychosis 100. Rocky has started taking haloperidol
(Haldol).
97. Ivy, who is on the psychiatric unit is copying
and Which of the following instructions is most

imitating the movements of her primary nurse. appropriate for Ricky before taking

During recovery, she says, “I thought the nurse haloperidol?

was my mirror. I felt connected only when I saw a. Should report feelings of restlessness or

my nurse.” This behavior is known by which of agitation at once

the following terms? b. Use a sunscreen outdoors on a yearround

a. Modeling basis

b. Echopraxia c. Be aware you’ll feel increased energy

c. Ego-syntonicity taking this drug

d. Ritualism d. This drug will indirectly control essential

98. Jun approaches the nurse and tells that he hypertension

hears
144
a voice telling him that he’s evil and deserves to
Answers and Rationale – Care of Clients with
die. Which of the following terms describes the
Physiologic and Psychosocial Alterations
client’s perception?
1. Answer: (D) Focusing
a. Delusion
Rationale: The nurse is using focusing by
b. Disorganized speech
suggesting that the client discuss a specific
c. Hallucination issue.

d. Idea of reference The nurse didn’t restate the question, make

observation, or ask further question (exploring). 7. Answer: (C) Superego

2. Answer: (D) Remove all other clients from the Rationale: This behavior shows a weak sense of

dayroom. moral consciousness. According to Freudian

Rationale: The nurse’s first priority is to consider theory, personality disorders stem from a weak

the safety of the clients in the therapeutic superego.

setting. The other actions are appropriate 8. Answer: (C) Skeletal muscle paralysis.

responses after ensuring the safety of other Rationale: Anectine is a depolarizing muscle

clients. relaxant causing paralysis. It is used to reduce

3. Answer: (A) The client is disruptive. the intensity of muscle contractions during the

Rationale: Group activity provides too much convulsive stage, thereby reducing the risk of

stimulation, which the client will not be able to bone fractures or dislocation.

handle (harmful to self) and as a result will be 9. Answer: (D) Increase calories, carbohydrates,

disruptive to others. and protein.

4. Answer: (C) Agree to talk with the mother Rationale: This client increased protein for
and tissue

the father together. building and increased calories to replace what

is
Rationale: By agreeing to talk with both parents,
burned up (usually via carbohydrates).
the nurse can provide emotional support and
10. Answer: (C) Acting overly solicitous toward
further assess and validate the family’s needs.
the
5. Answer: (A) Perceptual disorders.
child.
Rationale: Frightening visual hallucinations are
Rationale: This behavior is an example of
especially common in clients experiencing
reaction formation, a coping mechanism.
alcohol withdrawal.
11. Answer: (A) By designating times during
6. Answer: (D) Suggest that it takes a while which
before
the client can focus on the behavior.
seeing the results.
Rationale: The nurse should designate times
Rationale: The client needs a specific response;
during which the client can focus on the
that it takes 2 to 3 weeks (a delayed effect) until
compulsive behavior or obsessive thoughts. The
the therapeutic blood level is reached.
nurse should urge the client to reduce the
frequency of the compulsive behavior gradually, on in your life to find out why it's happened."

not rapidly. She shouldn't call attention to or try Rationale: The nurse must be honest with the

to prevent the behavior. Trying to prevent the client by telling her that the paralysis has no

behavior may cause pain and terror in the client. physiologic cause while also conveying empathy

The nurse should encourage the client to and acknowledging that her symptoms are real.

verbalize anxieties to help distract attention The client will benefit from psychiatric

from the compulsive behavior. treatment, which will help her understand the

12. Answer: (D) Exploring the meaning of the underlying cause of her symptoms. After the

traumatic event with the client. psychological conflict is resolved, her symptoms

Rationale: The client with PTSD needs will disappear. Saying that it must be awful not

encouragement to examine and understand the to be able to move her legs wouldn't answer the

meaning of the traumatic event and consequent client's question; knowing that the cause is

losses. Otherwise, symptoms may worsen and psychological wouldn't necessarily make her feel

the client may become depressed or engage in better. Telling her that she has developed

self-destructive behavior such as substance paralysis to avoid leaving her parents or that her

abuse. The client must explore the meaning of personality caused her disorder wouldn't help

the event and won't heal without this, no her understand and resolve the underlying
matter
conflict.
how much time passes. Behavioral techniques,
145
such as relaxation therapy, may help decrease
14. Answer: (C) fluvoxamine (Luvox) and
the client's anxiety and induce sleep. The
clomipramine (Anafranil)
physician may prescribe antianxiety agents or
Rationale: The antidepressants fluvoxamine and
antidepressants cautiously to avoid
clomipramine have been effective in the
dependence;
treatment of OCD. Librium and Valium may be
sleep medication is rarely appropriate. A special
helpful in treating anxiety related to OCD but
diet isn't indicated unless the client also has an
aren't drugs of choice to treat the illness. The
eating disorder or a nutritional problem.
other medications mentioned aren't effective in
13. Answer: (C) "Your problem is real but there
is no the treatment of OCD.
physical basis for it. We'll work on what is going
15. Answer: (A) A warning about the drugs anxiety but don't relieve the anxiety itself.
delayed
Antipsychotic drugs are inappropriate because
therapeutic effect, which is from 14 to 30 days.
clients who experience panic attacks aren't
Rationale: The client should be informed that
psychotic. Mood stabilizers aren't indicated
the drug's therapeutic effect might not be
because panic attacks are rarely associated with
reached for 14 to 30 days. The client must be
mood changes.
instructed to continue taking the drug as
18. Answer: (B) 3 to 5 days
directed. Blood level checks aren't necessary.
Rationale: Monoamine oxidase inhibitors, such
NMS hasn't been reported with this drug, but
as tranylcypromine, have an onset of action of
tachycardia is frequently reported.
approximately 3 to 5 days. A full clinical
16. Answer: (B) Severe anxiety and fear.
response may be delayed for 3 to 4 weeks. The
Rationale: Phobias cause severe anxiety (such as
therapeutic effects may continue for 1 to 2
a panic attack) that is out of proportion to the
weeks after discontinuation.
threat of the feared object or situation. Physical
19. Answer: (B) Providing emotional support
signs and symptoms of phobias include profuse and

sweating, poor motor control, tachycardia, and individual counseling.

elevated blood pressure. Insomnia, an inability Rationale: Clients in the first stage of
Alzheimer's
to concentrate, and weight loss are common in
disease are aware that something is happening
depression. Withdrawal and failure to
to them and may become overwhelmed and
distinguish reality from fantasy occur in
frightened. Therefore, nursing care typically
schizophrenia.
focuses on providing emotional support and
17. Answer: (A) Antidepressants
individual counseling. The other options are
Rationale: Tricyclic and monoamine oxidase
appropriate during the second stage of
(MAO) inhibitor antidepressants have been
Alzheimer's disease, when the client needs
found to be effective in treating clients with
continuous monitoring to prevent minor
panic attacks. Why these drugs help control
illnesses from progressing into major problems
panic attacks isn't clearly understood.
and when maintaining adequate nutrition may
Anticholinergic agents, which are smoothmuscle
become a challenge. During this stage, offering
relaxants, relieve physical symptoms of
nourishing finger foods helps clients to feed Rationale: Methadone is used to detoxify opiate

themselves and maintain adequate nutrition. users because it binds with opioid receptors at

20. Answer: (C) Emotional lability, euphoria, and many sites in the central nervous system but

impaired memory doesn’t have the same deterious effects as

other
Rationale: Signs of antianxiety agent overdose
opiates, such as cocaine, heroin, and morphine.
include emotional lability, euphoria, and
Barbiturates, amphetamines, and
impaired memory. Phencyclidine overdose can
benzodiazepines are highly addictive and would
cause combativeness, sweating, and confusion.
require detoxification treatment.
Amphetamine overdose can result in agitation,
23. Answer: (B) Hallucinations
hyperactivity, and grandiose ideation.
Rationale: Hallucinations are visual, auditory,
Hallucinogen overdose can produce
gustatory, tactile, or olfactory perceptions that
suspiciousness, dilated pupils, and increased
have no basis in reality. Delusions are false
blood pressure.
beliefs, rather than perceptions, that the client
21. Answer: (D) A low tolerance for frustration
146
Rationale: Clients with an antisocial personality
accepts as real. Loose associations are rapid
disorder exhibit a low tolerance for frustration,
shifts among unrelated ideas. Neologisms are
emotional immaturity, and a lack of impulse
bizarre words that have meaning only to the
control. They commonly have a history of
client.
unemployment, miss work repeatedly, and quit
24. Answer: (C) Set up a strict eating plan for the
work without other plans for employment. They
client.
don't feel guilt about their behavior and
Rationale: Establishing a consistent eating plan
commonly perceive themselves as victims. They
and monitoring the client’s weight are very
also display a lack of responsibility for the
important in this disorder. The family and
outcome of their actions. Because of a lack of
friends
trust in others, clients with antisocial
should be included in the client’s care. The
personality
client
disorder commonly have difficulty developing
should be monitored during meals-not given
stable, close relationships.
privacy. Exercise must be limited and
22. Answer: (C) Methadone supervised.
25. Answer: (A) Highly important or famous. mechanism in which emotional conflict and

Rationale: A delusion of grandeur is a false anxiety is avoided by refusing to acknowledge

belief
feelings, desires, impulses, or external facts that
that one is highly important or famous. A
are consciously intolerable. Withdrawal is a
delusion of persecution is a false belief that one
common response to stress, characterized by
is being persecuted. A delusion of reference is a
apathy. Logical thinking is the ability to think
false belief that one is connected to events
rationally and make responsible decisions,
unrelated to oneself or a belief that one is which

responsible for the evil in the world. would lead the client admitting the problem and

26. Answer: (D) Listening attentively with a seeking help. Repression is suppressing past
neutral
events from the consciousness because of guilty
attitude and avoiding power struggles.
association.
Rationale: The nurse should listen to the client’s
28. Answer: (B) Paranoid thoughts
requests, express willingness to seriously
Rationale: Clients with schizotypal personality
consider the request, and respond later. The
disorder experience excessive social anxiety that
nurse should encourage the client to take short
can lead to paranoid thoughts. Aggressive
daytime naps because he expends so much
behavior is uncommon, although these clients
energy. The nurse shouldn’t try to restrain the
may experience agitation with anxiety. Their
client when he feels the need to move around
behavior is emotionally cold with a flattened
as
affect, regardless of the situation. These clients
long as his activity isn’t harmful. High calorie
demonstrate a reduced capacity for close or
finger foods should be offered to supplement
dependent relationships.
the client’s diet, if he can’t remain seated long
29. Answer: (C) Identify anxiety-causing
enough to eat a complete meal. The nurse
situations
shouldn’t be forced to stay seated at the table
Rationale: Bulimic behavior is generally a
to
maladaptive coping response to stress and
finid=sh a meal. The nurse should set limits in a
underlying issues. The client must identify
calm, clear, and self-confident tone of voice.
anxiety-causing situations that stimulate the
27. Answer: (D) Denial
bulimic behavior and then learn new ways of
Rationale: Denial is unconscious defense
coping with the anxiety. crisis because by definition a crisis would be

30. Answer: (A) Tension and irritability resolved in 6 weeks.

Rationale: An amphetamine is a nervous system 35. Answer: (B) Staying in the sun

stimulant that is subject to abuse because of its Rationale: Haldol causes photosensitivity.
Severe
ability to produce wakefulness and euphoria. An
sunburn can occur on exposure to the sun.
overdose increases tension and irritability.
36. Answer: (D) Moderate-level anxiety
Options B and C are incorrect because
Rationale: A moderately anxious person can
amphetamines stimulate norepinephrine, which
ignore peripheral events and focuses on central
increase the heart rate and blood flow. Diarrhea
concerns.
is a common adverse effect so option D is
37. Answer: (C) Diverse interest
incorrect.
Rationale: Before onset of depression, these
31. Answer: (B) “No, I do not hear your voices,
but I clients usually have very narrow, limited

believe you can hear them”. interest.

Rationale: The nurse, demonstrating knowledge 147

and understanding, accepts the client’s 38. Answer: (A) As their depression begins to

perceptions even though they are hallucinatory. improve

32. Answer: (C) Confusion for a time after Rationale: At this point the client may have
treatment
enough energy to plan and execute an attempt.
Rationale: The electrical energy passing through
39. Answer: (D) Disturbance in recalling recent
the cerebral cortex during ECT results in a
events related to cerebral hypoxia.
temporary state of confusion after treatment.
Rationale: Cell damage seems to interfere with
33. Answer: (D) Acceptance stage
registering input stimuli, which affects the
Rationale: Communication and intervention ability

during this stage are mainly nonverbal, as when to register and recall recent events; vascular

the client gestures to hold the nurse’s hand. dementia is related to multiple vascular lesions

34. Answer: (D) A higher level of anxiety of the cerebral cortex and subcortical structure.
continuing
40. Answer: (D) Encouraging the client to have
for more than 3 months. blood

Rationale: This is not an expected outcome of a levels checked as ordered.

Rationale: Blood levels must be checked to 6 weeks.
monthly
46. Answer: (D) Males are more likely to use
or bimonthly when the client is on maintenance lethal

therapy because there is only a small range methods than are females

between therapeutic and toxic levels. Rationale: This finding is supported by research;

41. Answer: (B) Fine hand tremors or slurred females account for 90% of suicide attempts but
speech
males are three times more successful because
Rationale: These are common side effects of
of methods used.
lithium carbonate.
47. Answer: (C) "Your cursing is interrupting the
42. Answer: (D) Presence
activity. Take time out in your room for 10
Rationale: The constant presence of a nurse
minutes."
provides emotional support because the client
Rationale: The nurse should set limits on client
knows that someone is attentive and available
behavior to ensure a comfortable environment
in
for all clients. The nurse should accept hostile or
case of an emergency.
quarrelsome client outbursts within limits
43. Answer: (A) Client’s perception of the
presenting without becoming personally offended, as in
problem. option A. Option B is incorrect because it
implies
Rationale: The nurse can be most therapeutic by
that the client’s actions reflect feelings toward
starting where the client is, because it is the
the staff instead of the client's own misery.
client’s concept of the problem that serves as
Judgmental remarks, such as option D, may
the starting point of the relationship.
decrease the client's self-esteem.
44. Answer: (B) Chocolate milk, aged cheese,
and 48. Answer: (C) lithium carbonate (Lithane)
yogurt’” Rationale: Lithium carbonate, an antimania
drug,
Rationale: These high-tyramine foods, when
is used to treat clients with cyclical
ingested in the presence of an MAO inhibitor,
schizoaffective disorder, a psychotic disorder
cause a severe hypertensive response.
once classified under schizophrenia that causes
45. Answer: (B) 4 to 6 weeks
affective symptoms, including maniclike activity.
Rationale: Crisis is self-limiting and lasts from 4
Lithium helps control the affective component only under the supervision of a physician.
of
50. Answer: (C) Neuroleptic malignant
this disorder. Phenelzine is a monoamine syndrome.

oxidase inhibitor prescribed for clients who Rationale: The client's signs and symptoms
don't
suggest neuroleptic malignant syndrome, a
respond to other antidepressant drugs such as lifethreatening

imipramine. Chlordiazepoxide, an antianxiety reaction to neuroleptic medication

agent, generally is contraindicated in psychotic that requires immediate treatment. Tardive

clients. Imipramine, primarily considered an dyskinesia causes involuntary movements of the

antidepressant agent, is also used to treat tongue, mouth, facial muscles, and arm and leg
clients
muscles. Dystonia is characterized by cramps
with agoraphobia and that undergoing cocaine
and rigidity of the tongue, face, neck, and back
detoxification.
muscles. Akathisia causes restlessness, anxiety,
49. Answer: (B) Report a sore throat or fever to
and jitteriness.
the
51. Answer: (B) Advising the client to sit up for 1
physician immediately.
minute before getting out of bed.
Rationale: A sore throat and fever are
Rationale: To minimize the effects of
indications of an infection caused by
amitriptyline-induced orthostatic hypotension,
agranulocytosis, a potentially life-threatening
148
complication of clozapine. Because of the risk of
the nurse should advise the client to sit up for 1
agranulocytosis, white blood cell (WBC) counts
minute before getting out of bed. Orthostatic
are necessary weekly, not monthly. If the WBC
hypotension commonly occurs with tricyclic
count drops below 3,000/μl, the medication
antidepressant therapy. In these cases, the
must be stopped. Hypotension may occur in
dosage may be reduced or the physician may
clients taking this medication. Warn the client to
prescribe nortriptyline, another tricyclic
stand up slowly to avoid dizziness from
antidepressant. Orthostatic hypotension
orthostatic hypotension. The medication should
disappears only when the drug is discontinued.
be continued, even when symptoms have been
52. Answer: (D) Dysthymic disorder.
controlled. If the medication must be stopped, it
Rationale: Dysthymic disorder is marked by
should be slowly tapered over 1 to 2 weeks and
feelings of depression lasting at least 2 years, Rationale: St. John's wort has been found to

accompanied by at least two of the following have serotonin-elevating properties, similar to

symptoms: sleep disturbance, appetite prescription antidepressants. Ginkgo biloba is

disturbance, low energy or fatigue, low prescribed to enhance mental acuity. Echinacea
selfesteem,
has immune-stimulating properties. Ephedra is a
poor concentration, difficulty making
naturally occurring stimulant that is similar to
decisions, and hopelessness. These symptoms
ephedrine.
may be relatively continuous or separated by
55. Answer: (B) Sodium
intervening periods of normal mood that last a
Rationale: Lithium is chemically similar to
few days to a few weeks. Cyclothymic disorder is
sodium. If sodium levels are reduced, such as
a chronic mood disturbance of at least 2 years'
from sweating or diuresis, lithium will be
duration marked by numerous periods of
reabsorbed by the kidneys, increasing the risk of
depression and hypomania. Atypical affective
toxicity. Clients taking lithium shouldn't restrict
disorder is characterized by manic signs and
their intake of sodium and should drink
symptoms. Major depression is a recurring,
adequate amounts of fluid each day. The other
persistent sadness or loss of interest or pleasure
electrolytes are important for normal body
in almost all activities, with signs and symptoms
functions but sodium is most important to the
recurring for at least 2 weeks.
absorption of lithium.
53. Answer: (C) 30 g mixed in 250 ml of water
56. Answer: (D) It's characterized by an acute
Rationale: The usual adult dosage of activated onset

charcoal is 5 to 10 times the estimated weight and lasts hours to a number of days
of
Rationale: Delirium has an acute onset and
the drug or chemical ingested, or a minimum
typically can last from several hours to several
dose of 30 g, mixed in 250 ml of water. Doses
days.
less than this will be ineffective; doses greater
57. Answer: (B) Impaired communication.
than this can increase the risk of adverse
Rationale: Initially, memory impairment may be
reactions, although toxicity doesn't occur with
the only cognitive deficit in a client with
activated charcoal, even at the maximum dose.
Alzheimer's disease. During the early stage of
54. Answer: (C) St. John's wort
this disease, subtle personality changes may livers, are necessary for a client taking a
also
monoamine oxidase inhibitor, not a tricyclic
be present. However, other than occasional
antidepressant.
irritable outbursts and lack of spontaneity, the
59. Answer: (C) Monitor vital signs, serum
client is usually cooperative and exhibits socially
electrolyte levels, and acid-base balance.
appropriate behavior. Signs of advancement to
Rationale: An anorexic client who requires
the middle stage of Alzheimer's disease include
hospitalization is in poor physical condition from
exacerbated cognitive impairment with obvious
starvation and may die as a result of
personality changes and impaired
arrhythmias, hypothermia, malnutrition,
communication, such as inappropriate
infection, or cardiac abnormalities secondary to
conversation, actions, and responses. During the
electrolyte imbalances. Therefore, monitoring
late stage, the client can't perform self-care
the client's vital signs, serum electrolyte level,
activities and may become mute.
and acid base balance is crucial. Option A may
58. Answer: (D) This medication may initially
worsen anxiety. Option B is incorrect because a
cause
weight obtained after breakfast is more
tiredness, which should become less
accurate
bothersome over time.
149
Rationale: Sedation is a common early adverse
than one obtained after the evening meal.
effect of imipramine, a tricyclic antidepressant,
Option D would reward the client with attention
and usually decreases as tolerance develops.
for not eating and reinforce the control issues
Antidepressants aren't habit forming and don't
that are central to the underlying psychological
cause physical or psychological dependence.
problem; also, the client may record food and
However, after a long course of high-dose
fluid intake inaccurately.
therapy, the dosage should be decreased
60. Answer: (D) Opioid withdrawal
gradually to avoid mild withdrawal symptoms.
Rationale: The symptoms listed are specific to
Serious adverse effects, although rare, include
opioid withdrawal. Alcohol withdrawal would
myocardial infarction, heart failure, and
show elevated vital signs. There is no real
tachycardia. Dietary restrictions, such as
withdrawal from cannibis. Symptoms of cocaine
avoiding aged cheeses, yogurt, and chicken
withdrawal include depression, anxiety, and
agitation. slurred speech, and confusion. At lithium levels

61. Answer: (A) Regression of 2.5 to 3 mEq/L or higher, urinary and fecal

Rationale: An adult who throws temper incontinence occurs, as well as seizures, cardiac

tantrums, such as this one, is displaying dysrythmias, peripheral vascular collapse, and

regressive behavior, or behavior that is death.

appropriate at a younger age. In projection, the 64. Answer: (C) No acts of aggression have been

client blames someone or something other than observed within 1 hour after the release of two

the source. In reaction formation, the client acts of the extremity restraints.

in opposition to his feelings. In Rationale: The best indicator that the behavior
is
intellectualization, the client overuses rational
controlled, if the client exhibits no signs of
explanations or abstract thinking to decrease
the aggression after partial release of restraints.

significance of a feeling or event. Options , B, and D do not ensure that the client

62. Answer: (A) Abnormal movements and has controlled the behavior.

involuntary movements of the mouth, tongue, 65. Answer: (A) increased attention span and

and face. concentration

Rationale: Tardive dyskinesia is a severe reaction Rationale: The medication has a paradoxic effect

associated with long term use of antipsychotic that decreases hyperactivity and impulsivity

medication. The clinical manifestations include among children with ADHD. B, C, D. Side effects

abnormal movements (dyskinesia) and of Ritalin include anorexia, insomnia, diarrhea

involuntary movements of the mouth, tongue and irritability.

(fly catcher tongue), and face. 66. Answer: (C) Moderate

63. Answer: (C) Blurred vision Rationale: The child with moderate mental

Rationale: At lithium levels of 2 to 2.5 mEq/L the retardation has an I.Q. of 35- 50 Profound

client will experienced blurred vision, muscle Mental retardation has an I.Q. of below 20; Mild

twitching, severe hypotension, and persistent mental retardation 50-70 and Severe mental

nausea and vomiting. With levels between 1.5 retardation has an I.Q. of 20-35.

and 2 mEq/L the client experiencing vomiting, 67. Answer: (D) Rearrange the environment to

diarrhea, muscle weakness, ataxia, dizziness, activate the child

Rationale: The child with autistic disorder does A. Agoraphobia is fear of open space or being a

not want change. Maintaining a consistent situation where escape is difficult. B. Social

environment is therapeutic. A. Angry outburst phobia is fear of performing in the presence of

can be re-channeling through safe activities. B. others in a way that will be humiliating or

Acceptance enhances a trusting relationship. C. embarrassing. D. Xenophobia is fear of

Ensure safety from self-destructive behaviors strangers.

like head banging and hair pulling. 71. Answer: (A) Revealing personal information
to
68. Answer: (B) cocaine
the client
Rationale: The manifestations indicate
Rationale: Counter-transference is an emotional
intoxication with cocaine, a CNS stimulant. A.
reaction of the nurse on the client based on her
Intoxication with heroine is manifested by
150
euphoria then impairment in judgment,
unconscious needs and conflicts. B and C. These
attention and the presence of papillary
are therapeutic approaches. D. This is
constriction. C. Intoxication with hallucinogen
transference reaction where a client has an
like LSD is manifested by grandiosity,
emotional reaction towards the nurse based on
hallucinations, synesthesia and increase in vital
her past.
signs D. Intoxication with Marijuana, a
72. Answer: (D) Hold the next dose and obtain
cannabinoid is manifested by sensation of
an
slowed time, conjunctival redness, social
order for a stat serum lithium level
withdrawal, impaired judgment and
Rationale: Diarrhea and vomiting are
hallucinations.
manifestations of Lithium toxicity. The next dose
69. Answer: (B) insidious onset
of lithium should be withheld and test is done
Rationale: Dementia has a gradual onset and to

progressive deterioration. It causes pronounced validate the observation. A. The manifestations

memory and cognitive disturbances. A,C and D are not due to drug interaction. B. Cogentin is

are all characteristics of delirium. used to manage the extra pyramidal symptom

70. Answer: (C) Claustrophobia side effects of antipsychotics. C. The common

Rationale: Claustrophobia is fear of closed side effects of Lithium are fine hand tremors,
space.
nausea, polyuria and polydipsia.
73. Answer: (C) A living, learning or working Rationale: Adventitious crisis is a crisis involving

environment. a traumatic event. It is not part of everyday life.

Rationale: A therapeutic milieu refers to a broad A. Situational crisis is from an external source

conceptual approach in which all aspects of the that upset ones psychological equilibrium C and

environment are channeled to provide a D. are the same. They are transitional or

therapeutic environment for the client. The six developmental periods in life

environmental elements include structure, 76. Answer: (C) Major depression

safety, norms; limit setting, balance and unit Rationale: The DSM-IV-TR classifies major

modification. A. Behavioral approach in depression as an Axis I disorder. Borderline

psychiatric care is based on the premise that personality disorder as an Axis II; obesity and

behavior can be learned or unlearned through hypertension, Axis III.

the use of reward and punishment. B. Cognitive 77. Answer: (B) Transference

approach to change behavior is done by Rationale: Transference is the unconscious

correcting distorted perceptions and irrational assignment of negative or positive feelings

beliefs to correct maladaptive behaviors. D. This evoked by a significant person in the client’s
past
is not congruent with therapeutic milieu.
to another person. Intellectualization is a
74. Answer: (B) Transference
defense mechanism in which the client avoids
Rationale: Transference is a positive or negative
dealing with emotions by focusing on facts.
feeling associated with a significant person in
Triangulation refers to conflicts involving three
the client’s past that are unconsciously assigned
family members. Splitting is a defense
to another A. Splitting is a defense mechanism
mechanism commonly seen in clients with
commonly seen in a client with personality
personality disorder in which the world is
disorder in which the world is perceived as all
perceived as all good or all bad.
good or all bad C. Countert-transference is a
78. Answer: (B) Hypochondriasis
phenomenon where the nurse shifts feelings
Rationale: Complains of vague physical
assigned to someone in her past to the patient
symptoms that have no apparent medical
D. Resistance is the client’s refusal to submit
causes
himself to the care of the nurse
are characteristic of clients with
75. Answer: (B) Adventitious
hypochondriasis. In many cases, the GI system is reuptake inhibitor used for depressive

affected. Conversion disorders are characterized disorders and obsessive-compulsive disorders.

by one or more neurologic symptoms. The Risperidome is indicated for psychotic disorders.

client’s symptoms don’t suggest severe anxiety. 81. Answer: (D) It promotes emotional support
or
A client experiencing sublimation channels
attention for the client
maladaptive feelings or impulses into socially
151
acceptable behavior
Rationale: Secondary gain refers to the benefits
79. Answer: (C) Hypochondriasis
of the illness that allow the client to receive
Rationale: Hypochodriasis in this case is shown
emotional support or attention. Primary gain
by the client’s belief that she has a serious
enables the client to avoid some unpleasant
illness, although pathologic causes have been
activity. A dysfunctional family may disregard
eliminated. The disturbance usually lasts at least
the real issue, although some conflict is
6 with identifiable life stressor such as, in this
relieved.
case, course examinations. Conversion disorders
Somatoform pain disorder is a preoccupation
are characterized by one or more neurologic
with pain in the absence of physical disease.
symptoms. Depersonalization refers to
82. Answer: (A) “I went to the mall with my
persistent recurrent episodes of feeling friends

detached from one’s self or body. Somatoform last Saturday”

disorders generally have a chronic course with Rationale: Clients with panic disorder tent to be

few remissions. socially withdrawn. Going to the mall is a sign of

80. Answer: (A) Triazolam (Halcion) working on avoidance behaviors.

Rationale: Triazolam is one of a group of Hyperventilating is a key symptom of panic

sedative hypnotic medication that can be used disorder. Teaching breathing control is a major

for a limited time because of the risk of intervention for clients with panic disorder. The

dependence. Paroxetine is a scrotonin-specific client taking medications for panic disorder;

such
reutake inhibitor used for treatment of
as tricylic antidepressants and benzodiazepines
depression panic disorder, and
obsessivecompulsive must be weaned off these drugs. Most clients

disorder. Fluoxetine is a scrotoninspecific

with panic disorder with agoraphobia don’t characteristic of a client with cognitive
have
impairment or bipolar disorder.
nutritional problems.
86. Answer: (D) It’s a mood disorder similar to
83. Answer: (A) “I’m sleeping better and don’t major
have
depression but of mild to moderate severity
nightmares”
Rationale: Dysthymic disorder is a mood
Rationale: MAO inhibitors are used to treat disorder
sleep
similar to major depression but it remains mild
problems, nightmares, and intrusive daytime
to moderate in severity. Cyclothymic disorder is
thoughts in individual with posttraumatic stress
a mood disorder characterized by a mood range
disorder. MAO inhibitors aren’t used to help
from moderate depression to hypomania.
control flashbacks or phobias or to decrease the
Bipolar I disorder is characterized by a single
craving for alcohol.
manic episode with no past major depressive
84. Answer: (D) Stopping the drug can cause
episodes. Seasonal- affective disorder is a form
withdrawal symptoms
of depression occurring in the fall and winter.
Rationale: Stopping antianxiety drugs such as
87. Answer: (A) Vascular dementia has more
benzodiazepines can cause the client to have abrupt

withdrawal symptoms. Stopping a onset

benzodiazepine doesn’t tend to cause Rationale: Vascular dementia differs from

depression, increase cognitive abilities, or Alzheimer’s disease in that it has a more abrupt

decrease sleeping difficulties. onset and runs a highly variable course.

85. Answer: (B) Behavioral difficulties Personally change is common in Alzheimer’s

Rationale: Adolescents tend to demonstrate disease. The duration of delirium is usually brief.

severe irritability and behavioral problems The inability to carry out motor activities is

rather than simply a depressed mood. Anxiety common in Alzheimer’s disease.

disorder is more commonly associated with 88. Answer: (C) Drug intoxication

small children rather than with adolescents. Rationale: This client was taking several

Cognitive impairment is typically associated medications that have a propensity for

with
producing delirium; digoxin (a digitalis
delirium or dementia. Labile mood is more
glycoxide), furosemide (a thiazide diuretic), and
diazepam (a benzodiazepine). Sufficient associations don’t necessarily start in a cogently,

supporting data don’t exist to suspect the other then becomes loose.

options as causes. 92. Answer: (C) Paranoid

89. Answer: (D) The client is experiencing visual Rationale: Because of their suspiciousness,

hallucination paranoid personalities ascribe malevolent

Rationale: The presence of a sensory stimulus activities to others and tent to be defensive,

correlates with the definition of a hallucination, becoming quarrelsome and argumentative.

which is a false sensory perception. Aphasia 152

refers to a communication problem. Dysarthria Clients with antisocial personality disorder can
is
also be antagonistic and argumentative but are
difficulty in speech production. Flight of ideas is
less suspicious than paranoid personalities.
rapid shifting from one topic to another.
Clients with histrionic personality disorder are
90. Answer: (D) The client looks at the shadow
dramatic, not suspicious and argumentative.
on a
Clients with schizoid personality disorder are
wall and tells the nurse she sees frightening
usually detached from other and tend to have
faces on the wall.
eccentric behavior.
Rationale: Minor memory problems are
93. Answer: (C) Explain that the drug is less
distinguished from dementia by their minor
affective
severity and their lack of significant interference
if the client smokes
with the client’s social or occupational lifestyle.
Rationale: Olanzapine (Zyprexa) is less effective
Other options would be included in the history
for clients who smoke cigarettes. Serotonin
data but don’t directly correlate with the client’s
syndrome occurs with clients who take a
lifestyle.
combination of antidepressant medications.
91. Answer: (D) Loose association
Olanzapine doesn’t cause euphoria, and
Rationale: Loose associations are conversations
extrapyramidal adverse reactions aren’t a
that constantly shift in topic. Concrete thinking
problem. However, the client should be aware
implies highly definitive thought processes. of

Flight of ideas is characterized by conversation adverse effects such as tardive dyskinesia.

that’s disorganized from the onset. Loose 94. Answer: (A) Lack of honesty
Rationale: Clients with antisocial personality as assessment of his itching, and itching isn’t as

disorder tent to engage in acts of dishonesty, adverse reaction of antipsychotic drugs, calling

shown by lying. Clients with schizotypal the physician to get the client’s medication

personality disorder tend to be superstitious. increased doesn’t address his physical

Clients with histrionic personality disorders tend complaints.

to overreact to frustrations and 97. Answer: (B) Echopraxia

disappointments, have temper tantrums, and Rationale: Echopraxia is the copying of

another’s
seek attention.
behaviors and is the result of the loss of ego
95. Answer: (A) “I’m not going to look just at the
boundaries. Modeling is the conscious copying
negative things about myself”
of someone’s behaviors. Ego-syntonicity refers
Rationale: As the client makes progress on
to behaviors that correspond with the
improving self-esteem, self- blame and negative
individual’s sense of self. Ritualism behaviors are
self-evaluation will decrease. Clients with
repetitive and compulsive.
dependent personality disorder tend to feel
98. Answer: (C) Hallucination
fragile and inadequate and would be extremely
Rationale: Hallucinations are sensory
unlikely to discuss their level of competence and
experiences that are misrepresentations of
progress. These clients focus on self and aren’t
reality or have no basis in reality. Delusions are
envious or jealous. Individuals with dependent
beliefs not based in reality. Disorganized speech
personality disorders don’t take over situations
is characterized by jumping from one topic to
because they see themselves as inept and
the next or using unrelated words. An idea of
inadequate.
reference is a belief that an unrelated situation
96. Answer: (C) Assess for possible physical
holds special meaning for the client.
problems such as rash
99. Answer: (C) Regression
Rationale: Clients with schizophrenia generally
Rationale: Regression, a return to earlier
have poor visceral recognition because they live
behavior to reduce anxiety, is the basic defense
so fully in their fantasy world. They need to have
mechanism in schizophrenia. Projection is a
as in-depth assessment of physical complaints
defense mechanism in which one blames others
that may spill over into their delusional
and attempts to justify actions; it’s used
symptoms. Talking with the client won’t provide
primarily by people with paranoid schizophrenia break in sterile technique for respiratory

and delusional disorder. Rationalization is a isolation?

defense mechanism used to justify one’s action. a. Opening the patient’s window to the

Repression is the basic defense mechanism in outside environment

the neuroses; it’s an involuntary exclusion of b. Turning on the patient’s room ventilator

painful thoughts, feelings, or experiences from c. Opening the door of the patient’s room

awareness. leading into the hospital corridor

100. Answer: (A) Should report feelings of d. Failing to wear gloves when

restlessness or agitation at once administering a bed bath

Rationale: Agitation and restlessness are 3. Which of the following patients is at greater
adverse risk

effect of haloperidol and can be treated with for contracting an infection?

antocholinergic drugs. Haloperidol isn’t likely to a. A patient with leukopenia

cause photosensitivity or control essential b. A patient receiving broad-spectrum

hypertension. Although the client may antibiotics

experience increased concentration and activity, c. A postoperative patient who has

these effects are due to a decreased in undergone orthopedic surgery

symptoms, not the drug itself. d. A newly diagnosed diabetic patient

153 4. Effective hand washing requires the use of:

PART III PRACTICE TEST I FOUNDATION OF a. Soap or detergent to promote

NURSING emulsification

1. Which element in the circular chain of b. Hot water to destroy bacteria

infection
c. A disinfectant to increase surface
can be eliminated by preserving skin integrity?
tension
a. Host
d. All of the above
b. Reservoir
5. After routine patient contact, hand washing
c. Mode of transmission
should last at least:
d. Portal of entry
a. 30 seconds
2. Which of the following will probably result in
b. 1 minute
a
c. 2 minute a. Yawning

d. 3 minutes b. Body hair

6. Which of the following procedures always c. Hiccupping

requires surgical asepsis? d. Rapid eye movements

a. Vaginal instillation of conjugated 10. All of the following statement are true about

estrogen donning sterile gloves except:

b. Urinary catheterization a. The first glove should be picked up by

c. Nasogastric tube insertion grasping the inside of the cuff.

d. Colostomy irrigation b. The second glove should be picked up by

7. Sterile technique is used whenever: inserting the gloved fingers under the

a. Strict isolation is required cuff outside the glove.

b. Terminal disinfection is performed c. The gloves should be adjusted by sliding

c. Invasive procedures are performed the gloved fingers under the sterile cuff

d. Protective isolation is necessary and pulling the glove over the wrist

8. Which of the following constitutes a break in d. The inside of the glove is considered

sterile technique while preparing a sterile field sterile

for a dressing change? 11. When removing a contaminated gown, the

nurse
a. Using sterile forceps, rather than sterile
should be careful that the first thing she touches
gloves, to handle a sterile item
is the:
b. Touching the outside wrapper of
a. Waist tie and neck tie at the back of the
sterilized material without sterile gloves
gown
c. Placing a sterile object on the edge of
b. Waist tie in front of the gown
the sterile field
c. Cuffs of the gown
d. Pouring out a small amount of solution
d. Inside of the gown
(15 to 30 ml) before pouring the solution
12. Which of the following nursing interventions
into a sterile container
is
9. A natural body defense that plays an active
considered the most effective form or universal
role
precautions?
in preventing infection is:
a. Cap all used needles before removing response

them from their syringes d. Presence of cardiac enzymes

154 16. Which of the following white blood cell

(WBC)
b. Discard all used uncapped needles and
counts clearly indicates leukocytosis?
syringes in an impenetrable protective
a. 4,500/mm³
container
b. 7,000/mm³
c. Wear gloves when administering IM
c. 10,000/mm³
injections
d. 25,000/mm³
d. Follow enteric precautions
17. After 5 days of diuretic therapy with 20mg of
13. All of the following measures are
recommended furosemide (Lasix) daily, a patient begins to

to prevent pressure ulcers except: exhibit fatigue, muscle cramping and muscle

a. Massaging the reddened are with lotion weakness. These symptoms probably indicate

b. Using a water or air mattress that the patient is experiencing:

c. Adhering to a schedule for positioning a. Hypokalemia

and turning b. Hyperkalemia

d. Providing meticulous skin care c. Anorexia

14. Which of the following blood tests should be d. Dysphagia

performed before a blood transfusion? 18. Which of the following statements about
chest
a. Prothrombin and coagulation time
X-ray is false?
b. Blood typing and cross-matching
a. No contradictions exist for this test
c. Bleeding and clotting time
b. Before the procedure, the patient should
d. Complete blood count (CBC) and
remove all jewelry, metallic objects, and
electrolyte levels.
buttons above the waist
15. The primary purpose of a platelet count is to
c. A signed consent is not required
evaluate the:
d. Eating, drinking, and medications are
a. Potential for clot formation
allowed before this test
b. Potential for bleeding
19. The most appropriate time for the nurse to
c. Presence of an antigen-antibody
obtain a sputum specimen for culture is: a. Locate the upper aspect of the upper

a. Early in the morning outer quadrant of the buttock about 5 to

b. After the patient eats a light breakfast 8 cm below the iliac crest

c. After aerosol therapy b. Palpate the lower edge of the acromion

d. After chest physiotherapy process and the midpoint lateral aspect

20. A patient with no known allergies is to of the arm

receive
c. Palpate a 1” circular area anterior to the
penicillin every 6 hours.
umbilicus
21. When administering the medication, the
d. Divide the area between the greater
nurse
femoral trochanter and the lateral
observes a fine rash on the patient’s skin. The
femoral condyle into thirds, and select
most appropriate nursing action would be to:
the middle third on the anterior of the
a. Withhold the moderation and notify the
thigh
physician
155
b. Administer the medication and notify
24. The mid-deltoid injection site is seldom used
the physician
for
c. Administer the medication with an
I.M. injections because it:
antihistamine
a. Can accommodate only 1 ml or less of
d. Apply corn starch soaks to the rash
medication
22. All of the following nursing interventions are
b. Bruises too easily
correct when using the Z- track method of drug
c. Can be used only when the patient is
injection except:
lying down
a. Prepare the injection site with alcohol
d. Does not readily parenteral medication
b. Use a needle that’s a least 1” long
25. The appropriate needle size for insulin
c. Aspirate for blood before injection injection

d. Rub the site vigorously after the is:

injection to promote absorption a. 18G, 1 ½” long

23. The correct method for determining the b. 22G, 1” long

vastus
c. 22G, 1 ½” long
lateralis site for I.M. injection is to:
d. 25G, 5/8” long hemolytic reaction to blood transfusion?

26. The appropriate needle gauge for a. Hemoglobinuria

intradermal
b. Chest pain
injection is:
c. Urticaria
a. 20G
d. Distended neck veins
b. 22G
31. Which of the following conditions may
c. 25G require

d. 26G fluid restriction?

27. Parenteral penicillin can be administered as a. Fever

an:
b. Chronic Obstructive Pulmonary Disease
a. IM injection or an IV solution
c. Renal Failure
b. IV or an intradermal injection
d. Dehydration
c. Intradermal or subcutaneous injection
32. All of the following are common signs and
d. IM or a subcutaneous injection
symptoms of phlebitis except:
28. The physician orders gr 10 of aspirin for a
a. Pain or discomfort at the IV insertion site
patient. The equivalent dose in milligrams is:
b. Edema and warmth at the IV insertion
a. 0.6 mg
site
b. 10 mg
c. A red streak exiting the IV insertion site
c. 60 mg
d. Frank bleeding at the insertion site
d. 600 mg
33. The best way of determining whether a
29. The physician orders an IV solution of patient
dextrose
has learned to instill ear medication properly is
5% in water at 100ml/hour. What would the
for the nurse to:
flow rate be if the drop factor is 15 gtt = 1 ml?
a. Ask the patient if he/she has used ear
a. 5 gtt/minute
drops before
b. 13 gtt/minute
b. Have the patient repeat the nurse’s
c. 25 gtt/minute
instructions using her own words
d. 50 gtt/minute
c. Demonstrate the procedure to the
30. Which of the following is a sign or symptom
patient and encourage to ask questions
of a
d. Ask the patient to demonstrate the 156

procedure d. Order a hemoglobin and hematocrit

34. Which of the following types of medications count 1 hour after the arteriography
can
37. The nurse explains to a patient that a cough:
be administered via gastrostomy tube?
a. Is a protective response to clear the
a. Any oral medications
respiratory tract of irritants
b. Capsules whole contents are dissolve in
b. Is primarily a voluntary action
water
c. Is induced by the administration of an
c. Enteric-coated tablets that are
antitussive drug
thoroughly dissolved in water
d. Can be inhibited by “splinting” the
d. Most tablets designed for oral use,
abdomen
except for extended-duration
38. An infected patient has chills and begins
compounds
shivering. The best nursing intervention is to:
35. A patient who develops hives after receiving
a. Apply iced alcohol sponges
an
b. Provide increased cool liquids
antibiotic is exhibiting drug:
c. Provide additional bedclothes
a. Tolerance
d. Provide increased ventilation
b. Idiosyncrasy
39. A clinical nurse specialist is a nurse who has:
c. Synergism
a. Been certified by the National League for
d. Allergy
Nursing
36. A patient has returned to his room after
femoral b. Received credentials from the Philippine
arteriography. All of the following are Nurses’ Association
appropriate nursing interventions except: c. Graduated from an associate degree
a. Assess femoral, popliteal, and pedal program and is a registered professional
pulses every 15 minutes for 2 hours nurse
b. Check the pressure dressing for d. Completed a master’s degree in the
sanguineous drainage prescribed clinical area and is a
c. Assess vital signs every 15 minutes for 2 registered professional nurse.
hours
40. The purpose of increasing urine acidity a. Maintain the drainage tubing and
through
collection bag level with the patient’s
dietary means is to:
bladder
a. Decrease burning sensations
b. Irrigate the patient with 1% Neosporin
b. Change the urine’s color
solution three times a daily
c. Change the urine’s concentration
c. Clamp the catheter for 1 hour every 4
d. Inhibit the growth of microorganisms
hours to maintain the bladder’s elasticity
41. Clay colored stools indicate:
d. Maintain the drainage tubing and
a. Upper GI bleeding
collection bag below bladder level to
b. Impending constipation
facilitate drainage by gravity
c. An effect of medication
45. The ELISA test is used to:
d. Bile obstruction
a. Screen blood donors for antibodies to
42. In which step of the nursing process would
human immunodeficiency virus (HIV)
the
b. Test blood to be used for transfusion for
nurse ask a patient if the medication she
HIV antibodies
administered relieved his pain?
c. Aid in diagnosing a patient with AIDS
a. Assessment
d. All of the above
b. Analysis
46. The two blood vessels most commonly used
c. Planning
for
d. Evaluation
TPN infusion are the:
43. All of the following are good sources of
a. Subclavian and jugular veins
vitamin A
b. Brachial and subclavian veins
except:
c. Femoral and subclavian veins
a. White potatoes
d. Brachial and femoral veins
b. Carrots
47. Effective skin disinfection before a surgical
c. Apricots
procedure includes which of the following
d. Egg yolks
methods?
44. Which of the following is a primary nursing
a. Shaving the site on the day before
intervention necessary for all patients with a
surgery
Foley Catheter in place?
b. Applying a topical antiseptic to the skin b. Appneustic breathing, atypical

on the evening before surgery pneumonia and respiratory alkalosis

c. Having the patient take a tub bath on c. Cheyne-Strokes respirations and

the morning of surgery spontaneous pneumothorax

d. Having the patient shower with an d. Kussmail’s respirations and

antiseptic soap on the evening v=before hypoventilation

and the morning of surgery 51. Immobility impairs bladder elimination,

resulting
48. When transferring a patient from a bed to a
in such disorders as
chair, the nurse should use which muscles to
a. Increased urine acidity and relaxation of
avoid back injury?
the perineal muscles, causing
a. Abdominal muscles
incontinence
157
b. Urine retention, bladder distention, and
b. Back muscles
infection
c. Leg muscles
c. Diuresis, natriuresis, and decreased
d. Upper arm muscles
urine specific gravity
49. Thrombophlebitis typically develops in
patients d. Decreased calcium and phosphate levels

with which of the following conditions? in the urine

a. Increases partial thromboplastin time 158

b. Acute pulsus paradoxus ANSWERS AND RATIONALE – FOUNDATION OF

c. An impaired or traumatized blood vessel NURSING

wall 1. D. In the circular chain of infection, pathogens

d. Chronic Obstructive Pulmonary Disease must be able to leave their reservoir and be

(COPD) transmitted to a susceptible host through a

50. In a recumbent, immobilized patient, lung portal of entry, such as broken skin.

ventilation can become altered, leading to such 2. C. Respiratory isolation, like strict isolation,

respiratory complications as: requires that the door to the door patient’s

a. Respiratory acidosis, ateclectasis, and room remain closed. However, the patient’s

hypostatic pneumonia room should be well ventilated, so opening the

window or turning on the ventricular is catheter insertion, and administration of

desirable. The nurse does not need to wear parenteral therapy, require sterile technique to

gloves for respiratory isolation, but good hand maintain a sterile environment. All equipment

washing is important for all types of isolation. must be sterile, and the nurse and the physician

3. A. Leukopenia is a decreased number of must wear sterile gloves and maintain surgical

leukocytes (white blood cells), which are asepsis. In the operating room, the nurse and

important in resisting infection. None of the physician are required to wear sterile gowns,

other situations would put the patient at risk for gloves, masks, hair covers, and shoe covers for

contracting an infection; taking broad- spectrum all invasive procedures. Strict isolation requires

antibiotics might actually reduce the infection the use of clean gloves, masks, gowns and

risk. equipment to prevent the transmission of highly

4. A. Soaps and detergents are used to help communicable diseases by contact or by

remove bacteria because of their ability to airborne routes. Terminal disinfection is the
lower
disinfection of all contaminated supplies and
the surface tension of water and act as
equipment after a patient has been discharged
emulsifying agents. Hot water may lead to skin
to prepare them for reuse by another patient.
irritation or burns.
The purpose of protective (reverse) isolation is
5. A. Depending on the degree of exposure to
to prevent a person with seriously impaired
pathogens, hand washing may last from 10
resistance from coming into contact who
seconds to 4 minutes. After routine patient
potentially pathogenic organisms.
contact, hand washing for 30 seconds effectively
8. C. The edges of a sterile field are considered
minimizes the risk of pathogen transmission.
contaminated. When sterile items are allowed
6. B. The urinary system is normally free of to

microorganisms except at the urinary meatus. come in contact with the edges of the field, the

Any procedure that involves entering this sterile items also become contaminated.
system
9. B. Hair on or within body areas, such as the
must use surgically aseptic measures to
nose, traps and holds particles that contain
maintain
microorganisms. Yawning and hiccupping do not
a bacteria-free state.
prevent microorganisms from entering or
7. C. All invasive procedures, including surgery,
leaving the body. Rapid eye movement marks area with lotion would promote venous return

the stage of sleep during which dreaming and reduce edema to the area. However,
occurs.
research has shown that massage only increases
10. D. The inside of the glove is always
the likelihood of cellular ischemia and necrosis
considered to
to the area.
be clean, but not sterile.
14. B. Before a blood transfusion is performed,
11. A. The back of the gown is considered clean,
the
the
blood of the donor and recipient must be
front is contaminated. So, after removing gloves
checked for compatibility. This is done by blood
and washing hands, the nurse should untie the
typing (a test that determines a person’s blood
back of the gown; slowly move backward away
type) and cross-matching (a procedure that
from the gown, holding the inside of the gown
determines the compatibility of the donor’s and
and keeping the edges off the floor; turn and
recipient’s blood after the blood types has been
fold the gown inside out; discard it in a
matched). If the blood specimens are
contaminated linen container; then wash her
incompatible, hemolysis and antigen-antibody
hands again.
reactions will occur.
12. B. According to the Centers for Disease
Control 159
(CDC), blood-to-blood contact occurs most 15. A. Platelets are disk-shaped cells that are
commonly when a health care worker attempts essential for blood coagulation. A platelet count
to cap a used needle. Therefore, used needles determines the number of thrombocytes in
should never be recapped; instead they should blood available for promoting hemostasis and
be inserted in a specially designed puncture assisting with blood coagulation after injury. It
resistant, labeled container. Wearing gloves is also is used to evaluate the patient’s potential
not always necessary when administering an for bleeding; however, this is not its primary
I.M.
purpose. The normal count ranges from 150,000
injection. Enteric precautions prevent the
to 350,000/mm3. A count of 100,000/mm3 or
transfer of pathogens via feces.
less indicates a potential for bleeding; count of
13. A. Nurses and other health care
professionals less than 20,000/mm3 is associated with

previously believed that massaging a reddened spontaneous bleeding.

16. D. Leukocytosis is any transient increase in morning ensures an adequate supply of bacteria
the
for culturing and decreases the risk of
number of white blood cells (leukocytes) in the
contamination from food or medication.
blood. Normal WBC counts range from 5,000 to
20. A. Initial sensitivity to penicillin is commonly
100,000/mm3. Thus, a count of 25,000/mm3
manifested by a skin rash, even in individuals
indicates leukocytosis.
who have not been allergic to it previously.
17. A. Fatigue, muscle cramping, and muscle
Because of the danger of anaphylactic shock, he
weaknesses are symptoms of hypokalemia (an
nurse should withhold the drug and notify the
inadequate potassium level), which is a
physician, who may choose to substitute
potential
another drug. Administering an antihistamine is
side effect of diuretic therapy. The physician
a dependent nursing intervention that requires
usually orders supplemental potassium to
a
prevent hypokalemia in patients receiving
written physician’s order. Although applying
diuretics. Anorexia is another symptom of
corn starch to the rash may relieve discomfort, it
hypokalemia. Dysphagia means difficulty
is not the nurse’s top priority in such a
swallowing.
potentially life-threatening situation.
18. A. Pregnancy or suspected pregnancy is the
21. D. The Z-track method is an I.M. injection
only
technique in which the patient’s skin is pulled in
contraindication for a chest X-ray. However, if a
such a way that the needle track is sealed off
chest X-ray is necessary, the patient can wear a
after the injection. This procedure seals
lead apron to protect the pelvic region from
medication deep into the muscle, thereby
radiation. Jewelry, metallic objects, and buttons
minimizing skin staining and irritation. Rubbing
would interfere with the X-ray and thus should
the injection site is contraindicated because it
not be worn above the waist. A signed consent
is may cause the medication to extravasate into
not required because a chest X-ray is not an the skin.
invasive examination. Eating, drinking and 22. D. The vastus lateralis, a long, thick muscle
that
medications are allowed because the X-ray is of
extends the full length of the thigh, is viewed by
the chest, not the abdominal region.
many clinicians as the site of choice for I.M.
19. A. Obtaining a sputum specimen early in this
injections because it has relatively few major I.M. injections; and a 25G needle, for

nerves and blood vessels. The middle third of subcutaneous insulin injections.
the
26. A. Parenteral penicillin can be administered
muscle is recommended as the injection site. I.M.

The patient can be in a supine or sitting position or added to a solution and given I.V. It cannot be

for an injection into this site. administered subcutaneously or intradermally.

23. A. The mid-deltoid injection site can 27. D. gr 10 x 60mg/gr 1 = 600 mg

accommodate only 1 ml or less of medication 28. C. 100ml/60 min X 15 gtt/ 1 ml = 25

gtt/minute
because of its size and location (on the deltoid
29. A. Hemoglobinuria, the abnormal presence
muscle of the arm, close to the brachial artery
of
and radial nerve).
hemoglobin in the urine, indicates a hemolytic
24. D. A 25G, 5/8” needle is the recommended
reaction (incompatibility of the donor’s and
size
recipient’s blood). In this reaction, antibodies in
for insulin injection because insulin is
the recipient’s plasma combine rapidly with
administered by the subcutaneous route. An
donor RBC’s; the cells are hemolyzed in either
18G, 1 ½” needle is usually used for I.M.
circulatory or reticuloendothelial system.
injections in children, typically in the vastus
160
lateralis. A 22G, 1 ½” needle is usually used for
Hemolysis occurs more rapidly in ABO
adult I.M. injections, which are typically
incompatibilities than in Rh incompatibilities.
administered in the vastus lateralis or
Chest pain and urticarial may be symptoms of
ventrogluteal site.
impending anaphylaxis. Distended neck veins
25. D. Because an intradermal injection does
are
not
an indication of hypervolemia.
penetrate deeply into the skin, a small-bore 25G
30. C. In real failure, the kidney loses their
needle is recommended. This type of injection is
ability to
used primarily to administer antigens to
effectively eliminate wastes and fluids. Because
evaluate reactions for allergy or sensitivity
of this, limiting the patient’s intake of oral and
studies. A 20G needle is usually used for I.M.
I.V. fluids may be necessary. Fever, chronic
injections of oil- based medications; a 22G
obstructive pulmonary disease, and dehydration
needle for I.M. injections; and a 25G needle, for
are conditions for which fluids should be from an immunologic response following a

encouraged. previous sensitizing exposure to the drug. The

31. D. Phlebitis, the inflammation of a vein, can reaction can range from a rash or hives to
be
anaphylactic shock. Tolerance to a drug means
caused by chemical irritants (I.V. solutions or
that the patient experiences a decreasing
medications), mechanical irritants (the needle
physiologic response to repeated administration
or
of the drug in the same dosage. Idiosyncrasy is
catheter used during venipuncture or
an individual’s unique hypersensitivity to a drug,
cannulation), or a localized allergic reaction to
food, or other substance; it appears to be
the needle or catheter. Signs and symptoms of
genetically determined. Synergism, is a drug
phlebitis include pain or discomfort, edema and
interaction in which the sum of the drug’s
heat at the I.V. insertion site, and a red streak
combined effects is greater than that of their
going up the arm or leg from the I.V. insertion
separate effects.
site.
35. D. A hemoglobin and hematocrit count
32. D. Return demonstration provides the most
would be
certain evidence for evaluating the effectiveness
ordered by the physician if bleeding were
of patient teaching.
suspected. The other answers are appropriate
33. D. Capsules, enteric-coated tablets, and
nursing interventions for a patient who has
most
undergone femoral arteriography.
extended duration or sustained release
products 36. A. Coughing, a protective response that
clears
should not be dissolved for use in a gastrostomy
the respiratory tract of irritants, usually is
tube. They are pharmaceutically manufactured
involuntary; however it can be voluntary, as
in these forms for valid reasons, and altering
when a patient is taught to perform coughing
them destroys their purpose. The nurse should
exercises. An antitussive drug inhibits coughing.
seek an alternate physician’s order when an
Splinting the abdomen supports the abdominal
ordered medication is inappropriate for delivery
muscles when a patient coughs.
by tube.
37. C. In an infected patient, shivering results
34. D. A drug-allergy is an adverse reaction
from
resulting
the body’s attempt to increase heat production
and the production of neutrophils and licensing examination to become a registered

phagocytotic action through increased skeletal professional nurse.

muscle tension and contractions. Initial 39. D. Microorganisms usually do not grow in an

vasoconstriction may cause skin to feel cold to acidic environment.

the touch. Applying additional bed clothes helps 40. D. Bile colors the stool brown. Any
inflammation
to equalize the body temperature and stop the
or obstruction that impairs bile flow will affect
chills. Attempts to cool the body result in
further the stool pigment, yielding light, clay-colored

shivering, increased metabloism, and thus stool. Upper GI bleeding results in black or tarry

increased heat production. stool. Constipation is characterized by small,

38. D. A clinical nurse specialist must have hard masses. Many medications and foods will

completed a master’s degree in a clinical discolor stool – for example, drugs containing

specialty and be a registered professional nurse. iron turn stool black.; beets turn stool red.

The National League of Nursing accredits 41. D. In the evaluation step of the nursing
process,
educational programs in nursing and provides a
the nurse must decide whether the patient has
testing service to evaluate student nursing
achieved the expected outcome that was
competence but it does not certify nurses. The
identified in the planning phase.
American Nurses Association identifies
161
requirements for certification and offers
42. A. The main sources of vitamin A are yellow
examinations for certification in many areas of
and
nursing, such as medical surgical nursing. These
green vegetables (such as carrots, sweet
certification (credentialing) demonstrates that
potatoes, squash, spinach, collard greens,
the nurse has the knowledge and the ability to
broccoli, and cabbage) and yellow fruits (such as
provide high quality nursing care in the area of
apricots, and cantaloupe). Animal sources
her certification. A graduate of an associate
include liver, kidneys, cream, butter, and egg
degree program is not a clinical nurse specialist:
yolks.
however, she is prepared to provide bed side
43. D. Maintaing the drainage tubing and
nursing with a high degree of knowledge and collection

skill. She must successfully complete the bag level with the patient’s bladder could result
in reflux of urine into the kidney. Irrigating the organisms to another body site rather than rinse

bladder with Neosporin and clamping the them away.

catheter for 1 hour every 4 hours must be 47. C. The leg muscles are the strongest muscles
in
prescribed by a physician.
the body and should bear the greatest stress
44. D. The ELISA test of venous blood is used to
when lifting. Muscles of the abdomen, back,
assess blood and potential blood donors to
and
human immunodeficiency virus (HIV). A positive
upper arms may be easily injured.
ELISA test combined with various signs and
48. C. The factors, known as Virchow’s triad,
symptoms helps to diagnose acquired
collectively predispose a patient to
immunodeficiency syndrome (AIDS)
thromboplebitis; impaired venous return to the
45. D. Tachypnea (an abnormally rapid rate of
heart, blood hypercoagulability, and injury to a
breathing) would indicate that the patient was
blood vessel wall. Increased partial
still hypoxic (deficient in oxygen).The partial
thromboplastin time indicates a prolonged
pressures of arterial oxygen and carbon dioxide
bleeding time during fibrin clot formation,
listed are within the normal range. Eupnea
commonly the result of anticoagulant (heparin)
refers
therapy. Arterial blood disorders (such as pulsus
to normal respiration.
paradoxus) and lung diseases (such as COPD) do
46. D. Studies have shown that showering with
an not necessarily impede venous return of injure

antiseptic soap before surgery is the most vessel walls.

effective method of removing microorganisms 49. A. Because of restricted respiratory

movement, a
from the skin. Shaving the site of the intended
recumbent, immobilize patient is at particular
surgery might cause breaks in the skin, thereby
risk for respiratory acidosis from poor gas
increasing the risk of infection; however, if
exchange; atelectasis from reduced surfactant
indicated, shaving, should be done immediately
and accumulated mucus in the bronchioles, and
before surgery, not the day before. A topical
hypostatic pneumonia from bacterial growth
antiseptic would not remove microorganisms
caused by stasis of mucus secretions.
and would be beneficial only after proper
50. B. The immobilized patient commonly
cleaning and rinsing. Tub bathing might transfer
suffers
from urine retention caused by decreased postpartum for discharge, recommendations for

muscle tone in the perineum. This leads to which of the following contraceptive methods

bladder distention and urine stagnation, which would be avoided?

provide an excellent medium for bacterial a. Diaphragm

growth leading to infection. Immobility also b. Female condom

results in more alkaline urine with excessive c. Oral contraceptives

amounts of calcium, sodium and phosphate, a d. Rhythm method

gradual decrease in urine production, and an 4. For which of the following clients would the

increased specific gravity. nurse expect that an intrauterine device would

162 not be recommended?

PRACTICE TEST II Maternal and Child Health a. Woman over age 35

1. For the client who is using oral b. Nulliparous woman

contraceptives,
c. Promiscuous young adult
the nurse informs the client about the need to
d. Postpartum client
take the pill at the same time each day to
5. A client in her third trimester tells the nurse,
accomplish which of the following?
“I’m constipated all the time!” Which of the
a. Decrease the incidence of nausea
following should the nurse recommend?
b. Maintain hormonal levels
a. Daily enemas
c. Reduce side effects
b. Laxatives
d. Prevent drug interactions
c. Increased fiber intake
2. When teaching a client about contraception.
d. Decreased fluid intake
Which of the following would the nurse include
6. Which of the following would the nurse use
as the most effective method for preventing as

sexually transmitted infections? the basis for the teaching plan when caring for a

a. Spermicides pregnant teenager concerned about gaining too

b. Diaphragm much weight during pregnancy?

c. Condoms a. 10 pounds per trimester

d. Vasectomy b. 1 pound per week for 40 weeks

3. When preparing a woman who is 2 days c. ½ pound per week for 40 weeks
d. A total gain of 25 to 30 pounds suprapubic region

7. The client tells the nurse that her last c. Fetoscope placed midway between the
menstrual
umbilicus and the xiphoid process
period started on January 14 and ended on
d. External electronic fetal monitor placed
January 20. Using Nagele’s rule, the nurse
at the umbilicus
determines her EDD to be which of the
10. When developing a plan of care for a client
following?
newly diagnosed with gestational diabetes,
a. September 27
which of the following instructions would be the
b. October 21
priority?
c. November 7
a. Dietary intake
d. December 27
b. Medication
8. When taking an obstetrical history on a
c. Exercise
pregnant
d. Glucose monitoring
client who states, “I had a son born at 38 weeks
11. A client at 24 weeks gestation has gained 6
gestation, a daughter born at 30 weeks
gestation pounds in 4 weeks. Which of the following
would
and I lost a baby at about 8 weeks,” the nurse
be the priority when assessing the client?
should record her obstetrical history as which of
a. Glucosuria
the following?
b. Depression
a. G2 T2 P0 A0 L2
c. Hand/face edema
b. G3 T1 P1 A0 L2
d. Dietary intake
c. G3 T2 P0 A0 L2
12. A client 12 weeks’ pregnant come to the
d. G4 T1 P1 A1 L2
emergency department with abdominal
9. When preparing to listen to the fetal heart
rate 163
at 12 weeks’ gestation, the nurse would use cramping and moderate vaginal bleeding.
which of the following? Speculum examination reveals 2 to 3 cms
a. Stethoscope placed midline at the cervical dilation. The nurse would document
umbilicus these findings as which of the following?
b. Doppler placed midline at the a. Threatened abortion
b. Imminent abortion 16. The nurse assesses the vital signs of a client,
4
c. Complete abortion
hours’ postpartum that are as follows: BP 90/60;
d. Missed abortion
temperature 100.4ºF; pulse 100 weak, thready;
13. Which of the following would be the priority
R 20 per minute. Which of the following should
nursing diagnosis for a client with an ectopic
the nurse do first?
pregnancy?
a. Report the temperature to the physician
a. Risk for infection
b. Recheck the blood pressure with
b. Pain
another cuff
c. Knowledge Deficit
c. Assess the uterus for firmness and
d. Anticipatory Grieving
position
14. Before assessing the postpartum client’s
uterus d. Determine the amount of lochia

for firmness and position in relation to the 17. The nurse assesses the postpartum vaginal

umbilicus and midline, which of the following discharge (lochia) on four clients. Which of the

should the nurse do first? following assessments would warrant

a. Assess the vital signs notification of the physician?

b. Administer analgesia a. A dark red discharge on a 2-day

c. Ambulate her in the hall postpartum client

d. Assist her to urinate b. A pink to brownish discharge on a client

15. Which of the following should the nurse do who is 5 days postpartum

when a primipara who is lactating tells the nurse c. Almost colorless to creamy discharge on

that she has sore nipples? a client 2 weeks after delivery

a. Tell her to breast feed more frequently d. A bright red discharge 5 days after

b. Administer a narcotic before breast delivery

feeding 18. A postpartum client has a temperature of

c. Encourage her to wear a nursing 101.4ºF, with a uterus that is tender when

brassiere palpated, remains unusually large, and not

d. Use soap and water to clean the nipples descending as normally expected. Which of the

following should the nurse assess next?

a. Lochia reflex response should be further assessed for

b. Breasts which of the following?

c. Incision a. Talipes equinovarus

d. Urine b. Fractured clavicle

19. Which of the following is the priority focus c. Congenital hypothyroidism

of
d. Increased intracranial pressure
nursing practice with the current early
164
postpartum discharge?
22. During the first 4 hours after a male
a. Promoting comfort and restoration of
circumcision, assessing for which of the
health
following is the priority?
b. Exploring the emotional status of the
a. Infection
family
b. Hemorrhage
c. Facilitating safe and effective self-and
c. Discomfort
newborn care
d. Dehydration
d. Teaching about the importance of family
23. The mother asks the nurse. “What’s wrong
planning with

20. Which of the following actions would be my son’s breasts? Why are they so enlarged?”
least
Whish of the following would be the best
effective in maintaining a neutral thermal
response by the nurse?
environment for the newborn?
a. “The breast tissue is inflamed from the
a. Placing infant under radiant warmer
trauma experienced with birth”
after bathing
b. “A decrease in material hormones
b. Covering the scale with a warmed
present before birth causes
blanket prior to weighing
enlargement,”
c. Placing crib close to nursery window for
c. “You should discuss this with your
family viewing
doctor. It could be a malignancy”
d. Covering the infant’s head with a knit
d. “The tissue has hypertrophied while the
stockinette
baby was in the uterus”
21. A newborn who has an asymmetrical Moro
24. Immediately after birth the nurse notes the
following on a male newborn: respirations 78; a. 2 ounces

apical hearth rate 160 BPM, nostril flaring; mild b. 3 ounces

intercostal retractions; and grunting at the end c. 4 ounces

of expiration. Which of the following should the d. 6 ounces

nurse do? 27. The postterm neonate with meconium-

stained
a. Call the assessment data to the
amniotic fluid needs care designed to especially
physician’s attention
monitor for which of the following?
b. Start oxygen per nasal cannula at 2
a. Respiratory problems
L/min.
b. Gastrointestinal problems
c. Suction the infant’s mouth and nares
c. Integumentary problems
d. Recognize this as normal first period of
d. Elimination problems
reactivity
28. When measuring a client’s fundal height,
25. The nurse hears a mother telling a friend on
which
the
of the following techniques denotes the correct
telephone about umbilical cord care. Which of
method of measurement used by the nurse?
the following statements by the mother
a. From the xiphoid process to the
indicates effective teaching?
umbilicus
a. “Daily soap and water cleansing is best”
b. From the symphysis pubis to the xiphoid
b. ‘Alcohol helps it dry and kills germs”
process
c. “An antibiotic ointment applied daily
c. From the symphysis pubis to the fundus
prevents infection”
d. From the fundus to the umbilicus
d. “He can have a tub bath each day”
29. A client with severe preeclampsia is
26. A newborn weighing 3000 grams and
admitted
feeding
with of BP 160/110, proteinuria, and severe
every 4 hours needs 120 calories/kg of body
pitting edema. Which of the following would be
weight every 24 hours for proper growth and
most important to include in the client’s plan of
development. How many ounces of 20 cal/oz
care?
formula should this newborn receive at each
a. Daily weights
feeding to meet nutritional needs?
b. Seizure precautions
c. Right lateral positioning b. Parotid gland

d. Stress reduction c. Skene’s gland

30. A postpartum primipara asks the nurse, d. Bartholin’s gland

“When
33. To differentiate as a female, the hormonal
can we have sexual intercourse again?” Which
stimulation of the embryo that must occur
of
involves which of the following?
the following would be the nurse’s best
a. Increase in maternal estrogen secretion
response?
b. Decrease in maternal androgen
a. “Anytime you both want to.”
secretion
b. “As soon as choose a contraceptive
c. Secretion of androgen by the fetal gonad
method.”
d. Secretion of estrogen by the fetal gonad
c. “When the discharge has stopped and
34. A client at 8 weeks’ gestation calls
the incision is healed.”
complaining
d. “After your 6 weeks examination.”
of slight nausea in the morning hours. Which of
31. When preparing to administer the vitamin K
the following client interventions should the
injection to a neonate, the nurse would select
nurse question?
which of the following sites as appropriate for
a. Taking 1 teaspoon of bicarbonate of
the injection?
soda in an 8-ounce glass of water
a. Deltoid muscle
b. Eating a few low-sodium crackers before
b. Anterior femoris muscle
getting out of bed
c. Vastus lateralis muscle
c. Avoiding the intake of liquids in the
d. Gluteus maximus muscle
morning hours
165
d. Eating six small meals a day instead of
32. When performing a pelvic examination, the
thee large meals
nurse observes a red swollen area on the right
35. The nurse documents positive ballottement
side of the vaginal orifice. The nurse would in

document this as enlargement of which of the the client’s prenatal record. The nurse

following? understands that this indicates which of the

a. Clitoris following?
a. Palpable contractions on the abdomen that the contractions of a primigravida client are

b. Passive movement of the unengaged not strong enough to dilate the cervix. Which of

fetus the following would the nurse anticipate doing?

c. Fetal kicking felt by the client a. Obtaining an order to begin IV oxytocin

d. Enlargement and softening of the uterus infusion

36. During a pelvic exam the nurse notes a b. Administering a light sedative to allow
purpleblue
the patient to rest for several hour
tinge of the cervix. The nurse documents
c. Preparing for a cesarean section for
this as which of the following?
failure to progress
a. Braxton-Hicks sign
d. Increasing the encouragement to the
b. Chadwick’s sign
patient when pushing begins
c. Goodell’s sign
39. A multigravida at 38 weeks’ gestation is
d. McDonald’s sign
admitted with painless, bright red bleeding and
37. During a prenatal class, the nurse explains
mild contractions every 7 to 10 minutes. Which
the
of the following assessments should be
rationale for breathing techniques during
avoided?
preparation for labor based on the
a. Maternal vital sign
understanding that breathing techniques are
b. Fetal heart rate
most important in achieving which of the
c. Contraction monitoring
following?
d. Cervical dilation
a. Eliminate pain and give the expectant
40. Which of the following would be the nurse’s
parents something to do
most appropriate response to a client who asks
b. Reduce the risk of fetal distress by
why she must have a cesarean delivery if she
increasing uteroplacental perfusion has

c. Facilitate relaxation, possibly reducing a complete placenta previa?

the perception of pain a. “You will have to ask your physician

d. Eliminate pain so that less analgesia and when he returns.”

anesthesia are needed b. “You need a cesarean to prevent

38. After 4 hours of active labor, the nurse notes hemorrhage.”

c. “The placenta is covering most of your a. Lanugo

cervix.” b. Hydramnio

d. “The placenta is covering the opening of c. Meconium

the uterus and blocking your baby.” d. Vernix

41. The nurse understands that the fetal head is 44. A patient is in labor and has just been told
in she

which of the following positions with a face has a breech presentation. The nurse should be

presentation? particularly alert for which of the following?

a. Completely flexed a. Quickening

b. Completely extended b. Ophthalmia neonatorum

c. Partially extended c. Pica

166 d. Prolapsed umbilical cord

d. Partially flexed 45. When describing dizygotic twins to a couple,

on
42. With a fetus in the left-anterior breech
which of the following would the nurse base the
presentation, the nurse would expect the fetal
explanation?
heart rate would be most audible in which of
the a. Two ova fertilized by separate sperm

following areas? b. Sharing of a common placenta

a. Above the maternal umbilicus and to the c. Each ova with the same genotype

right of midline d. Sharing of a common chorion

b. In the lower-left maternal abdominal 46. Which of the following refers to the single
cell
quadrant
that reproduces itself after conception?
c. In the lower-right maternal abdominal
a. Chromosome
quadrant
b. Blastocyst
d. Above the maternal umbilicus and to the
c. Zygote
left of midline
d. Trophoblast
43. The amniotic fluid of a client has a greenish
tint. 47. In the late 1950s, consumers and health care

The nurse interprets this to be the result of professionals began challenging the routine use

which of the following? of analgesics and anesthetics during childbirth.

Which of the following was an outgrowth of this a. Follicle-stimulating hormone

concept? b. Testosterone

a. Labor, delivery, recovery, postpartum c. Leuteinizing hormone

(LDRP) d. Gonadotropin releasing hormone

b. Nurse-midwifery 167

c. Clinical nurse specialist ANSWERS AND RATIONALE – MATERNAL AND

d. Prepared childbirth CHILD HEALTH

48. A client has a midpelvic contracture from a 1. B. Regular timely ingestion of oral
contraceptives
previous pelvic injury due to a motor vehicle
is necessary to maintain hormonal levels of the
accident as a teenager. The nurse is aware that
drugs to suppress the action of the
this could prevent a fetus from passing through
hypothalamus and anterior pituitary leading to
or around which structure during childbirth?
inappropriate secretion of FSH and LH.
a. Symphysis pubis
Therefore, follicles do not mature, ovulation is
b. Sacral promontory
inhibited, and pregnancy is prevented. The
c. Ischial spines
estrogen content of the oral site contraceptive
d. Pubic arch
may cause the nausea, regardless of when the
49. When teaching a group of adolescents about
pill is taken. Side effects and drug interactions
variations in the length of the menstrual cycle,
may occur with oral contraceptives regardless of
the nurse understands that the underlying
the time the pill is taken.
mechanism is due to variations in which of the
2. C. Condoms, when used correctly and
following phases?
consistently, are the most effective
a. Menstrual phase
contraceptive method or barrier against
b. Proliferative phase
bacterial and viral sexually transmitted
c. Secretory phase
infections. Although spermicides kill sperm,
d. Ischemic phase
they
50. When teaching a group of adolescents about
do not provide reliable protection against the
male hormone production, which of the
spread of sexually transmitted infections,
following would the nurse include as being
especially intracellular organisms such as HIV.
produced by the Leydig cells?
Insertion and removal of the diaphragm along method, avoidance of intercourse during this

with the use of the spermicides may cause period, is safe and effective.

vaginal irritations, which could place the client 4. C. An IUD may increase the risk of pelvic
at
inflammatory disease, especially in women with
risk for infection transmission. Male sterilization
more than one sexual partner, because of the
eliminates spermatozoa from the ejaculate, but
increased risk of sexually transmitted infections.
it does not eliminate bacterial and/or viral
An UID should not be used if the woman has an
microorganisms that can cause sexually
active or chronic pelvic infection, postpartum
transmitted infections.
infection, endometrial hyperplasia or
3. A. The diaphragm must be fitted individually carcinoma,
to
or uterine abnormalities. Age is not a factor in
ensure effectiveness. Because of the changes to
determining the risks associated with IUD use.
the reproductive structures during pregnancy
Most IUD users are over the age of 30. Although
and following delivery, the diaphragm must be
there is a slightly higher risk for infertility in
refitted, usually at the 6 weeks’ examination
women who have never been pregnant, the IUD
following childbirth or after a weight loss of 15
is an acceptable option as long as the riskbenefit
lbs or more. In addition, for maximum
ratio is discussed. IUDs may be inserted
effectiveness, spermicidal jelly should be placed
immediately after delivery, but this is not
in the dome and around the rim. However,
recommended because of the increased risk
spermicidal jelly should not be inserted into the and

vagina until involution is completed at rate of expulsion at this time.

approximately 6 weeks. Use of a female condom 5. C. During the third trimester, the enlarging

protects the reproductive system from the uterus places pressure on the intestines. This

introduction of semen or spermicides into the coupled with the effect of hormones on smooth

vagina and may be used after childbirth. Oral muscle relaxation causes decreased intestinal

contraceptives may be started within the first motility (peristalsis). Increasing fiber in the diet

postpartum week to ensure suppression of will help fecal matter pass more quickly through

ovulation. For the couple who has determined the intestinal tract, thus decreasing the amount

the female’s fertile period, using the rhythm of water that is absorbed. As a result, stool is
softer and easier to pass. Enemas could appropriately. To obtain a date of September 27,

precipitate preterm labor and/or electrolyte loss 168

and should be avoided. Laxatives may cause 7 days have been added to the last day of the

preterm labor by stimulating peristalsis and may LMP (rather than the first day of the LMP), plus
4
interfere with the absorption of nutrients. Use
months (instead of 3 months) were counted
for more than 1 week can also lead to laxative
back. To obtain the date of November 7, 7 days
dependency. Liquid in the diet helps provide a
have been subtracted (instead of added) from
semisolid, soft consistency to the stool. Eight to
the first day of LMP plus November indicates
ten glasses of fluid per day are essential to
counting back 2 months (instead of 3 months)
maintain hydration and promote stool
from January. To obtain the date of December
evacuation.
27, 7 days were added to the last day of the
6. D. To ensure adequate fetal growth and
LMP
development during the 40 weeks of a
(rather than the first day of the LMP) and
pregnancy, a total weight gain 25 to 30 pounds
December indicates counting back only 1 month
is
(instead of 3 months) from January.
recommended: 1.5 pounds in the first 10 weeks;
8. D. The client has been pregnant four times,
9 pounds by 30 weeks; and 27.5 pounds by 40
including current pregnancy (G). Birth at 38
weeks. The pregnant woman should gain less
weeks’ gestation is considered full term (T),
weight in the first and second trimester than in
while birth form 20 weeks to 38 weeks is
the third. During the first trimester, the client
considered preterm (P). A spontaneous abortion
should only gain 1.5 pounds in the first 10
occurred at 8 weeks (A). She has two living
weeks, not 1 pound per week. A weight gain of
½ children (L).

pound per week would be 20 pounds for the 9. B. At 12 weeks gestation, the uterus rises out
of
total pregnancy, less than the recommended
the pelvis and is palpable above the symphysis
amount.
pubis. The Doppler intensifies the sound of the
7. B. To calculate the EDD by Nagele’s rule, add 7
fetal pulse rate so it is audible. The uterus has
days to the first day of the last menstrual period
merely risen out of the pelvis into the
and count back 3 months, changing the year
abdominal
cavity and is not at the level of the umbilicus. rapid weight gain, preeclampsia should be

The fetal heart rate at this age is not audible suspected, which may be caused by fluid

with a stethoscope. The uterus at 12 weeks is retention manifested by edema, especially of

the
just above the symphysis pubis in the abdominal
hands and face. The three classic signs of
cavity, not midway between the umbilicus and
preeclampsia are hypertension, edema, and
the xiphoid process. At 12 weeks the FHR would
proteinuria. Although urine is checked for
be difficult to auscultate with a fetoscope.
glucose at each clinic visit, this is not the
Although the external electronic fetal monitor
priority.
would project the FHR, the uterus has not risen
Depression may cause either anorexia or
to the umbilicus at 12 weeks.
excessive food intake, leading to excessive
10. A. Although all of the choices are important
weight gain or loss. This is not, however, the
in
priority consideration at this time. Weight gain
the management of diabetes, diet therapy is the
thought to be caused by excessive food intake
mainstay of the treatment plan and should
would require a 24-hour diet recall. However,
always be the priority. Women diagnosed with
excessive intake would not be the primary
gestational diabetes generally need only diet
consideration for this client at this time.
therapy without medication to control their
12. B. Cramping and vaginal bleeding coupled
blood sugar levels. Exercise, is important for all
with
pregnant women and especially for diabetic
cervical dilation signifies that termination of the
women, because it burns up glucose, thus
pregnancy is inevitable and cannot be
decreasing blood sugar. However, dietary intake,
prevented. Thus, the nurse would document an
not exercise, is the priority. All pregnant women
imminent abortion. In a threatened abortion,
with diabetes should have periodic monitoring
cramping and vaginal bleeding are present, but
of serum glucose. However, those with
there is no cervical dilation. The symptoms may
gestational diabetes generally do not need daily
subside or progress to abortion. In a complete
glucose monitoring. The standard of care
abortion all the products of conception are
recommends a fasting and 2- hour postprandial
expelled. A missed abortion is early fetal
blood sugar level every 2 weeks.
intrauterine death without expulsion of the
11. C. After 20 weeks’ gestation, when there is a
products of conception.
13. B. For the client with an ectopic pregnancy, ease of correct latching-on for feeding.
Narcotics
lower abdominal pain, usually unilateral, is the
administered prior to breast feeding are passed
primary symptom. Thus, pain is the priority.
through the breast milk to the infant, causing
Although the potential for infection is always
excessive sleepiness. Nipple soreness is not
present, the risk is low in ectopic pregnancy
severe enough to warrant narcotic analgesia. All
because pathogenic microorganisms have not
postpartum clients, especially lactating mothers,
been introduced from external sources. The
should wear a supportive brassiere with wide
client may have a limited knowledge of the
cotton straps. This does not, however, prevent
pathology and treatment of the condition and
or reduce nipple soreness. Soaps are drying to
will most likely experience grieving, but this is
the skin of the nipples and should not be used
not the priority at this time.
on the breasts of lactating mothers. Dry nipple
14. D. Before uterine assessment is performed,
it is skin predisposes to cracks and fissures, which

essential that the woman empty her bladder. A can become sore and painful.

full bladder will interfere with the accuracy of 16. D. A weak, thready pulse elevated to 100
BPM
the assessment by elevating the uterus and
may indicate impending hemorrhagic shock. An
displacing to the side of the midline. Vital sign
increased pulse is a compensatory mechanism
assessment is not necessary unless an
of
abnormality in uterine assessment is identified.
the body in response to decreased fluid volume.
Uterine assessment should not cause acute pain
Thus, the nurse should check the amount of
that requires administration of analgesia.
lochia present. Temperatures up to 100.48F in
Ambulating the client is an essential component
the first 24 hours after birth are related to the
of postpartum care, but is not necessary prior to
dehydrating effects of labor and are considered
assessment of the uterus.
normal. Although rechecking the blood pressure
15. A. Feeding more frequently, about every 2
may be a correct choice of action, it is not the
hours, will decrease the infant’s frantic, vigorous
first action that should be implemented in light
sucking from hunger and will decrease breast
of the other data. The data indicate a potential
engorgement, soften the breast, and promote
impending hemorrhage. Assessing the uterus
169 for
firmness and position in relation to the 18. A. The data suggests an infection of the
umbilicus
endometrial lining of the uterus. The lochia may
and midline is important, but the nurse should
be decreased or copious, dark brown in
check the extent of vaginal bleeding first. Then
appearance, and foul smelling, providing further
it
evidence of a possible infection. All the client’s
would be appropriate to check the uterus,
which data indicate a uterine problem, not a breast
may be a possible cause of the hemorrhage. problem. Typically, transient fever, usually
17. D. Any bright red vaginal discharge would be 101ºF, may be present with breast
considered abnormal, but especially 5 days after engorgement. Symptoms of mastitis include
delivery, when the lochia is typically pink to influenza-like manifestations. Localized infection
brownish. Lochia rubra, a dark red discharge, is of an episiotomy or C-section incision rarely
present for 2 to 3 days after delivery. Bright red causes systemic symptoms, and uterine
vaginal bleeding at this time suggests late involution would not be affected. The client
data
postpartum hemorrhage, which occurs after the
do not include dysuria, frequency, or urgency,
first 24 hours following delivery and is generally
symptoms of urinary tract infections, which
caused by retained placental fragments or
would necessitate assessing the client’s urine.
bleeding disorders. Lochia rubra is the normal
19. C. Because of early postpartum discharge
dark red discharge occurring in the first 2 to 3
and
days after delivery, containing epithelial cells,
limited time for teaching, the nurse’s priority is
erythrocyes, leukocytes and decidua. Lochia
to facilitate the safe and effective care of the
serosa is a pink to brownish serosanguineous
client and newborn. Although promoting
discharge occurring from 3 to 10 days after
comfort and restoration of health, exploring the
delivery that contains decidua, erythrocytes,
family’s emotional status, and teaching about
leukocytes, cervical mucus, and microorganisms.
family planning are important in
Lochia alba is an almost colorless to yellowish
postpartum/newborn nursing care, they are not
discharge occurring from 10 days to 3 weeks
the priority focus in the limited time presented
after delivery and containing leukocytes,
by early post-partum discharge.
decidua, epithelial cells, fat, cervical mucus,
20. C. Heat loss by radiation occurs when the
cholesterol crystals, and bacteria.
infant’s crib is placed too near cold walls or given vitamin K to facilitate clotting, the

windows. Thus placing the newborn’s crib close 170

to the viewing window would be least effective. prophylactic dose is often not sufficient to

Body heat is lost through evaporation during prevent bleeding. Although infection is a

bathing. Placing the infant under the radiant possibility, signs will not appear within 4 hours

warmer after bathing will assist the infant to be after the surgical procedure. The primary

rewarmed. Covering the scale with a warmed discomfort of circumcision occurs during the

blanket prior to weighing prevents heat loss surgical procedure, not afterward. Although

through conduction. A knit cap prevents heat feedings are withheld prior to the circumcision,

loss from the head a large head, a large body the chances of dehydration are minimal.

surface area of the newborn’s body. 23. B. The presence of excessive estrogen and

21. B. A fractured clavicle would prevent the progesterone in the maternal- fetal blood
normal
followed by prompt withdrawal at birth
Moro response of symmetrical sequential
precipitates breast engorgement, which will
extension and abduction of the arms followed
spontaneously resolve in 4 to 5 days after birth.
by
The trauma of the birth process does not cause
flexion and adduction. In talipes equinovarus
inflammation of the newborn’s breast tissue.
(clubfoot) the foot is turned medially, and in
Newborns do not have breast malignancy. This
plantar flexion, with the heel elevated. The feet
reply by the nurse would cause the mother to
are not involved with the Moro reflex.
have undue anxiety. Breast tissue does not
Hypothyroiddism has no effect on the primitive
hypertrophy in the fetus or newborns.
reflexes. Absence of the Moror reflex is the
most 24. D. The first 15 minutes to 1 hour after birth
is
significant single indicator of central nervous
the first period of reactivity involving respiratory
system status, but it is not a sign of increased
and circulatory adaptation to extrauterine life.
intracranial pressure.
The data given reflect the normal changes
22. B. Hemorrhage is a potential risk following
during
any
this time period. The infant’s assessment data
surgical procedure. Although the infant has
been reflect normal adaptation. Thus, the physician
does not need to be notified and oxygen is not meconium fluid may be aspirated, causing

needed. The data do not indicate the presence mechanical obstruction or chemical

of choking, gagging or coughing, which are signs pneumonitis. The infant is not at increased risk

of excessive secretions. Suctioning is not for gastrointestinal problems. Even though the

necessary. skin is stained with meconium, it is

noninfectious
25. B. Application of 70% isopropyl alcohol to
the (sterile) and nonirritating. The postterm

cord minimizes microorganisms (germicidal) and meconium- stained infant is not at additional
risk
promotes drying. The cord should be kept dry
for bowel or urinary problems.
until it falls off and the stump has healed.
28. C. The nurse should use a nonelastic,
Antibiotic ointment should only be used to treat
flexible,
an infection, not as a prophylaxis. Infants should
paper measuring tape, placing the zero point on
not be submerged in a tub of water until the
the superior border of the symphysis pubis and
cord falls off and the stump has completely
stretching the tape across the abdomen at the
healed.
midline to the top of the fundus. The xiphoid
26. B. To determine the amount of formula and
needed,
umbilicus are not appropriate landmarks to use
do the following mathematical calculation. 3 kg
when measuring the height of the fundus
x
(McDonald’s measurement).
120 cal/kg per day = 360 calories/day feeding q
4 29. B. Women hospitalized with severe

hours = 6 feedings per day = 60 calories per preeclampsia need decreased CNS stimulation
to
feeding: 60 calories per feeding; 60 calories per
prevent a seizure. Seizure precautions provide
feeding with formula 20 cal/oz = 3 ounces per
environmental safety should a seizure occur.
feeding. Based on the calculation. 2, 4 or 6
Because of edema, daily weight is important but
ounces are incorrect.
not the priority. Preclampsia causes vasospasm
27. A. Intrauterine anoxia may cause relaxation
of and therefore can reduce utero-placental

the anal sphincter and emptying of meconium perfusion. The client should be placed on her
left
into the amniotic fluid. At birth some of the
side to maximize blood flow, reduce blood
pressure, and promote diuresis. Interventions to maximus muscle should not be until the child

reduce stress and anxiety are very important to has been walking 2 years.

facilitate coping and a sense of control, but 32. D. Bartholin’s glands are the glands on either

seizure precautions are the priority. side of the vaginal orifice. The clitoris is female

30. C. Cessation of the lochial discharge signifies 171

healing of the endometrium. Risk of erectile tissue found in the perineal area above
hemorrhage
the urethra. The parotid glands are open into
and infection are minimal 3 weeks after a the

normal vaginal delivery. Telling the client mouth. Skene’s glands open into the posterior

anytime is inappropriate because this response wall of the female urinary meatus.

does not provide the client with the specific 33. D. The fetal gonad must secrete estrogen for
the
information she is requesting. Choice of a
embryo to differentiate as a female. An increase
contraceptive method is important, but not the
in maternal estrogen secretion does not affect
specific criteria for safe resumption of sexual
differentiation of the embryo, and maternal
activity. Culturally, the 6- weeks’ examination
estrogen secretion occurs in every pregnancy.
has been used as the time frame for resuming
Maternal androgen secretion remains the same
sexual activity, but it may be resumed earlier.
as before pregnancy and does not affect
31. C. The middle third of the vastus lateralis is
the differentiation. Secretion of androgen by the

preferred injection site for vitamin K fetal gonad would produce a male fetus.

administration because it is free of blood vessels 34. A. Using bicarbonate would increase the
amount
and nerves and is large enough to absorb the
of sodium ingested, which can cause
medication. The deltoid muscle of a newborn is
complications. Eating low-sodium crackers
not large enough for a newborn IM injection.
would be appropriate. Since liquids can increase
Injections into this muscle in a small child might
nausea avoiding them in the morning hours
cause damage to the radial nerve. The anterior
when nausea is usually the strongest is
femoris muscle is the next safest muscle to use
appropriate. Eating six small meals a day would
in a newborn but is not the safest. Because of
keep the stomach full, which often decrease
the proximity of the sciatic nerve, the gluteus
nausea.
35. B. Ballottement indicates passive movement progress labor before a cesarean would be
of
necessary. It is too early to anticipate client
the unengaged fetus. Ballottement is not a
pushing with contractions.
contraction. Fetal kicking felt by the client
39. D. The signs indicate placenta previa and
represents quickening. Enlargement and vaginal

softening of the uterus is known as Piskacek’s exam to determine cervical dilation would not

sign. be done because it could cause hemorrhage.

36. B. Chadwick’s sign refers to the purple-blue Assessing maternal vital signs can help
tinge
determine maternal physiologic status. Fetal
of the cervix. Braxton Hicks contractions are
heart rate is important to assess fetal well-being
painless contractions beginning around the 4th
and should be done. Monitoring the
month. Goodell’s sign indicates softening of the contractions

cervix. Flexibility of the uterus against the cervix will help evaluate the progress of labor.

is known as McDonald’s sign. 40. D. A complete placenta previa occurs when

the
37. C. Breathing techniques can raise the pain
placenta covers the opening of the uterus, thus
threshold and reduce the perception of pain.
blocking the passageway for the baby. This
They also promote relaxation. Breathing
response explains what a complete previa is and
techniques do not eliminate pain, but they can
the reason the baby cannot come out except by
reduce it. Positioning, not breathing, increases
cesarean delivery. Telling the client to ask the
uteroplacental perfusion.
physician is a poor response and would increase
38. A. The client’s labor is hypotonic. The nurse
the patient’s anxiety. Although a cesarean
should call the physical and obtain an order for
would
an infusion of oxytocin, which will assist the
help to prevent hemorrhage, the statement
uterus to contact more forcefully in an attempt does

to dilate the cervix. Administering light sedative not explain why the hemorrhage could occur.

would be done for hypertonic uterine With a complete previa, the placenta is covering

contractions. Preparing for cesarean section is the entire cervix, not just most of it.

unnecessary at this time. Oxytocin would 41. B. With a face presentation, the head is

increase the uterine contractions and hopefully completely extended. With a vertex
presentation, the head is completely or partially 46. C. The zygote is the single cell that
reproduces
flexed. With a brow (forehead) presentation, the
itself after conception. The chromosome is the
head would be partially extended.
material that makes up the cell and is gained
42. D. With this presentation, the fetal upper
torso from each parent. Blastocyst and trophoblast
are
and back face the left upper maternal
abdominal later terms for the embryo after zygote.

wall. The fetal heart rate would be most audible 172

above the maternal umbilicus and to the left of 47. D. Prepared childbirth was the direct result
of
the middle. The other positions would be
the 1950’s challenging of the routine use of
incorrect.
analgesic and anesthetics during childbirth. The
43. C. The greenish tint is due to the presence of
LDRP was a much later concept and was not a
meconium. Lanugo is the soft, downy hair on
the direct result of the challenging of routine use of

shoulders and back of the fetus. Hydramnios analgesics and anesthetics during childbirth.

represents excessive amniotic fluid. Vernix is the Roles for nurse midwives and clinical nurse

white, cheesy substance covering the fetus. specialists did not develop from this challenge.

44. D. In a breech position, because of the space 48. C. The ischial spines are located in the mid-
pelvic
between the presenting part and the cervix,
region and could be narrowed due to the
prolapse of the umbilical cord is common.
previous pelvic injury. The symphysis pubis,
Quickening is the woman’s first perception of
sacral promontory, and pubic arch are not part
fetal movement. Ophthalmia neonatorum
of the mid-pelvis.
usually results from maternal gonorrhea and is
49. B. Variations in the length of the menstrual
conjunctivitis. Pica refers to the oral intake of
cycle
nonfood substances.
are due to variations in the proliferative phase.
45. A. Dizygotic (fraternal) twins involve two ova
The menstrual, secretory and ischemic phases
fertilized by separate sperm. Monozygotic
do not contribute to this variation.
(identical) twins involve a common placenta,
50. B. Testosterone is produced by the Leyding
same genotype, and common chorion. cells

in the seminiferous tubules. Follicle-stimulating

hormone and leuteinzing hormone are released opportunistic infection

by the anterior pituitary gland. The d. Evidence of extreme weight loss and

hypothalamus is responsible for releasing high fever

gonadotropin-releasing hormone. 4. Nurse Maureen is aware that a client who has

173 been diagnosed with chronic renal failure

MEDICAL SURGICAL NURSING recognizes an adequate amount of high-

biologicvalue
1. Marco who was diagnosed with brain tumor
was protein when the food the client selected

scheduled for craniotomy. In preventing the from the menu was:

development of cerebral edema after surgery, a. Raw carrots

the nurse should expect the use of: b. Apple juice

a. Diuretics c. Whole wheat bread

b. Antihypertensive d. Cottage cheese

c. Steroids 5. Kenneth who has diagnosed with uremic

d. Anticonvulsants syndrome has the potential to develop

2. Halfway through the administration of blood, complications. Which among the following

the female client complains of lumbar pain. complications should the nurse anticipates:
After
a. Flapping hand tremors
stopping the infusion Nurse Hazel should:
b. An elevated hematocrit level
a. Increase the flow of normal saline
c. Hypotension
b. Assess the pain further
d. Hypokalemia
c. Notify the blood bank
6. A client is admitted to the hospital with
d. Obtain vital signs. benign

3. Nurse Maureen knows that the positive prostatic hyperplasia, the nurse most relevant

diagnosis for HIV infection is made based on assessment would be:

which of the following: a. Flank pain radiating in the groin

a. A history of high risk sexual behaviors. b. Distention of the lower abdomen

b. Positive ELISA and western blot tests c. Perineal edema

c. Identification of an associated d. Urethral discharge

7. A client has undergone with penile implant. c. Deficient fluid volume

After 24 hrs of surgery, the client’s scrotum was d. Pain

edematous and painful. The nurse should: 11. Nurse Hazel teaches the client with angina
about
a. Assist the client with sitz bath
common expected side effects of nitroglycerin
b. Apply war soaks in the scrotum
including:
c. Elevate the scrotum using a soft support
a. high blood pressure
d. Prepare for a possible incision and
b. stomach cramps
drainage.
c. headache
8. Nurse hazel receives emergency laboratory
d. shortness of breath
results for a client with chest pain and
12. The following are lipid abnormalities. Which
immediately informs the physician. An increased
of
myoglobin level suggests which of the
the following is a risk factor for the
following?
development
a. Liver disease
of atherosclerosis and PVD?
b. Myocardial damage
a. High levels of low density lipid (LDL)
c. Hypertension
cholesterol
d. Cancer
b. High levels of high density lipid (HDL)
9. Nurse Maureen would expect the client with
cholesterol
mitral stenosis would demonstrate symptoms
c. Low concentration triglycerides
associated with congestion in the:
d. Low levels of LDL cholesterol.
a. Right atrium
174
b. Superior vena cava
13. Which of the following represents a
c. Aorta significant

d. Pulmonary risk immediately after surgery for repair of

aortic
10. A client has been diagnosed with
hypertension. aneurysm?

The nurse priority nursing diagnosis would be: a. Potential wound infection

a. Ineffective health maintenance b. Potential ineffective coping

b. Impaired skin integrity c. Potential electrolyte balance

d. Potential alteration in renal perfusion d. 60 60 70 years

14. Nurse Josie should instruct the client to eat 18. Marie with acute lymphocytic leukemia
suffers
which of the following foods to obtain the best
from nausea and headache. These clinical
supply of Vitamin B12?
manifestations may indicate all of the following
a. dairy products
except
b. vegetables
a. effects of radiation
c. Grains
b. chemotherapy side effects
d. Broccoli
c. meningeal irritation
15. Karen has been diagnosed with aplastic
anemia. d. gastric distension

The nurse monitors for changes in which of the 19. A client has been diagnosed with
Disseminated
following physiologic functions?
Intravascular Coagulation (DIC). Which of the
a. Bowel function
following is contraindicated with the client?
b. Peripheral sensation
a. Administering Heparin
c. Bleeding tendencies
b. Administering Coumadin
d. Intake and out put
c. Treating the underlying cause
16. Lydia is scheduled for elective splenectomy.
d. Replacing depleted blood products
Before the clients goes to surgery, the nurse in
20. Which of the following findings is the best
charge final assessment would be:
indication that fluid replacement for the client
a. signed consent
with hypovolemic shock is adequate?
b. vital signs
a. Urine output greater than 30ml/hr
c. name band
b. Respiratory rate of 21 breaths/minute
d. empty bladder
c. Diastolic blood pressure greater than 90
17. What is the peak age range in acquiring
acute mmhg

lymphocytic leukemia (ALL)? d. Systolic blood pressure greater than 110

a. 4 to 12 years. mmhg

b. 20 to 30 years 21. Which of the following signs and symptoms

c. 40 to 50 years would Nurse Maureen include in teaching plan

as an early manifestation of laryngeal cancer? information about the advantages of using a
pen
a. Stomatitis
like insulin delivery devices. The nurse explains
b. Airway obstruction
that the advantages of these devices over
c. Hoarseness
syringes include:
d. Dysphagia
a. Accurate dose delivery
22. Karina a client with myasthenia gravis is to
b. Shorter injection time
receive immunosuppressive therapy. The nurse
175
understands that this therapy is effective
c. Lower cost with reusable insulin
because it:
cartridges
a. Promotes the removal of antibodies that
d. Use of smaller gauge needle.
impair the transmission of impulses
25. A male client’s left tibia is fractures in an
b. Stimulates the production of
automobile accident, and a cast is applied. To
acetylcholine at the neuromuscular
assess for damage to major blood vessels from
junction.
the fracture tibia, the nurse in charge should
c. Decreases the production of
monitor the client for:
autoantibodies that attack the
a. Swelling of the left thigh
acetylcholine receptors.
b. Increased skin temperature of the foot
d. Inhibits the breakdown of acetylcholine
c. Prolonged reperfusion of the toes after
at the neuromuscular junction.
blanching
23. A female client is receiving IV Mannitol. An
d. Increased blood pressure
assessment specific to safe administration of the
26. After a long leg cast is removed, the male
said drug is:
client
a. Vital signs q4h
should:
b. Weighing daily
a. Cleanse the leg by scrubbing with a brisk
c. Urine output hourly
motion
d. Level of consciousness q4h
b. Put leg through full range of motion
24. Patricia a 20 year old college student with
twice daily
diabetes mellitus requests additional
c. Report any discomfort or stiffness to the
physician 30. A male client has undergone spinal surgery,
the
d. Elevate the leg when sitting for long
nurse should:
periods of time.
a. Observe the client’s bowel movement
27. While performing a physical assessment of a
and voiding patterns
male client with gout of the great toe,
b. Log-roll the client to prone position
NurseVivian should assess for additional tophi
c. Assess the client’s feet for sensation and
(urate deposits) on the:
circulation
a. Buttocks
d. Encourage client to drink plenty of fluids
b. Ears
31. Marina with acute renal failure moves into
c. Face
the
d. Abdomen
diuretic phase after one week of therapy. During
28. Nurse Katrina would recognize that the
this phase the client must be assessed for signs
demonstration of crutch walking with tripod gait
of developing:
was understood when the client places weight
a. Hypovolemia
on the:
b. renal failure
a. Palms of the hands and axillary regions
c. metabolic acidosis
b. Palms of the hand
d. hyperkalemia
c. Axillary regions
32. Nurse Judith obtains a specimen of clear
d. Feet, which are set apart nasal

29. Mang Jose with rheumatoid arthritis states, drainage from a client with a head injury. Which
“the
of the following tests differentiates mucus from
only time I am without pain is when I lie in bed
cerebrospinal fluid (CSF)?
perfectly still”. During the convalescent stage,
a. Protein
the nurse in charge with Mang Jose should
b. Specific gravity
encourage:
c. Glucose
a. Active joint flexion and extension
d. Microorganism
b. Continued immobility until pain subsides
33. A 22 year old client suffered from his first
c. Range of motion exercises twice daily tonicclonic

d. Flexion exercises three times daily seizure. Upon awakening the client asks
the nurse, “What caused me to have a seizure? d. “You will need to accept the necessity

Which of the following would the nurse include for a quiet and inactive lifestyle”.

in the primary cause of tonic-clonic seizures in 36. The nurse is aware the early indicator of
hypoxia
adults more the 20 years?
in the unconscious client is:
a. Electrolyte imbalance
a. Cyanosis
b. Head trauma
b. Increased respirations
c. Epilepsy
c. Hypertension
d. Congenital defect
d. Restlessness
34. What is the priority nursing assessment in
the 37. A client is experiencing spinal shock. Nurse

first 24 hours after admission of the client with Myrna should expect the function of the
bladder
thrombotic CVA?
to be which of the following?
a. Pupil size and papillary response
a. Normal
b. cholesterol level
b. Atonic
c. Echocardiogram
c. Spastic
d. Bowel sounds
d. Uncontrolled
35. Nurse Linda is preparing a client with
multiple 38. Which of the following stage the carcinogen
is
sclerosis for discharge from the hospital to
irreversible?
home. Which of the following instruction is
most a. Progression stage

appropriate? b. Initiation stage

176 c. Regression stage

a. “Practice using the mechanical aids that d. Promotion stage

you will need when future disabilities 39. Among the following components thorough
pain
arise”.
assessment, which is the most significant?
b. “Follow good health habits to change
a. Effect
the course of the disease”.
b. Cause
c. “Keep active, use stress reduction
c. Causing factors
strategies, and avoid fatigue.
d. Intensity a. Headache

40. A 65 year old female is experiencing flare up b. Bladder distension

of
c. Dizziness
pruritus. Which of the client’s action could
d. Ability to move legs
aggravate the cause of flare ups?
45. Nurse Katrina should anticipate that all of
a. Sleeping in cool and humidified the

environment following drugs may be used in the attempt to

b. Daily baths with fragrant soap control the symptoms of Meniere's disease

c. Using clothes made from 100% cotton except:

d. Increasing fluid intake a. Antiemetics

41. Atropine sulfate (Atropine) is b. Diuretics

contraindicated in
c. Antihistamines
all but one of the following client?
d. Glucocorticoids
a. A client with high blood
46. Which of the following complications
b. A client with bowel obstruction associated

c. A client with glaucoma with tracheostomy tube?

d. A client with U.T.I a. Increased cardiac output

42. Among the following clients, which among b. Acute respiratory distress syndrome
them
(ARDS)
is high risk for potential hazards from the
c. Increased blood pressure
surgical experience?
d. Damage to laryngeal nerves
a. 67-year-old client
47. Nurse Faith should recognize that fluid shift
b. 49-year-old client in a

c. 33-year-old client client with burn injury results from increase in

d. 15-year-old client the:

43. Nurse Jon assesses vital signs on a client a. Total volume of circulating whole blood

undergone epidural anesthesia. b. Total volume of intravascular plasma

44. Which of the following would the nurse c. Permeability of capillary walls
assess
d. Permeability of kidney tubules
next?
48. An 83-year-old woman has several d. Promote means of communication
ecchymotic
178
areas on her right arm. The bruises are probably
ANSWERS AND RATIONALE – MEDICAL
caused by: SURGICAL

a. increased capillary fragility and NURSING

permeability 1. C. Glucocorticoids (steroids) are used for their

b. increased blood supply to the skin anti-inflammatory action, which decreases the

c. self-inflicted injury development of edema.

d. elder abuse 2. A. The blood must be stopped at once, and

then
177
normal saline should be infused to keep the line
49. Nurse Anna is aware that early adaptation of
patent and maintain blood volume.
client with renal carcinoma is:
3. B. These tests confirm the presence of HIV
a. Nausea and vomiting
antibodies that occur in response to the
b. flank pain
presence of the human immunodeficiency virus
c. weight gain
(HIV).
d. intermittent hematuria
4. D. One cup of cottage cheese contains
50. A male client with tuberculosis asks Nurse
Brian approximately 225 calories, 27g of protein, 9g of

how long the chemotherapy must be continued. fat, 30mg cholesterol, and 6g of carbohydrate.

Nurse Brian’s accurate reply would be: Proteins of high biologic value (HBV) contain

a. 1 to 3 weeks optimal levels of amino acids essential for life.

b. 6 to 12 months 5. A. Elevation of uremic waste products causes

c. 3 to 5 months irritation of the nerves, resulting in flapping

d. 3 years and more hand tremors.

51. A client has undergone laryngectomy. The 6. B. This indicates that the bladder is distended

immediate nursing priority would be: with urine, therefore palpable.

a. Keep trachea free of secretions 7. C. Elevation increases lymphatic drainage,

b. Monitor for signs of infection reducing edema and pain.

c. Provide emotional support 8. B. Detection of myoglobin is a diagnostic tool

to
determine whether myocardial damage has or prolonged aortic cross-clamping during the

occurred. surgery.

9. D. When mitral stenosis is present, the left 14. A. Good source of vitamin B12 are dairy

atrium has difficulty emptying its contents into products and meats.

the left ventricle because there is no valve to 15. C. Aplastic anemia decreases the bone
marrow
prevent back ward flow into the pulmonary
vein, production of RBC’s, white blood cells, and

the pulmonary circulation is under pressure. platelets. The client is at risk for bruising and

10. A. Managing hypertension is the priority for bleeding tendencies.

the
16. B. An elective procedure is scheduled in
client with hypertension. Clients with advance

hypertension frequently do not experience pain, so that all preparations can be completed ahead

deficient volume, or impaired skin integrity. It is of time. The vital signs are the final check that

the asymptomatic nature of hypertension that must be completed before the client leaves the

makes it so difficult to treat. room so that continuity of care and assessment

11. C. Because of its widespread vasodilating is provided for.

effects,
17. A. The peak incidence of Acute Lymphocytic
nitroglycerin often produces side effects such as
Leukemia (ALL) is 4 years of age. It is uncommon
headache, hypotension and dizziness.
after 15 years of age.
12. A. An increased in LDL cholesterol
18. D. Acute Lymphocytic Leukemia (ALL) does
concentration
not
has been documented at risk factor for the
cause gastric distention. It does invade the
development of atherosclerosis. LDL cholesterol
central nervous system, and clients experience
is not broken down into the liver but is
headaches and vomiting from meningeal
deposited into the wall of the blood vessels.
irritation.
13. D. There is a potential alteration in renal
19. B. Disseminated Intravascular Coagulation
perfusion manifested by decreased urine (DIC)
output.
has not been found to respond to oral
The altered renal perfusion may be related to
anticoagulants such as Coumadin.
renal artery embolism, prolonged hypotension,
20. A. Urine output provides the most sensitive
indication of the client’s response to therapy for 27. B. Uric acid has a low solubility, it tends to

hypovolemic shock. Urine output should be precipitate and form deposits at various sites

consistently greater than 30 to 35 mL/hr. 179

21. C. Early warning signs of laryngeal cancer where blood flow is least active, including
can
cartilaginous tissue such as the ears.
vary depending on tumor location. Hoarseness
28. B. The palms should bear the client’s weight
lasting 2 weeks should be evaluated because it to
is
avoid damage to the nerves in the axilla.
one of the most common warning signs.
29. A. Active exercises, alternating extension,
22. C. Steroids decrease the body’s immune
flexion, abduction, and adduction, mobilize
response thus decreasing the production of
exudates in the joints relieves stiffness and pain.
antibodies that attack the acetylcholine
30. C. Alteration in sensation and circulation
receptors at the neuromuscular junction
indicates damage to the spinal cord, if these
23. C. The osmotic diuretic mannitol is
occurs notify physician immediately.
contraindicated in the presence of inadequate
31. A. In the diuretic phase fluid retained during
renal function or heart failure because it the

increases the intravascular volume that must be oliguric phase is excreted and may reach 3 to 5

filtered and excreted by the kidney. liters daily, hypovolemia may occur and fluids

24. A. These devices are more accurate because should be replaced.

they are easily to used and have improved 32. C. The constituents of CSF are similar to
those of
adherence in insulin regimens by young people
blood plasma. An examination for glucose
because the medication can be administered
content is done to determine whether a body
discreetly.
fluid is a mucus or a CSF. A CSF normally
25. C. Damage to blood vessels may decrease
contains
the
glucose.
circulatory perfusion of the toes, this would
33. B. Trauma is one of the primary causes of
indicate the lack of blood supply to the
brain
extremity.
damage and seizure activity in adults. Other
26. D. Elevation will help control the edema that
common causes of seizure activity in adults
usually occurs.
include neoplasms, withdrawal from drugs and 41. C. Atropine sulfate is contraindicated with

alcohol, and vascular disease. glaucoma patients because it increases

34. A. It is crucial to monitor the pupil size and intraocular pressure.

papillary response to indicate changes around 42. A. A 67 year old client is greater risk because
the
the cranial nerves.
older adult client is more likely to have a
35. C. The nurse most positive approach is to
lesseffective
encourage the client with multiple sclerosis to
immune system.
stay active, use stress reduction techniques and
43. B. The last area to return sensation is in the
avoid fatigue because it is important to support
perineal area, and the nurse in charge should
the immune system while remaining active.
monitor the client for distended bladder.
36. D. Restlessness is an early indicator of
44. D. Glucocorticoids play no significant role in
hypoxia.
disease treatment.
The nurse should suspect hypoxia in
unconscious 45. D. Tracheostomy tube has several potential

client who suddenly becomes restless. complications including bleeding, infection and

37. B. In spinal shock, the bladder becomes laryngeal nerve damage.

completely atonic and will continue to fill unless 46. C. In burn, the capillaries and small vessels

the client is catheterized. dilate, and cell damage cause the release of a

38. A. Progression stage is the change of tumor histamine-like substance. The substance causes
from
the capillary walls to become more permeable
the preneoplastic state or low degree of
and significant quantities of fluid are lost.
malignancy to a fast growing tumor that cannot
47. A. Aging process involves increased capillary
be reversed.
fragility and permeability. Older adults have a
39. D. Intensity is the major indicative of
decreased amount of subcutaneous fat and
severity of
cause an increased incidence of bruise like
pain and it is important for the evaluation of the
lesions caused by collection of extravascular
treatment.
blood in loosely structured dermis.
40. B. The use of fragrant soap is very drying to
skin 48. D. Intermittent pain is the classic sign of
renal
hence causing the pruritus.
carcinoma. It is primarily due to capillary 3. Nurse Monet is caring for a female client who
erosion
has suicidal tendency. When accompanying the
by the cancerous growth.
client to the restroom, Nurse Monet should…
49. B. Tubercle bacillus is a drug resistant
a. Give her privacy
organism
b. Allow her to urinate
and takes a long time to be eradicated. Usually a
c. Open the window and allow her to get
combination of three drugs is used for minimum
some fresh air
of 6 months and at least six months beyond
d. Observe her
culture conversion.
4. Nurse Maureen is developing a plan of care
50. A. Patent airway is the most priority;
for a
therefore
female client with anorexia nervosa. Which
removal of secretions is necessary
action should the nurse include in the plan?
180
a. Provide privacy during meals
PSYCHIATRIC NURSING
b. Set-up a strict eating plan for the client
1. Marco approached Nurse Trish asking for
advice c. Encourage client to exercise to reduce
on how to deal with his alcohol addiction. Nurse anxiety
Trish should tell the client that the only effective d. Restrict visits with the family
treatment for alcoholism is: 5. A client is experiencing anxiety attack. The
most
a. Psychotherapy
appropriate nursing intervention should
b. Alcoholics anonymous (A.A.)
include?
c. Total abstinence
a. Turning on the television
d. Aversion Therapy
b. Leaving the client alone
2. Nurse Hazel is caring for a male client who
c. Staying with the client and speaking in
experience false sensory perceptions with no
short sentences
basis in reality. This perception is known as:
d. Ask the client to play with other clients
a. Hallucinations
6. A female client is admitted with a diagnosis of
b. Delusions
delusions of GRANDEUR. This diagnosis reflects
c. Loose associations a

d. Neologisms belief that one is:

a. Being Killed 10. Nurse Tony was caring for a 41 year old
female
b. Highly famous and important
client. Which behavior by the client indicates
c. Responsible for evil world
adult cognitive development?
d. Connected to client unrelated to oneself
a. Generates new levels of awareness
7. A 20 year old client was diagnosed with
b. Assumes responsibility for her actions
dependent personality disorder. Which behavior
c. Has maximum ability to solve problems
is not likely to be evidence of ineffective
and learn new skills
individual coping?
d. Her perception are based on reality
a. Recurrent self-destructive behavior
11. A neuromuscular blocking agent is
b. Avoiding relationship
administered
c. Showing interest in solitary activities
to a client before ECT therapy. The Nurse should
d. Inability to make choices and decision
carefully observe the client for?
without advise
a. Respiratory difficulties
8. A male client is diagnosed with schizotypal
b. Nausea and vomiting
personality disorder. Which signs would this
c. Dizziness
client exhibit during social situation?
d. Seizures
a. Paranoid thoughts
12. A 75 year old client is admitted to the
b. Emotional affect hospital

c. Independence need with the diagnosis of dementia of the

d. Aggressive behavior Alzheimer’s type and depression. The symptom

9. Nurse Claire is caring for a client diagnosed that is unrelated to depression would be?
with
a. Apathetic response to the environment
bulimia. The most appropriate initial goal for a
b. “I don’t know” answer to questions
client diagnosed with bulimia is?
c. Shallow of labile effect
a. Encourage to avoid foods
d. Neglect of personal hygiene
b. Identify anxiety causing situations
181
c. Eat only three meals a day
13. Nurse Trish is working in a mental health
d. Avoid shopping plenty of groceries facility;

the nurse priority nursing intervention for a

newly admitted client with bulimia nervosa Nurse Trish recognizes that the basis of O.C.

would be to? disorder is often:

a. Teach client to measure I & O a. Problems with being too conscientious

b. Involve client in planning daily meal b. Problems with anger and remorse

c. Observe client during meals c. Feelings of guilt and inadequacy

d. Monitor client continuously d. Feeling of unworthiness and

14. Nurse Patricia is aware that the major health hopelessness

complication associated with intractable 17. Mario is complaining to other clients about
not
anorexia nervosa would be?
being allowed by staff to keep food in his room.
a. Cardiac dysrhythmias resulting to
Which of the following interventions would be
cardiac arrest
most appropriate?
b. Glucose intolerance resulting in
a. Allowing a snack to be kept in his room
protracted hypoglycemia
b. Reprimanding the client
c. Endocrine imbalance causing cold
c. Ignoring the clients behavior
amenorrhea
d. Setting limits on the behavior
d. Decreased metabolism causing cold
18. Conney with borderline personality disorder
intolerance
who
15. Nurse Anna can minimize agitation in a
is to be discharge soon threatens to “do
disturbed client by?
something” to herself if discharged. Which of
a. Increasing stimulation the

b. limiting unnecessary interaction following actions by the nurse would be most

c. increasing appropriate sensory important?

perception a. Ask a family member to stay with the

d. ensuring constant client and staff client at home temporarily

contact b. Discuss the meaning of the client’s

16. A 39 year old mother with obsessive- statement with her

compulsive
c. Request an immediate extension for the
disorder has become immobilized by her
client
elaborate hand washing and walking rituals.
d. Ignore the clients statement because it’s
a sign of manipulation d. Haloperidol (Haldol)

19. Joey a client with antisocial personality 22. Which of the following foods would the
disorder nurse

belches loudly. A staff member asks Joey, “Do Trish eliminate from the diet of a client in

you know why people find you repulsive?” this alcohol withdrawal?

statement most likely would elicit which of the a. Milk

following client reaction? b. Orange Juice

a. Depensiveness c. Soda

b. Embarrassment d. Regular Coffee

c. Shame 23. Which of the following would Nurse Hazel

d. Remorsefulness expect to assess for a client who is exhibiting

20. Which of the following approaches would be late signs of heroin withdrawal?

most appropriate to use with a client suffering a. Yawning & diaphoresis

from narcissistic personality disorder when 182

discrepancies exist between what the client b. Restlessness & Irritability

states and what actually exist? c. Constipation & steatorrhea

a. Rationalization d. Vomiting and Diarrhea

b. Supportive confrontation 24. To establish open and trusting relationship

with
c. Limit setting
a female client who has been hospitalized with
d. Consistency
severe anxiety, the nurse in charge should?
21. Cely is experiencing alcohol withdrawal
exhibits a. Encourage the staff to have frequent

tremors, diaphoresis and hyperactivity. Blood interaction with the client

pressure is 190/87 mmhg and pulse is 92 bpm. b. Share an activity with the client

Which of the medications would the nurse c. Give client feedback about behavior

expect to administer? d. Respect client’s need for personal space

a. Naloxone (Narcan) 25. Nurse Monette recognizes that the focus of

b. Benzlropine (Cogentin) environmental (MILIEU) therapy is to:

c. Lorazepam (Ativan) a. Manipulate the environment to bring

about positive changes in behavior b. Speech lag

b. Allow the client’s freedom to determine c. Shuttering

whether or not they will be involved in d. Echolalia

activities 29. A 60 year old female client who lives alone

tells
c. Role play life events to meet individual
the nurse at the community health center “I
needs
really don’t need anyone to talk to”. The TV is
d. Use natural remedies rather than drugs
my best friend. The nurse recognizes that the
to control behavior
client is using the defense mechanism known
26. Nurse Trish would expect a child with a
as?
diagnosis
a. Displacement
of reactive attachment disorder to:
b. Projection
a. Have more positive relation with the
c. Sublimation
father than the mother
d. Denial
b. Cling to mother & cry on separation
30. When working with a male client suffering
c. Be able to develop only superficial
phobia about black cats, Nurse Trish should
relation with the others
anticipate that a problem for this client would
d. Have been physically abuse
be?
27. When teaching parents about childhood
a. Anxiety when discussing phobia
depression Nurse Trina should say?
b. Anger toward the feared object
a. It may appear acting out behavior
c. Denying that the phobia exist
b. Does not respond to conventional
d. Distortion of reality when completing
treatment
daily routines
c. Is short in duration & resolves easily
31. Linda is pacing the floor and appears
d. Looks almost identical to adult
extremely
depression
anxious. The duty nurse approaches in an
28. Nurse Perry is aware that language
attempt to alleviate Linda’s anxiety. The most
development
therapeutic question by the nurse would be?
in autistic child resembles:
a. Would you like to watch TV?
a. Scanning speech
b. Would you like me to talk with you?
c. Are you feeling upset now? b. Slow pulse, 10% weight loss & alopecia

d. Ignore the client 183

32. Nurse Penny is aware that the symptoms c. Compulsive behavior, excessive fears &
that
nausea
distinguish post-traumatic stress disorder from
d. Excessive activity, memory lapses & an
other anxiety disorder would be:
increased pulse
a. Avoidance of situation & certain
35. A characteristic that would suggest to Nurse
activities that resemble the stress
Anne that an adolescent may have bulimia
b. Depression and a blunted affect when
would be:
discussing the traumatic situation
a. Frequent regurgitation & re-swallowing
c. Lack of interest in family & others
of food
d. Re-experiencing the trauma in dreams or
b. Previous history of gastritis
flashback
c. Badly stained teeth
33. Nurse Benjie is communicating with a male
d. Positive body image
client
36. Nurse Monette is aware that extremely
with substance-induced persisting dementia;
the depressed clients seem to do best in settings
client cannot remember facts and fills in the where they have:
gaps with imaginary information. Nurse Benjie is a. Multiple stimuli
aware that this is typical of? b. Routine Activities
a. Flight of ideas c. Minimal decision making
b. Associative looseness d. Varied Activities
c. Confabulation 37. To further assess a client’s suicidal potential.
d. Concretism Nurse Katrina should be especially alert to the
34. Nurse Joey is aware that the signs & client expression of:
symptoms
a. Frustration & fear of death
that would be most specific for diagnosis
b. Anger & resentment
anorexia are?
c. Anxiety & loneliness
a. Excessive weight loss, amenorrhea &
d. Helplessness & hopelessness
abdominal distension
38. A nursing care plan for a male client with d. Weak ego
bipolar
41. A 23 year old client has been admitted with
I disorder should include: a

a. Providing a structured environment diagnosis of schizophrenia says to the nurse

b. Designing activities that will require the “Yes, its march, March is little woman”. That’s

client to maintain contact with reality literal you know”. These statement illustrate:

c. Engaging the client in conversing about a. Neologisms

current affairs b. Echolalia

d. Touching the client provide assurance c. Flight of ideas

39. When planning care for a female client using d. Loosening of association

ritualistic behavior, Nurse Gina must recognize 42. A long term goal for a paranoid male client
who
that the ritual:
has unjustifiably accused his wife of having
a. Helps the client focus on the inability to
many
deal with reality
extramarital affairs would be to help the client
b. Helps the client control the anxiety
develop:
c. Is under the client’s conscious control
a. Insight into his behavior
d. Is used by the client primarily for
b. Better self-control
secondary gains
c. Feeling of self-worth
40. A 32 year old male graduate student, who
d. Faith in his wife
has
43. A male client who is experiencing disordered
become increasingly withdrawn and neglectful
thinking about food being poisoned is admitted
of his work and personal hygiene, is brought to
to the mental health unit. The nurse uses which
the psychiatric hospital by his parents. After
communication technique to encourage the
detailed assessment, a diagnosis of
client to eat dinner?
schizophrenia is made. It is unlikely that the
a. Focusing on self-disclosure of own food
client will demonstrate:
preference
a. Low self esteem
b. Using open ended question and silence
b. Concrete thinking
c. Offering opinion about the need to eat
c. Effective self-boundaries
d. Verbalizing reasons that the client may
not choose to eat indicate a need to provide additional

44. Nurse Nina is assigned to care for a client information?

diagnosed with Catatonic Stupor. When Nurse a. “Abuse occurs more in low-income

Nina enters the client’s room, the client is found families”

lying on the bed with a body pulled into a fetal b. “Abuser Are often jealous or selfcentered”

position. Nurse Nina should? c. “Abuser use fear and intimidation”

a. Ask the client direct questions to d. “Abuser usually have poor self-esteem”

encourage talking 47. During electroconvulsive therapy (ECT) the

client
b. Rake the client into the dayroom to be
receives oxygen by mask via positive pressure
with other clients
ventilation. The nurse assisting with this
c. Sit beside the client in silence and
procedure knows that positive pressure
occasionally ask open-ended question
ventilation is necessary because?
d. Leave the client alone and continue with
a. Anesthesia is administered during the
providing care to the other clients
procedure
184
b. Decrease oxygen to the brain increases
45. Nurse Tina is caring for a client with delirium
and confusion and disorientation

states that “look at the spiders on the wall”. c. Grand mal seizure activity depresses

What should the nurse respond to the client? respirations

a. “You’re having hallucination, there are d. Muscle relaxations given to prevent

no spiders in this room at all” injury during seizure activity depress

b. “I can see the spiders on the wall, but respirations.

they are not going to hurt you” 48. When planning the discharge of a client with

c. “Would you like me to kill the spiders” chronic anxiety, Nurse Chris evaluates

d. “I know you are frightened, but I do not achievement of the discharge maintenance

see spiders on the wall” goals. Which goal would be most appropriately

46. Nurse Jonel is providing information to a having been included in the plan of care

community group about violence in the family. requiring evaluation?

Which statement by a group member would a. The client eliminates all anxiety from
daily situations NURSING

b. The client ignores feelings of anxiety 1. Answer: C

c. The client identifies anxiety producing Rationale: Total abstinence is the only effective

situations treatment for alcoholism

d. The client maintains contact with a crisis 2. Answer: A

counselor Rationale: Hallucinations are visual, auditory,

49. Nurse Tina is caring for a client with gustatory, tactile or olfactory perceptions that
depression
have no basis in reality.
who has not responded to antidepressant
3. Answer: D
medication. The nurse anticipates that what
Rationale: The Nurse has a responsibility to
treatment procedure may be prescribed.
observe continuously the acutely suicidal client.
a. Neuroleptic medication
The Nurse should watch for clues, such as
b. Short term seclusion
communicating suicidal thoughts, and
c. Psychosurgery messages;

d. Electroconvulsive therapy hoarding medications and talking about death.

50. Mario is admitted to the emergency room 4. Answer: B

with
Rationale: Establishing a consistent eating plan
drug-included anxiety related to over ingestion
and monitoring client’s weight are important to
of prescribed antipsychotic medication. The
this disorder.
most important piece of information the nurse
5. Answer: C
in charge should obtain initially is the:
Rationale: Appropriate nursing interventions for
a. Length of time on the med.
an anxiety attack include using short sentences,
b. Name of the ingested medication & the
staying with the client, decreasing stimuli,
amount ingested
remaining calm and medicating as needed.
c. Reason for the suicide attempt
6. Answer:B
d. Name of the nearest relative & their
Rationale: Delusion of grandeur is a false belief
phone number
that one is highly famous and important.
185
7. Answer: D
ANSWERS AND RATIONALE – PSYCHIATRIC
Rationale: Individual with dependent Rationale: These clients often hide food or force
personality
vomiting; therefore they must be carefully
disorder typically shows indecisiveness
monitored.
submissiveness and clinging behavior so that
14. Answer: A
others will make decisions with them.
Rationale: These clients have severely depleted
8. Answer: A
levels of sodium and potassium because of their
Rationale: Clients with schizotypal personality
starvation diet and energy expenditure, these
disorder experience excessive social anxiety that
electrolytes are necessary for cardiac
can lead to paranoid thoughts
functioning.
9. Answer: B
15. Answer: B
Rationale: Bulimia disorder generally is a
Rationale: Limiting unnecessary interaction will
maladaptive coping response to stress and
decrease stimulation and agitation.
underlying issues. The client should identify
16. Answer: C
anxiety causing situation that stimulate the
Rationale: Ritualistic behavior seen in this
bulimic behavior and then learn new ways of
disorder is aimed at controlling guilt and
coping with the anxiety.
inadequacy by maintaining an absolute set
10. Answer: A
pattern of behavior.
Rationale: An adult age 31 to 45 generates new
17. Answer: D
level of awareness.
Rationale: The nurse needs to set limits in the
11. Answer: A
client’s manipulative behavior to help the client
Rationale: Neuromuscular Blocker, such as
control dysfunctional behavior. A consistent
SUCCINYLCHOLINE (Anectine) produces
approach by the staff is necessary to decrease
respiratory depression because it inhibits
manipulation.
contractions of respiratory muscles.
18. Answer: B
12. Answer: C
Rationale: Any suicidal statement must be
Rationale: With depression, there is little or no
assessed by the nurse. The nurse should discuss
emotional involvement therefore little alteration
the client’s statement with her to determine its
in affect.
meaning in terms of suicide.
13. Answer: D
19. Answer: A
Rationale: When the staff member ask the client late signs of heroin withdrawal, along with

if he wonders why others find him repulsive, the muscle spasm, fever, nausea, repetitive,

client is likely to feel defensive because the abdominal cramps and backache.

question is belittling. The natural tendency is to 24. Answer: D

counterattack the threat to self-image. Rationale: Moving to a client’s personal space

20. Answer: B increases the feeling of threat, which increases

Rationale: The nurse would specifically use anxiety.

supportive confrontation with the client to point 25. Answer: A

out discrepancies between what the client Rationale: Environmental (MILIEU) therapy aims
states
at having everything in the client’s surrounding
and what actually exists to increase
area toward helping the client.
responsibility for self.
26. Answer: C
21. Answer: C
Rationale: Children who have experienced
Rationale: The nurse would most likely
attachment difficulties with primary caregiver
administer benzodiazepine, such as lorazepan
are not able to trust others and therefore relate
(ativan) to the client who is experiencing
superficially
symptom: The client’s experiences symptoms of
27. Answer: A
withdrawal because of the rebound
Rationale: Children have difficulty verbally
phenomenon when the sedation of the CNS
expressing their feelings, acting out behavior,
from alcohol begins to decrease.
such as temper tantrums, may indicate
22. Answer: D
underlying depression.
186
28. Answer: D
Rationale: Regular coffee contains caffeine
Rationale: The autistic child repeats sounds or
which acts as psychomotor stimulants and leads
words spoken by others.
to feelings of anxiety and agitation. Serving
29. Answer: D
coffee top the client may add to tremors or
Rationale: The client statement is an example of
wakefulness.
the use of denial, a defense that blocks problem
23. Answer: D
by unconscious refusing to admit they exist
Rationale: Vomiting and diarrhea are usually the
30. Answer: A
Rationale: Discussion of the feared object indicate that this client is unable to continue the

triggers an emotional response to the object. struggle of life.

31. Answer: B 38. Answer: A

Rationale: The nurse presence may provide the Rationale: Structure tends to decrease agitation

client with support & feeling of control. and anxiety and to increase the client’s feeling
of
32. Answer: D
security.
Rationale: Experiencing the actual trauma in
39. Answer: B
dreams or flashback is the major symptom that
Rationale: The rituals used by a client with
distinguishes post-traumatic stress disorder
from obsessive compulsive disorder help control the

other anxiety disorder. anxiety level by maintaining a set pattern of

33. Answer: C action.

Rationale: Confabulation or the filling in of 40. Answer: C

memory gaps with imaginary facts is a defense Rationale: A person with this disorder would not

mechanism used by people experiencing have adequate self-boundaries

memory deficits. 41. Answer: D

34. Answer: A Rationale: Loose associations are thoughts that

Rationale: These are the major signs of anorexia are presented without the logical connections

nervosa. Weight loss is excessive (15% of usually necessary for the listening to interpret

expected weight) the message.

35. Answer: C 42. Answer: C

Rationale: Dental enamel erosion occurs from Rationale: Helping the client to develop feeling

repeated self-induced vomiting. of self-worth would reduce the client’s need to

36. Answer: B use pathologic defenses.

Rationale: Depression usually is both emotional 43. Answer: B

& physical. A simple daily routine is the best, Rationale: Open ended questions and silence
are
least stressful and least anxiety producing.
strategies used to encourage clients to discuss
37. Answer: D
their problem in descriptive manner.
Rationale: The expression of these feeling may
44. Answer: C Rationale: Electroconvulsive therapy is an

Rationale: Clients who are withdrawn may be effective treatment for depression that has not

immobile and mute, and require consistent, responded to medication

repeated interventions. Communication with 50. Answer: B

withdrawn clients requires much patience from Rationale: In an emergency, lives saving facts
are
the nurse. The nurse facilitates communication
obtained first. The name and the amount of
with the client by sitting in silence, asking
openended medication ingested are of outmost important
in
question and pausing to provide
treating this potentially life threatening
opportunities for the client to respond.
situation.
45. Answer: D
188
Rationale: When hallucination is present, the
FOUNDATION OF PROFESSIONAL NURSING
nurse should reinforce reality with the client.
PRACTICE
46. Answer: A
Situation 1 - Mr. Ibarra is assigned to the triage
187
area and
Rationale: Personal characteristics of abuser
while on duty, he assesses the condition of Mrs.
include low self-esteem, immaturity, Simon

dependence, insecurity and jealousy. who came in with asthma. She has difficulty
breathing
47. Answer: D
and her respiratory rate is 40 per minute. Mr.
Rationale: A short acting skeletal muscle Ibarra is
relaxant
asked to inject the client epinephrine 0.3mg
such as succinylcholine (Anectine) is
subcutaneously
administered during this procedure to prevent
1. The indication for epinephrine injection for
injuries during seizure. Mrs
48. Answer: C Simon is to:
Rationale: Recognizing situations that produce a. Reduce anaphylaxis
anxiety allows the client to prepare to cope with b. Relieve hypersensitivity to allergen
anxiety or avoid specific stimulus. c. Relieve respirator distress due to bronchial
49. Answer: D spasm

d. Restore client’s cardiac rhythm

2. When preparing the epinephrine injection a. Syringe 3-5ml and needle gauge 21 to 23
from an
b. Tuberculin syringe 1 mi with needle gauge 26
ampule, the nurse initially: or 27

a. Taps the ampule at the top to allow fluid to c. Syringe 2ml and needle gauge 22
flow to
d. Syringe 1-3ml and needle gauge 25 to 27
the base of the ampule
5. The rationale for giving medications through
b. Checks expiration date of the medication the
ampule
subcutaneous route is;
c. Removes needle cap of syringe and pulls
a. There are many alternative sites for
plunger to
subcutaneous
expel air
injection
d. Breaks the neck of the ampule with a gauze
b. Absorption time of the medicine is slower
wrapped
c. There are less pain receptors in this area
around it
d. The medication can be injected while the
3. Mrs. Simon is obese. When administering a
client is in
subcutaneous injection to an obese patient, it is
any position
best
Situation 2 - The use of massage and meditation
for the nurse to:
to help
a Inject needle at a 15 degree angle' over the
decrease stress and pain have been strongly
stretched
recommended based on documented
skin of the client
testimonials.
b. Pinch skin at the Injection site and use airlock
6. Martha wants to do a study on, this topic.
technique "Effects of

c. Pull skin of patient down to administer the massage and meditation on stress and pain."
drug in a Z The type

track of research that best suits this topic is:

d. Spread skin or pinch at the injection site and a. applied research

inject
b. qualitative research
needle at a 45-90 degree angle
c. basic research
4. When preparing for a subcutaneous injection,
d. quantitative research
the
7. The type of research design that does not
proper size of syringe and needle would be:
manipulate
independent variable is: 189

a. experimental design Situation 3 - Richard has a nursing diagnosis of

b. quasi-experimental design ineffective airway clearance related to excessive

c. non-experimental design secretions and is at risk for infection because of

retained
d. quantitative design
secretions. Part of Nurse Mario's nursing care
8. This research topic has the potential to
plan is to
contribute to
loosen and remove excessive secretions in the
nursing because it seeks to:
airway,
a. include new modalities of care
11. Mario listens to Richard's bilateral sounds
b. resolve a clinical problem and finds

c. clarify an ambiguous modality of care that congestion is in the upper lobes of the
lungs. The
d. enhance client care
appropriate position to drain the anterior and
9. Martha does review of related literature for posterior
the
apical segments of the lungs when Mario does
purpose of:
percussion would be:
a. determine statistical treatment of data
research a. Client lying on his back then flat on his
abdomen on
b. gathering data about what is already known
or Trendelenburg position

unknown b. Client seated upright in bed or on a chair then

leaning
c. to identify if problem can be replicated
forward in sitting position then flat on his back
d. answering the research question and on
10. Client’s rights should be protected when his abdomen
doing
c. Client lying flat on his back and then flat on
research using human subjects. Martha his
identifies these
abdomen
rights as follows EXCEPT:
d. Client lying on his right then left side on
a. right of self-determination
Trendelenburg position
b. right to compensation
12. When documenting outcome of Richard's
c. right of privacy treatment
d. right not to be harmed
Mario should include the following in his b. Client can tolerate sitting and lying position
recording
c. Client has no signs of infection
EXCEPT:
d. Time of fast food and fluid intake of the client
a. Color, amount and consistent of sputum
15. The purpose of chest percussion and
b. Character of breath sounds and vibration is to
respirator/rate before
loosen secretions in the lungs. The difference
and after procedure between

c. Amount of fluid intake of client before and the procedure is;

after the
a. Percussion uses only one hand white
procedure vibration uses

d. Significant changes in vital signs both hands

13. When assessing Richard for chest percussion b. Percussion delivers cushioned blows to the
or chest with

chest vibration and postural drainage Mario cupped palms while gently shakes secretion
would loose on the

focus on the following EXCEPT: exhalation cycle

a. Amount of food and fluid taken during the c. In both percussion and vibration the hands
last meal are on top

before treatment of each other and hand action is in tune with

client's
b. Respiratory rate, breath sounds and location
of breath rhythm

congestion d. Percussion slaps the chest to loosen

secretions while
c. Teaching the client's relatives to perform 'the
vibration shakes the secretions along with the
procedure
inhalation
d. Doctor's order regarding position restriction
of air
and
Situation 4 - A 61 year old man, Mr. Regalado, is
client's tolerance for lying flat
admitted to the private ward for observation;
14. Mario prepares Richard for postural
after
drainage and
complaints of severe chest pain. You are
percussion. Which of the flowing is a special
assigned to take
consideration when doing the procedure?
care of the client.
a. Respiratory rate of 16 to 20 per minute
16. When doing an initial assessment, the best c. Check his physical environment to decrease
way for noise level

you to identify the client’s priority problem is to: d. Take his blood pressure before sleeping and
upon
a. Interview the client for chief complaints and
other 190

symptoms waking up

b. Talk to the relatives to gather data about 19. Mr. Regalado's lower extremities are swollen
history of and

illness shiny. He has pitting pedal edema. When taking

care of
c. Do auscultation to check for chest congestion
Mr. Regalado, which of the following
d. Do a physical examination white asking the
intervention
client
would be the most appropriate immediate
relevant questions
nursing
17. Upon establishing Mr. Regalado's nursing
approach.
needs,
a. Moisturize lower extremities to prevent skin
the next nursing approach would be to:
irritation
a. introduce the client to the ward staff to put
b. Measure fluid intake and output to decrease
the client
edema
and family at ease
c. Elevate lower extremities for postural
b. Give client and relatives a brief tour of the drainage
physical set
d. Provide the client a list of food low in sodium
up the unit
20. Mr. Regalado will be discharged from your
c. Take his vital signs for a baseline assessment unit

d. Establish priority needs and implement within the hour. Nursing actions when preparing
appropriate a

interventions client for discharge include all EXCEPT:

18. Mr. Regalado says he has "trouble going to a. Making a final physical assessment before
sleep". client

In order to plan your nursing intervention you leaves the hospital

will.
b. Giving instructions about his medication
a. Observe his sleeping patterns in the next few regimen
days
c. Walking the client to the hospital exit to
b. Ask him what he means by this statement ensure his
safety God has abandoned her. The nurse understands
that
d. Proper recording of pertinent data
Nancy is grieving for her self and is in the stage
Situation 5 - Nancy, mother of 2 young kids. 36
of:
years old,
a. bargaining
had a mammogram and was told that she has
breast b. denial

cysts and that she may need surgery. This c. anger

causes her
d. acceptance
anxiety as shown by increase in her pulse and
23. The nurse visits Nancy and prods her to eat
respiratory
her
rate, sweating and feelings of tension.
food. Nancy replies "what's the use? My time is
21. Considering her level of anxiety, the nurse running
can best
out. The nurse's best response would be:
assist Nancy by:
a. "The doctor ordered full diet for you so that
a. Giving her activities to divert her attention you will

b. Giving detailed explanations about the be strong for surgery."

treatments she
b. "I understand how you fee! but you have 1o
will undergo try for

c. Preparing her and her family in case surgery is your children's sake."
not
c. "Have you told your, doctor how you feel? Are
successful you

d. Giving her clear but brief information at the changing your mind) about surgery?"
level of
d. "You sound like you are giving up."
her understanding
24. The nurse feels sad about Nancy's illness
22. Nancy blames God for her situation. She is and tells
easily
her head nurse during the end of shift
provoked to tears and wants to be left alone, endorsement
refusing
that "it's unfair for Nancy to have cancer when
to eat or talk to her family. A religious person she is
before,
still so young and with two kinds. The best
she now refuses to pray or go to church stating response of
that
the head nurse would be:
a. Advise the nurse to "be strong and learn to she is in the menopausal stage.
control her
26. Instruction on health promotion regarding
feelings" urinary

b. Assign the nurse to another client to avoid elimination is important. Which would you
sympathy include?

for the client a. Hold urine, as long as she can before

emptying the
c. Reassure the nurse that the client has hope if
she goes bladder to strengthen her sphincters muscles

through all statements prescribed for her b. If burning sensation is experienced while
voiding,
c. Ask the other nurses what they feel about the
patient drink pineapple-juice

to find out if they share the same feelings c. After urination, wipe from anal area up
towards the
25. Realizing that she feels angry about Nancy's
191
condition, the nurse Seams that being self-
aware is a pubis

conscious process that she should do in any d. Jell client to empty the bladder at each
situation voiding

like this because: 27. Mrs. Seva also tells the nurse that she is
often
a. This is a necessary part of the nurse -client
constipated. Because she is aging, what physical
relationship process
changes predispose her to constipation?
b. The nurse is a role model for the client and
should be a. inhibition of the parasympathetic reflex

strong b. weakness of sphincter muscles of the anus

C. How the nurse thinks and feels affect her c. loss of tone of the smooth muscles of the
actions color

towards her client and her work d. decreased ability to absorb fluids in the lower

d. The nurse has to be therapeutic at all times intestines

and
28. The nurse understands that one of these
should not be affected factors

Situation 6 – Mrs. Seva, 32 years old, asks you contributes to constipation:

about
a. excessive exercise
possible problems regarding her elimination
b. high fiber diet
now that
c. no regular tine for defecation daily d. Making sure that linen are smooth and dry at
all times
d. prolonged use of laxatives
Situation 7 - Using Maslow's need theory,
29. Mrs. Seva talks about rear of being
Airway,
incontinent due
Breathing and Circulation are the physiological
to a prior experience of dribbling urine when
needs
laughing
vital to life. The nurse's knowledge and ability to
or sneezing and when she has a full bladder.
identify
Your most
and immediately intervene to meet these needs
appropriate .instruction would be to:
is
a. tell client to drink less fluids to avoid
important to save lives.
accidents
31. Which of these clients has a problem with
b. instruct client to start wearing thin adult
the
diapers
transport of oxygen from the lungs to the
c. ask the client to bring change of underwear
tissues:
"just in
a. Carol with a tumor in the brain
case"
b. Theresa with anemia
d. teach client pelvic exercise to strengthen
perineal c. Sonny Boy with a fracture in the femur

muscles d. Brigette with diarrhea

30. Mrs. Seva asked for instructions for skin care 32. You noted from the lab exams in the chart of
for her Mr.

mother who has urinary incontinence and is Santos that he has reduced oxygen in the blood.
almost
This condition is called:
always in bed. Your instruction would focus on
a. Cyanosis
prevention of skin irritation and breakdown by
b. Hypoxia
a. Using thick diapers to absorb urine well
c. Hypoxemia
b. Drying the skin with baby powder to prevent
d. Anemia
or mask
33. You will nasopharyngeal suctioning Mr.
the smell of ammonia
Abad. Your
c. Thorough washing, rising and during of skin
guide for the length of insertion of the tubing
area that
for an
get wet with urine
adult would be:
a. tip of the nose to the base of the .neck hypertension: Your task is to take blood
pressure
b. the distance from the tip of the nose to the
middle of readings and you are informed about avoiding
the
the cheek
common mistakes in BP taking that lead to 'false
c. the distance from the tip of the nose to the
or
tip of the
inaccurate blood pressure readings.
ear lobe
36. When taking blood pressure reading the cuff
d. eight to ten inches
should
34. While doing nasopharyngeal suctioning
be:
on .Mr.
192
Abad, the nurse can avoid trauma to the area
by: a. deflated fully then immediately start second
reading
a. Apply suction for at least 20-30 seconds each
time to for same client

ensure that all secretions are removed b deflated quickly after inflating up to 180
mmHg
b. Using gloves to prevent introduction of
pathogens to c. large enough to wrap around upper arm of
the adult
the respiratory system
client 1 cm above brachial artery
c. Applying no suction while inserting the
catheter d. inflated to 30 mmHg above the estimated
systolic BP
d. Rotating catheter as it is inserted with gentle
suction based on palpation of radial or bronchial artery

35. Myrna has difficulty breathing when on her 37. Chronic Obstructive Pulmonary Disease
back (COPD) in

and must sit upright in bed to breath, effectively one of the leading causes of death worldwide
and and is a

comfortably. The nurse documents this preventable disease. The primary cause of COPD
condition as: is:

a. Apnea a. tobacco hack

b. Orthopnea b. bronchitis

c. Dyspnea c. asthma

d. Tachypnea d. cigarette smoking

Situation 8 - You are assigned to screen for

38. In your health education class for clients d. nutrition
with
Situation 9 - Nurse Rivera witnesses a vehicular
diabetes you teach, them the areas, for control . accident

Diabetes which include all EXCEPT: near the hospital where she works. She decides
to get
a. regular physical activity
involved and help the victims of the accident.
b. thorough knowledge of foot care
41. Her priority nursing action would be to:
c. prevention nutrition
a. Assess damage to property
d. proper nutrition
b. Assist in the police investigation since she is a
39. You teach your clients the difference
witness
between, Type
c. Report the incident immediately to the local
I (IDDM) and Type II (NDDM) Diabetes. Which of
police
the
authorities
following is true?
d. Assess the extent of injuries incurred by the
a. both types diabetes mellitus clients are all
victims, of
prone to
the accident
developing ketosis
42. Priority attention should be given to which
b. Type II (NIDDM) is more common and is also
of these
preventable compared to Type I (IDDM)
clients?
diabetes which
a. Linda who shows severe anxiety due to
is genetic in etiology
trauma of the
c. Type I (IDDM) is characterized by fasting
accident
hyperglycemia
b. Ryan who has chest injury, is pate and with
d. Type II (IDDM) is characterized by abnormal difficulty
immune
of breathing
response
c. Noel who has lacerations on the arms with
40. Lifestyle-related diseases in general share mildbleeding
areas
c. Andy whose left ankle swelled and has some
common risk factors. These are the following abrasions
except
43. In the emergency room, Nurse Rivera is
a. physical activity assigned to

b. smoking attend to the client with .lacerations on the

arms, while
c. genetics
assessing the extent of the wound the nurse d. Providing instructions regarding wound care
observes
Situation 10 - While working in the clinic, a new
that the wound is now starting to bleed client,
profusely. The
Geline, 35 years old, arrives for her doctor's
most immediate nursing action would be to:
193
a. Apply antiseptic to prevent infection
appointment. As the clinic nurse, you are to
b. Clean the wound vigorously of contaminants assist the

c. Control and. reduce bleeding of the wound client fiil up forms, gather data and make an
assessment.
d. Bandage the wound and elevate the arm
46. The nurse purpose of your initial nursing
44. The nurse applies pressure dressing on the
interview
bleeding
is to:
site. This intervention is done to:
a. Record pertinent information in the client
a. Reduce the need to change dressing
chart for
frequently
health team to read
b. Allow the pus to surface faster
b Assist the client find solutions to her health
c. Protect the wound from micro organisms in
concerns
the air
c. Understand her lifestyle, health needs and
d. Promote hemostasis
possible
45. After the treatment, the client is sent home
problems to develop a plan of care
and
d. Make nursing diagnoses for identified health
asked to come back for follow-up care. Your
problems
responsibilities when the client is to be
47. While interviewing Geline, she starts to
discharged
moan and
include the following EXCEPT:
doubles up in pain, She tells you that this pain
a. Encouraging the client to go to the, occurs
outpatient clinic
about an hour after taking black coffee without
for follow up care
breakfast for a few weeks now. You will record
b. Accurate recording, of treatment done and this as

instructions given to client follows:

c. Instructing the client to see you after a. Claims to have abdominal pains after intake
discharge for of coffee

further assistance unrelieved by analgesics

b. After drinking coffee, the client experienced energy level
severe
d. Discuss with her the importance of eating a
abdominal pain variety of

c. Client complained of intermittent abdominal food from the major food groups with plenty of
pain an fluids

hour after drinking coffee 49. Geline tells you that she drinks 4-5 cups of
black
d. Client reported abdominal pain an hour after
drinking coffee and diet cola drinks. She also smokes up
to a
black coffee for three weeks now
pack of cigarettes daily. She confesses that she is
48. Geline tells you that she drinks black coffee
in her
frequently within the day to "have energy and
2nd month of pregnancy but she does not want
be wide
to
awake" and she eats nothing for breakfast and
become fat that is why she limits her food
eats
intake. You
strictly vegetable salads for lunch and dinner to
warn or caution her about which of the
lose
following?
weight. She has lost weight during the past two
a. Caffeine products affect the central nervous
weeks,
system
in planning a healthy balanced diet with Geline,
and may cause the mother to have a "nervous
you
breakdown"
will:
b. Malnutrition and its possible effects on
a. Start her off with a cleansing diet to free her
growth and
body of
development problems in the unborn fetus
toxins then change to a vegetarian, diet and
drink plenty c. Caffeine causes a stimulant effect on both the
mother
of fluids
and the baby
b. Plan a high protein, diet; low carbohydrate
diet for her d. Studies show conclusively that caffeine
causes mental
considering her favorite food
retardation
c. Instruct her to attend classes in nutrition to
find food 50. Your health education plan for Geline
stresses
rich in complex carbohydrates to maintain daily
high proper diet for a pregnant woman and the
prevention
of non-communicable diseases that are approves your work schedules and directs your
influenced by work,

her lifestyle these include of the following she is demonstrating:

EXCEPT:
a. Responsibility
a. Cardiovascular diseases
b. Delegation
b. Cancer
c. Accountability
c. Diabetes Mellitus
d. Authority
d. Osteoporosis
54. The following tasks can be safely delegated'
Situation 11 - Management of nurse by a
practitioners is
nurse to a non-nurse health worker EXCEPT:
done by qualified nursing leaders who have had
194
clinical
a. Transfer a client from bed to chair
experience and management experience.
b. Change IV infusions
51. An example of a management function of a
nurse is: c. Irrigation of a nasogastric tube
a. Teaching patient do breathing and coughing d. Take vital signs
exercises
55. You made a mistake in giving the medicine
b. Preparing for a surprise party for a client to the
c. Performing nursing procedures for clients wrong client You notify the client’s doctor and
write an
d. Directing and evaluating the staff nurses
incident report. You are demonstrating:
52. Your head nurse in the unit believes that the
staff a. Responsibility
nurses are not capable of decision making so b. Accountability
she makes
c. Authority
the decisions for everyone without consulting
anybody. d. Autocracy

This type of leadership is: Situation 12 – Mr. Dizon, 84 years old, is brought
to the
a. Laissez faire leadership
.Emergency Room for complaint of hypertension
b. Democratic leadership flushed
c. Autocratic leadership face, severe headache, and nausea. You are
doing the
d. Managerial leadership
initial assessment of vital signs.
53. When the head nurse in your ward plots and
56. You are to measure the client’s initial blood reading to be:

pressure reading by doing all of the following a. Inconsistent

EXCEPT:
b. low systolic and high diastolic pressure
a. Take the blood pressure reading on both arms
c. higher than what the reading should be
for
d. lower than what the reading should be
comparison
59. Through the client’s health history, you
b. Listen to and identify the phases of
gather that
Korotkoff’s sounds
Mr. Dizon smokes and drinks coffee. When
c. Pump the cuff up to around 50 mmHg above
taking the
the point
blood pressure of a client who recently smoked
where the pulse is obliterated
or
d. Observe procedures for infection control
drank coffee, how long should be the nurse wait
57. A pulse oximeter is attached to Mr. Dizon’s before
finger
taking the client’s blood pressure for accurate
to: reading?

a. Determine if the client’s hemoglobin level is a. 15 minutes

low and if
b. 30 minutes
he needs blood transfusion
c. 1 hour
b. Check level of client’s tissue perfusion
d. 5 minutes
c. Measure the efficacy of the client’s anti
60. While the client has the pulse oximeter on
hypertensive
his
medications
fingertip, you notice that the sunlight is shining
d. Detect oxygen saturation of arterial blood on .the
before
area where the oximeter is. Your action will be
symptoms of hypoxemia develops to:

58. After a few hours in the Emergency Room, a. Set and turn on the alarm of the oximeter
Mr.
b. Do nothing since there is no identified
Dizon is admitted to the ward with an order of problem
hourly
c. Cover the fingertip sensor with a towel or
monitoring of blood pressure. The nurse finds bedsheet
that the
d. Change the location of the sensor every four
cuff is too narrow and this will cause the blood hours
pressure
Situation 13 - The nurse's understanding of c. Assume that ethical questions are the
ethico-legal responsibility: of

responsibilities will guide his/her nursing the health team

practice.
d. Be accountable for his or her own actions
61. The principles that .govern right and proper
64. You inform the patient about his rights
conducts of a person regarding life, biology and which
the
include the following EXCEPT:
health professions is referred to as:
195
a. Morality
a. Right to expect reasonable continuity of care
b. Religion
b. Right to consent to or decline to participate in
c. Values
research studies or experiments
d. Bioethics
c. Right to obtain information about another
62. The purpose of having nurses’ code of ethics patient
is:
d. Right to expect that the records about his
a. Delineate the scope and areas of nursing care will be
practice
treated as confidential
b. Identify nursing action recommended for
65. The principle states that a person has
specific
unconditional
healthcare situations
worth and has the capacity to determine his
c. To help the public understand professional own
conduct,
destiny.
expected of nurses
a. Bioethics
d. To define the roles and functions of the
b. Justice
health care
c. Fidelity
giver, nurses, clients
d. Autonomy
63. The most important nursing responsibility
where Situation 14 – Your director of nursing wants to
improve
ethical situations emerge in patient care is to:
the quality of health care offered in the hospital.
a. Act only when advised that the action is
As a
ethically
staff nurse in that hospital you know that this
sound
entails
b. Not take sides remain neutral and fair
quality assurance programs.
66. The following mechanisms can be utilized as doctor in charge calls to order a DNR (do not
part of
resuscitate) for the client. Which of the
the quality assessment program of your hospital following is the

EXCEPT: appropriate action when getting DNR order over

the
a. Patient satisfaction surveys provided
phone?
b. Peer review clinical records of care of client
a. Have the registered nurse, family
c. RO of the Nursing Intervention Classification
spokesperson, nurse
d.
supervisor and doctor sign
67. The nurse of the Standards of Nursing
b. Have two nurses validate the phone order,
Practice is
both
important in the hospital. Which of the
nurses sign the order and the doctor should sign
following
his
statements best describes what it is?
order within 24 hours.
a. These are statements that describe the
c. Have the registered nurse, family and doctor
maximum or
sign the
highest level of acceptable performance in
order
nursing
d. Have 1 nurse take the order and sign it and
practice.
have the
b. It refers to the scope of nursing as defined in
doctor sign it within 24 hours
Republic
69. To ensure the client safety before starting
Act 9173
blood
c. It is a license issued by the Professional
transfusion the following are needed before the
Regulation
procedure can be done EXCEPT:
Commission to protect the public from
substandard a. take baseline vital signs

nursing practice. b. blood should be warmed to room

temperature for 30
d. The Standards of care includes the various
steps of the minutes before blood transfusion is
administered
nursing process and the standards of
professional c. have two nurses verify client identification,
blood
performance.
type, unit number and expiration date of blood
68. You are taking care of critically ill client and
the d. get a consent signed for blood transfusion
70. Part of standards of care has to do with the c. use herbs and spices
use of
d. limit intake of preserved or processed food
restraints. Which of the following statements is
73. Teaching strategies and approaches when
NOT
giving
true?
nutrition education is influenced by age, sex and
a. Doctor’s order for restraints should be signed
196
within
immediate concerns of the group. Your
24 hours
presentation
b. Remove and reapply restraints every two
for a group of young mothers would be best if
hours
you
c. Check client’s pulse, blood pressure and
focus on:
circulation
a. diets limited in salt and fat
every four hours
b. harmful effect on drugs and alcohol intake
d. Offer food and toileting every two hours
c. commercial preparation of dishes
Situation 15 – During the NUTRITION
EDUCATION class d. cooking demonstration and meal planning
discussion a 58 year old man, Mr. Bruno shows 74. Cancer cure is dependent on
increased
a. use of alternative methods of healing
interest.
b. watching out for warning signs of cancer
71. Mr. Bruno asks what the "normal" allowable
salt c. proficiency in doing breast self-examination

intake is. Your best response to Mr. Bruno is: d. early detection and prompt treatment

a. 1 tsp of salt/day with iodine and sprinkle of 75. The role of the health worker in health
MSG education is

b. 5 gms per day or 1 tsp of table salt/day to:

c. 1 tbsp of salt/day with some patis and toyo a. report incidence of non-communicable
disease to
d. 1 tsp of salt/day but not patis or toyo
community health center
72. Your instructions to reduce or limit salt
intake b. educate as many people about warning signs
of noncommunicable
include all the following EXCEPT:
diseases
a. eat natural food with little or no salt added
c. focus on smoking cessation projects
b. limit use of table salt and use condiments
instead d. monitor clients with hypertension
Situation 16 – You are assigned to take care of nitroglycerin to your client. The following
10 important

patients during the morning shift. The guidelines to observe EXCEPT:

endorsement
a. Apply to hairlines clean are of the skin not
includes the IV infusion and medications for subject to
these
much wrinkling
clients.
b. Patches may be applied to distal part of the
76. Mr. Felipe, 36 years old is to be given
extremities like forearm
2700ml of
c. Change application and site regularly to
D5RL to infuse for 18 hours starting at 8am. At
prevent
what
irritation of the skin
rate should the IV fluid be flowing hourly?
d. Wear gloves to avoid any medication of your
a. 100 ml/hour
hand
b. 210 ml/hour
79. You will be applying eye drops to Miss
c. 150 ml/hour Romualdez.

d. 90 ml/hour After checking all the necessary information and

77. Mr. Atienza is to receive 150mg/hour of cleaning the affected eyelid and eyelashes you
D5W IV
administer the ophthalmic drops by instilling the
infusion for 12 hours for a total of 1800ml. He is eye
also
drops.
losing gastric fluid which must be replaced every
a. directly onto the cornea
two
b. pressing on the lacrimal duct
hours. Between 8am to 10am. Mr. Atienza has
lost c. into the outer third of the lower conjunctival
sac
250ml of gastric fluid. How much fluid should he
d. from the inner canthus going towards the
receive at 11am?
side of the
a. 350 ml/hour
eye
b. 275 ml/hour
80. When applying eye ointment, the following
c. 400 ml/hour
guidelines apply EXCEPT:
d. 200 ml/hour
a. squeeze about 2 cm of ointment and gently
78. You are to apply a transdermal patch of close but

not squeeze eye

b. apply ointment from the inner canthus going a. makes the assignment to teach the staff
outward member

of the affected eye b. is assigning the responsibility to the aide but

not the
c. discard the first bead of the eye ointment
before accountability for those tasks

application because the tube likely to expel c. does not have to supervise or evaluate the
more than aide

desired amount of ointment d. most know how to perform task delegated

d. hold the tube above the conjunctival sac do 83. Connie, the-new nurse, appears tired and
not let tip sluggish

touch the conjuctiva and lacks the enthusiasms she give six weeks
ago when
Situation 17 – The staff nurse supervisor request
all the she started the job. The nurse supervisor
should:
staff nurses to “brainstorm” and learn ways to
instruct a. empathize with the nurse and listen to her

diabetic clients on self-administration of insulin. b. tell her to take the day off
She
c. discuss how she is adjusting to her new job
wants to ensure that there are nurses available
d. ask about her family life
daily to
84. Process of formal negotiations of working
do health education classess.
conditions between a group of registered nurses
81. The plan of the nurse supervisor is an
and
example of
employer is:
a. in service education process
a. grievance
b. efficient management of human resources
b. arbitration
c. increasing human resources
c. collective bargaining
d. primary prevention
d. strike
82. When Mrs. Guevarra, a nurse, delegates
aspects of 85. You are attending a certification program on
the clients care to the nurse-aide who is an cardiopulmonary resuscitation (CPR) offered
unlicensed and
staff, Mrs. Guevarra. required by the hospital employing you. This is;
197 a. professional course towards credits

b. in-service education
c. advance training based on nurse's priorities

d. continuing education b. Goals and intervention developed by nurse

and client
Situation 18 - There are various developments in
health should be approved by the doctor

education that the nurse should know about. c. Nurse will decide goals and, interventions
needed to
86. The provision of health information in the
rural meet client goals

areas nationwide through television and radio d. Client will decide the goals and interventions
required
programs and video conferencing is referred to
as: to meet her goals

a. Community health program 89. Nurse Beatrice is providing tertiary

prevention to
b. Telehealth program
Mrs. De Villa. An example of tertiary provestion
c. Wellness program
is:
d. Red cross program
a. Marriage counseling
87. A nearby community provides blood
b. Self-examination for breast cancer
pressure
c. Identifying complication of diabetes
screening, height and weight measurement
smoking d. Poison, control

cessation classes and aerobics class services. 90. Mrs. Ostrea has a schedule for Pap Smear.
This type She has a

of program is referred to as: strong family history of cervical cancer. This is an

a. outreach program example of:

b. hospital extension program a. tertiary prevention

c. barangay health center b. secondary prevention

d. wellness center c. health screening

88. Part of teaching client in health promotion is d. primary prevention

responsibility for one’s health. When Danica Situation: 19 - Ronnie has a vehicular accident
states she where he

need to improve her nutritional status this sustained injury to his left ankle. In the
means: Emergency

a. Goals and interventions to be followed by Room, you notice how anxious he looks.
client are
91. You establish rapport with him and to NURSING PRACTICE
reduce his
1. C
anxiety you initially
2. B
a. Take him to the radiology, section for X-ray of
3. D
affected
4. D
extremity
5. B
b. Identify yourself and state your purpose in
being with 6. B
the client 7. C
c. Talk to the physician for an order of Valium 8. D
d. Do inspection and palpation to check extent 9. B
of his
10. B
injuries
11. B
92. While doing your assessment, Ronnie asks
you "Do I 12. C

have a fracture? I don't want to have a cast.” 13. C

The most 14. D
appropriate nursing response would be: 15. A
a. "You have to have an X-ray first to know if you 16. A
have a
17. C
fracture."
18. B
198
19. A
b. "Why do you; sound so scared? It is just a cast
and it's 20. C

not painful" 21. D

c. "You seem to be concerned about being in a 22. C

cast." 23. D
d. "Based on my assessment, there doesn’t 24. D
seem to be a
25. C
fracture."
26. D
199
27. C
ANSWER KEY - FOUNDATION OF PROFESSIONAL
28. D
29. D 58. C

30. C 59. B

31. B 60. C

32. C 61. D

33. C 62. C

34. C 63. D

35. B 64. C

36. D 65. D

37. D 66. D

38. B 67. A

39. B 68. D

40. C 69. D

41. D 70. C

42. B 71. B

43. D 72. B

44. D 73. D

45. C 74. D

46. C 75. B

47. D 76. C

48. D 77. -

49. B 78. B

50. D 79. B

51. D 80. C

52. C 81. C

53. D 82. B

54. B 83. C

55. B 84. C

56. C 85. B

57. D 86. B
87. A a. Eat more frequent small meals instead of
three large
88. D
one daily
89. C
b. Walk for at least half an hour daily to
90. B
stimulate
91. B
peristalsis
92. C
c. Drink more milk, increased calcium intake
200 prevents

COMMUNITY HEALTH NURSING AND CARE OF constipation

THE
d. Drink eight full glasses of fluid such as water
MOTHER AND CHILD daily

Situation 1 - Nurse Minette is an independent 3. If you were Minette, which of the following
Nurse actions,

Practitioner following-up referred clients in their would alert you that a new mother is entering a

respective homes. Here she handles a case of postpartial at taking-hold phase?

POSTPARTIAL MOTHER AND FAMILY focusing on a. She urges the baby to stay awake so that she
HOME can

CARE. breast-feed him in her

1. Nurse Minette needs to schedule a first home b. She tells you she was in a lot of pain all during
visit to labor

OB client Leah. When is a first home-care visit c. She says that she has not selected a name fir
typically the baby

made? as yet

a. Within 4 days after discharge d. She sleeps as if exhausted from the effort of
labor
b. Within 24 hours after discharge
4. At 6-week postpartum visit what should this
c. Within 1 hour after discharge
postpartial mother's fundic height be?
d. Within 1 week of discharge
a. Inverted and palpable at the cervix
2. Leah is developing constipation from being on
bed b. Six fingerbreadths below the umbilicus

rest. What measures would you suggest she c. No longer palpable on her abdomen
take to
d. One centimeter above the symphysis pubis
help prevent this?
5. This postpartal mother wants to loose the b. R.A. 223
weight she
c. R.A. 9173
gained in pregnancy, so she is reluctant to
d. R.A. 7164
increase her
7. By force of law, therefore, the PRC-Board of
calorin intake for breast-feeding. By how much
Nursing
should a
released Resolution No. 14 Series of the
lactating mother increase her caloric intake
entitled:
during the
"Adoption of a Nursing Specialty Certification
first 6 months after birth?
Program
a. 350 kcal/day
and Creation of Nursing Specialty Certification
b. 5CO kcal/day Council."

c. 200 kcal/day This rule-making power is called:

d. 1,000 kcal/day a. Quasi-Judicial Power

Situation 2 - As the CPES is applicable for all b. Regulatory Power

professional
c. Quasi/Legislative Power
nurse, the professional growth and
d. Executive/Promulgation Power
development of
8. Under the PRC-Board of Nursing Resolution
Nurses with specialties shall be addressed by a
Specialty promulgating the adoption of a Nursing
Specialty-
Certification Council.
Certification Program and Council, which two (2)
The following questions apply to these special
of the
groups of
following serves as the strongest for its
nurses.
enforcement?
6. Which of the following serves as the legal
(a) Advances made in science aid technology
basis and
have
statute authority for the Board of nursing to
provided the climate for specialization in almost
promulgate measures to effect the creation of a all

Specialty Certification Council and promulgate aspects of human endeavor and

professional development programs for this (b) As necessary consequence, there has
group of emerged a new

nurse-professionals? concept known as globalization which seeks to

remove
a. R.A. 7610
barriers in trade, .industry and services imposed b. The Board of Nursing shall oversee the
by the administration

national laws of countries all over the world; of the NSCP through the various Nursing
and Specialty

(c) Awareness of this development should impel Boards which will eventually, be created
the
c. The Board of Nursing at the time exercised
nursing sector to prepare our people in the their
services
powers under R.A. 7164 in order to adopt the
sector to meet .the above challenges; and creation of

201 the Nursing Specialty Certification /council and

Program
(d) Current trends of specialization in nursing
practice d. The Board of Nursing consulted nursing
leaders of
recognized by; the International Council of
Nurses (ICN) national nursing associations and other
concerned
of which the Philippines is a member for the
benefit of nursing groups which later decided to ask a
special group
the Filipino in terms of deepening and refining
nursing of nurses of .the program for nursing specialty

practice and enhancing the quality of nursing certification

care.
10. The NSCC was created for the purpose of
a. b & c are strong justification
implementing the Nursing Specialty policy
b. a & b are strong justification under the

c. a & c are strong justification direct supervision and stewardship of the Board
of
d. a & d are strong justification
Nursing. Who shall comprise the NSCC?
9. Which of the following is NOT a correct
statement as a. A Chairperson who is the current President of
the APO
regards Specialty Certification?
a member from .the Academe, and the last
a. The Board of Nursing intended to create the
member
Nursing
coming from the Regulatory Board
Specialty Certification Program as a means of
b. The Chairperson and members of the
perpetuating the creation of an elite force of
Regulatory
Filipino
Board ipso facto acts as the CPE Council
Nurse Professionals
c. A Chairperson, chosen from among the 12. In community health nursing, which of the
Regulatory following

Board Members, a Vice Chairperson appointed is our unit of service as nurses?

by the
a. The Community
BON at-large; two other members also chosen
b. The Extended Members of every family
at-large;
c. The individual members of the Barangay
and one representing the consumer group
d. The Family
d. A Chairperson who is the President of the
Association 13. A very important part of the Community
Health
from the Academe; a member from the
Regulatory Nursing Assessment Process includes
Board, and the last member coming from the a. the application of professional judgment in
APO estimating
Situation 3 - Nurse Anna is a new BSEN graduate importance of facts to family and community
and has
b. evaluation structures arid qualifications of
just passed her Licensure Examination for health
Nurses in the
center team
Philippines. She has likewise been hired as a
new c. coordination with other sectors in relation to
health
Community Health Nurse in one of the Rural
Health concerns

Units in their City, which of the following d. carrying out nursing procedures as per plan of
conditions may action

be acceptable TRUTHS applied to Community 14. In community health nursing it is important

Health to take

Nursing Practice. into account the family health with an equally

11. Which of the following is the primary focus important need to perform ocular inspection of
of the

community health nursing practice? areas activities which are powerful elements of:

a. Cure of illnesses a. evaluation

b. Prevention of illness b. assessment

c. Rehabilitation back to health c. implementation

d. Promotion of health d. planning

15. The initial step in the PLANNING process in 18. The nurse would anticipate a cesarean birth
order to for a

engage in any nursing project or parties at the client who has which infection present at the
onset of
community level involves:
labor?
a. goal-setting
a. Herpes simplex virus
b. monitoring
b. Human papilloma virus
c. evaluation of data
c. Hepatitis
d. provision of data
d. Toxoplasmosia
Situation 4 - Please continue responding as a
19. After a vaginal examination, the nurse»e
professional nurse in these other health
situations determines that the client's fetus is in an
occiput
through the following questions.
posterior position. The nurse would anticipate
202
that the
16. Transmission of HIV from an infected
client will have:
individual to
a. A precipitous birth
another person occurs:
b. Intense back pain
a. Most frequency in nurses with needlesticks
c. Frequent leg cramps
b. Only if there is a large viral load in the blood
d. Nausea and vomiting
c. Most commonly as a result of sexual contact
20. The rationales for using a prostaglandin gel
d. In all infants born to women with HIV
for a
infection
client prior to the induction of labor is to:
17. The medical record of a client reveals a
condition in a. Soften and efface the cervix

which the fetus cannot pass through the b. Numb cervical' pain receptors
maternal
c. Prevent cervical lacerations
pelvis. The nurse interprets this as:
d. Stimulate uterine contractions
a. Contracted pelvis
Situation 5 - Nurse Lorena is a Family Planning
b. Maternal disproportion and

c. Cervical insufficiency Infertility Nurse Specialist and currently attends

to
d. Fetopelvic disproportion
FAMILY PANNING CLIENTS AND INFERTILE
COUPLES. The
following conditions pertain to meeting the a. endometrial implants can block the fallopian
nursing of tubes

this particular population group. b. the uterine cervix becomes inflamed and
swollen
21. Dina, 17 years old, asks you how a tubal
ligation c. ovaries stop producing adequate estrogen

prevents pregnancy. Which would be the best d. pressure on the pituitary leads to decreased
answer? FSH levels

a. Prostaglandins released from the cut fallopian 24. Lilia is scheduled to have a
tubes hysterosalpingogram.

can kill sperm Which of the following, instructions would you

give her
b. Sperm cannot enter the uterus, because the
cervical regarding this procedure?

entrance is blocked a. She will not be able to conceive for 3 months

after the
c. Sperm can no longer reach the ova, because
the procedure

fallopian tubes are blocked b. The sonogram of the uterus will reveal any
tumors
d. The ovary no longer releases ova, as there is
no where present

for them to go c. Many women experience mild bleeding as an

after
22. The Dators are a couple undergoing testing
for effect

infertility. Infertility is said to exist when: d. She may feel some cramping when the dye is
inserted
a. a woman has no uterus
25. Lilia's cousin on the other hand, knowing
b. a woman has no children
nurse
c. a couple has been trying to conceive for 1
Lorena's specialization asks what artificial
year
insemination
d. a couple has wanted a child for 6 months
by donor entails. Which would be your best
23. Another client names Lilia is diagnosed as answer if
having
you were Nurse Lorena?
endometriosis. This condition interferes with
a. Donor sperm are introduced vaginally into the
the
uterus
fertility because:
or cervix
b. Donor sperm are injected intra-abdominally a. Measles
into each
b. Tetanus toxoids
ovary
c. Hepatitis B vaccines
c. Artificial sperm are injected vaginally to test
d. DPT
tubal
29. This is the vaccine needed before a child
patency
reaches
d. The husband's sperm is administered
one (1) year in order for him/her to qualify as a
intravenously
"fully
weekly
immunized child".
Situation 6 - There are other important basic
a. DPT
knowledge
b. Measles
203
c. Hepatitis B
in the performance of our task as Community
Health d. BCG
Nurse in relation to IMMUNIZATION these 30. Which of the following dose of tetanus
include: toxoid is
26. The correct temperature to store vaccines in given to the mother to protect her .infant from
a
neonatal tetanus and likewise provide 10 years
refrigerator is:
protection for the mother?
a. between -4 deg C and +8 deg C
a. Tetanus toxoid 3
b. between 2 deg C and +8 deg C
b. Tetanus toxoid 2
c. between -8 deg C and 0 deg C
c. Tetanus toxoid 1
d. between -8 deg C and +8 deg C
d. Tetanus toxoid 4
27. Which of the following vaccines is not done
by Situation 7 - Records contain those,
comprehensive
intramuscular (IM) injection?
descriptions of patient's health conditions and
a. Measles vaccine needs and
b. DPT at the same serve as evidences of every nurse's
c. Hepa B vaccines accountability in the, care giving process.
Nursing
d. DPT
records normally differ from institution to,
28. This vaccine content is derived from RNA
institution
recombinants:
nonetheless they follow similar patterns intake and output, treatment, postoperative
of .meeting care,

needs for specifics, types of information. The postpartum care, and diabetic regimen, etc.,
following this is

pertalos to documentation/records used whenever specific measurements or

management. observations

31. This special form used when the patient is are needed to-be documented repeatedly. What
admitted is

to the unit. The nurse completes, the this?

information in
a. Nursing Kardex
this records particularly his/her .basic personal
b. Graphic Flow sheets
data,
c. Discharge Summary
current illness, previous health history, health
history d. Medicine and Treatment Record
of the family, emotional profile, environmental 33. These records show all medications and
history treatment
as well as physical assessment together with provided on a repeated basis. What do you call
nursing this
diagnosis on admission. What do you call this record?
record?
a. Nursing Health History and Assessment
a. Nursing Kardex Worksheet
b. Nursing Health History and Assessment b. Discharge Summary
Worksheet
c. Nursing Kardex
c. Medicine and Treatment Record
d. Medicine and Treatment Record
d. Discharge Summary
34. This flip-over card is usually kept in a
32. These, are sheets/forms which provide an portable file at
efficient
the Nurses Station. It has 2-parts: the activity
and time saving way to record information that and
must
treatment section and a nursing care plan
be obtained repeatedly at regular and/or short section. This
intervals, of .time. This does not replace the carries information about basic demographic
progress data,
notes; instead this record of information on vital primary medical diagnosis, current orders of the
signs,
physician to be carried out by the nurse, written
nursing care plan, nursing orders, scheduled c. Medicine and Treatment Record
tests and
d. Nursing Health History and Assessment
procedures, safety precautions in-patient care Worksheet
and
Situation 8 - As Filipino Professional Nurses we
factors related to daily living activities/ this must be
record is
knowledgeable, about the Code of Ethics for
used in the charge-of-shift reports or during the Filipino
beside
Nurses and practice these by heart. The next
rounds or walking rounds. What record is this? questions

a. Discharge Summary pertain to this Code of Ethics.

204 36. Which of the following is TRUE about the

Code of
b. Medicine and Treatment Record
Ethics of Filipino Nurses?
c. Nursing Health History and Assessment
Worksheet a. The Philippine Nurses Association for being
the
d. Nursing Kardex
accredited professional organization was given
35. Most nurses regard this as conventional
the
recording
privilege to formulate a Code of Ethics which
of the date, time and mode by which the
the Board
patient leaves
of Nurses promulgated
a healthcare unit but this record includes
importantly, b. Code of Nurses was first formulated in 1982
published
directs of planning for discharge that starts soon
after in the Proceedings of the Third Annual
Convention of the
the' person is admitted to a healthcare
institution, it is PNA House of Delegates

accepted that collaboration or multidisciplinary c. The present code utilized the Code of Good

involvement (of all members of the health Governance for the Professions in the
team) in Philippines

discharge results in comprehensive care. What d. Certificate of Registration of registered

do you nurses; may be

call this? revoked or suspended for violations of any

provisions of
a. Discharge Summary
the Code of Ethics
b. Nursing Kardex
37. Based on the Code of Ethics for Filipino 39. A nurse should be cognizant that
Nurses, professional

what is regarded as the hallmark of nursing programs for specialty certification by the Board
of
responsibility and accountability?
Nursing are accredited through the
a. Human rights of clients, regardless of creed
and a. Professional Regulation Commission

gender b. Nursing Specialty Certification Council

b. The privilege of being a registered c. Association of Deans of Philippine Colleges of

professional nurses Nursing

c. Health, being a fundamental right of every d. Philippine Nurse Association

individual
40. Mr. Santos, R.N. works in a nursing home,
d. Accurate documentation of actions and and he
outcomes
knows that one of his duties is to be an
38. Which of the following nurses behavior is advocate for his
regarded
patients. Mr. Santos knows a primary duty of an
as a violation of the Code of Ethics of Filipino
advocate is to:
Nurses?
a. act as the patient's legal representative
a. A nurse withholding harmful information to
the family b. complete all nursing responsibilities on time
members of a patient c. safeguard the well being of every patient
b. A nurse declining commission sent by a d. maintain the patient's right to privacy
doctor for her
Situation 9 - Nurse Joanna works as an OB-Gyne
referral Nurse
c. A nurse endorsing a person running for and attends to several HIGH-RISK PREGNANCIES:
congress
Particularly women with preexisting of Newly
d. Nurse Reviewers and/or nurse review center Acquired
managers who pays a considerable amount of illness. The following conditions apply.
cash for
41. Bernadette is a 22-year old woman. Which
reviewees who would memorize items from the
condition would make her more prone than
Licensure exams and submit these to them after others to
the
developing a Candida infection during
examination pregnancy?

a. Her husband plays gold 6 days a week

b. She was over 35 when she became pregnant c. I am careful to drink at least eight glasses of
fluid
c. She usually drinks tomato juice for breakfast
everyday
d. She has developed gestational diabetes
d. 1 understand why folic acid is important for
42. Bernadette develops a deep-vein thrombosis
red cell
following an auto accident and is prescribed
formation
heparin
44. Bernadette routinely takes acetylsalicylic
sub-Q. What should Joanna educate her about
acid
in regard
(aspirin) for arthritis. Why should she limit or
to this?
discontinue this toward the end of pregnancy?
a. Some infants will be born with allergic
symptoms to a. Aspirin can lead to deep vein thrombosis
following
heparin
birth
b. Her infant will be born with scattered
petechiae on his b. Newborns develop a red rash from salicylate
toxicity
trunk
c. Newborns develop withdrawal headaches
205
from
c. Heparin can cause darkened skin in newborns
salicylates
d. Heparin does not cross the placenta and so
d. Salicyates can lead to increased maternal
does not
bleeding at
affect a fetus
childbirth
43. The cousin of Bernadette with sickle-cell
45. Bernadette received a laceration on her leg
anemia
from
alerted Joanna that she may need further
her automotive accident. Why are lacerations of
instruction
lower
on prenatal care. Which statement signifies this
extremities potentially more serious in pregnant
fact?
women than others?
a. I've stopped jogging so I don't risk becoming
a. Lacerations can provoke allergic responses
dehydrated
because of
b. I take an iron pull every day to help grown
gonadothropic hormone
new red
b. Increased bleeding can occur from uterine
blood cells
pressure on

leg veins
c. A woman is less able to keep the laceration d. Difficulty to awaken
clean
48. Which of the following is the most
because o f her fatigue important

d. Healing is limited during pregnancy, so these responsibility of a nurse in the prevention of

will not necessary

heal until after birth deaths from pneumonia and other severe
diseases?
Situation 10 - Still in your self-managed Child
Health a. Giving of antibiotics

Nursing Clinic, your encounter these cases b. Taking of the temperature of the sick child
pertaining to
c. Provision of Careful Assessment
the CARE OF CHILDREN WITH PULMONARY
d. Weighing of the sick child
AFFECTIONS.
49. You were able to identify factors that lead to
46. Josie brought her 3-rnonths old child to your
clinic respiratory problems in the community where
your
because of cough and colds. Which of the
following is health facility serves. Your primary role
therefore in
your primary action?
order to reduce morbidity due to pneumonia is
a. Give contrimoxazole tablet or syrup
to:
b. Assess the patient using the chart on
a. Teach mothers how to recognize early signs
management of
and
children with cough
symptoms of pneumonia
c. Refer to the doctor
b. Make home visits to sick children
d. Teach the mother how to count her child's
c. Refer cases to hospitals
bearing
d. Seek assistance and mobilize the BHWs to
47. In responding to the care concerns of
have a
children with
meeting with mothers
severe disease, referral to the hospital of the
essence 50. Which of the following is the principal focus
on the
especially if the child manifests which of the
following? CARI program of the Department of Health?
a. Wheezing a. Enhancement of health team capabilities
b. Stopped bleeding b. Teach mothers how to detect signs and where
to refer
c. Fast breathing
c. Mortality reduction through early detection d. when children are under 5 years of age

d. Teach other community health workers how 53. Baby John was given a drug at birth to
to assess reverse the

patients effects of a narcotic given to his mother in'

labor. What
Situation 11 - You are working as a Pediatric
Nurse in drug is commonly used for this?

your own Child Health Nursing Clinic, the a. Naloxone (Narcan)

following cases
b. Morphine Sulfate
pertain to ASSESSMENT AND CARE OP THE
c. Sodium Chloride
NEWBORN AT
d. Penicillin G
RISK conditions.
54. Why are small-for-gestational-age newborns
51. Theresa, a mother with a 2 year old
at risks
daughter asks,
for difficulty maintaining body temperature?
"at what are can I be able to take the blood
pressure of a. They do not have as many fat stores as other
infant’s
my daughter as a routine procedure since
hypertension b. They are more active than usual so throw off
covers
is common in the family?" Your answer to this
is: c. Their skin is more susceptible to conduction
of cold
206
d. They are preterm so are born relatively small
a. At 2 years you may
in size
b. As early as 1 year old
55. Baby John develops hyperbilirubinemia.
c. When she's 3- years old What is a

d. When she's 6 years old? method used to treat hyperbilirubinemia in a

newborn?
52. You typically gag children to inspect the back
of a. Keeping infants in a warm arid dark
environment
their throat. When is it important NOT to solicit
a gag b. Administration of a cardiovascular stimulant

reflex? c. Gentle exercise to stop muscle breakdown

a. when a girl has a geographic tongue d. Early feeding to speed passage of meconium

b. when a boy has a possible inguinal hernia Situation 12 - You are the nurse in the Out-
Patient-
c. when a child has symptoms of epiglottitis
Department and during your shift you c. There is no contraindication to immunization
encountered if the

multiple children's condition. The following child is well enough to go home and a child
questions should be

apply. immunized in the health center before referrals

are both
56. You assessed a child with visible severe
wasting, he correct

has: d. A child should be immunized in the center

before
a. edema
referral
b. LBM
59. A child with visible severe wasting or severe
c. kwashiorkor
palmar
d. marasmus
pallor may be classified as:
57. Which of the following conditions is NOT
a. moderate malnutrition/anemia
true about
b. severe malnutrition/anemia
contraindication to immunization?
c. not very tow weight no anemia
a. do not give DPT2 or DPT3 to a child who has
d. anemia/very low weight
convulsions within 3 days of DPT1
60. A child who has some palmar pallor can be
b. do not give BOG if the child has known
hepatitis . classified as:

c. do not give OPT to a child who has recurrent a. moderate anemia/normal weight

convulsion or active neurologic disease b. severe malnutrition/anemia

d. do not give BCG if the child has known AIDS c. anemia/very low weight

58. Which of the following statements about d. not very low eight to anemia

immunization is NOT true: Situation 13 - Nette, a nurse palpates the

abdomen of
a. A child with diarrhea who is due for OPV
should Mrs. Medina, a primigravida. She is unsure of
the date of
receive the OPV and make extra dose on the
next visit her last menstrual period. Leopold's Maneuver
is done.
b. There is no contraindication to immunization
if the The obstetrician told mat she appears to be 20
weeks
child is well enough to go home
pregnant. .
61. Nette explains this because the fundus is: with a Sow blood glucose

a. At the level the umbilicus, and the fetal heart d. of the rapid growth of the fetus
can be
64. The nurse assesses the woman at 20 weeks
heard with a fetoscope
gestation3 and expects the woman to report:
b. 18 cm, and the baby is just about to move
a. Spotting related to fetal implantation
c. is just over the symphysis, and fetal heart
b. Symptoms of diabetes as human placental
cannot be
lactogen is
heard
released
d. 28 cm, and fetal heart can be heard with a
c. Feeling fetal kicks
Doppler
d. Nausea and vomiting related HCG production
207
65. If Mrs. Medina comes to you for check-up on
62. In doing Leopold's maneuver palpation
June 2,
which
her EDO is June 11, what do you expect during
among the following is NOT considered a good
assessment?
preparation?
a. Fundic ht 2 fingers below xyphoid process,
a. The woman should lie in a supine position
engaged
wither
b. Cervix close, uneffaced, FH-midway between
knees flexed slightly
the
b. The hands of the nurse should be cold so that
umbilicus and symphysis pubis
abdominal muscles would contract and tighten
c. Cervix open, fundic ht. 2 fingers below
c. Be certain that your hands are warm (by xyphoid
washing them
process, floating .
in warm water first if necessary)
d. Fundic height at least at the level of the
d. The woman empties her bladder before xyphoid
palpation
process, engaged
63. In her pregnancy, she experienced fatigue
Situation 14: - Please continue responding as a
and
professional nurse in varied health situations
drowsiness. This probably occurs because:
through
a. of high blood pressure
the following questions.
b. she is expressing pressure
66. Which of the following medications would
c. the fetus utilizes her glucose stores and leaves the
her
nurse expect the physician to order for cravings
recurrent
d. There is progressive resistance to the effects
convulsive seizures of a 10-year old child of insulin
brought to
69. When providing prenatal education to a
your clinic? pregnant

a. Phenobarbital woman with asthma, which of the following

would be
b. Nifedipine
important for the nurse to do?
c. Butorphanol
a. Demonstrate how to assess her blood glucose
d. Diazepam
b. Teach correct administration of subcutaneous
67. RhoGAM is given to Rh-negative women to
prevent bronchodilators

maternal sensitization from occurring. The c. Ensure she seeks treatment for any acute
nurse is
exacerbation
aware that in addition to pregnancy, Rh-
d. Explain that she should avoid steroids during
negative
her
women would also receive this medication after
pregnancy
which
70. Which of the following conditions would
of the following?
cause an
a. Unsuccessful artificial insemination procedure
insulin-dependent diabetic client the most
b. Blood transfusion after hemorrhage difficulty

c. Therapeutic or spontaneous abortion during her pregnancy?

d. Head injury from a car accident a. Rh incompatibility

68. Which of the following would the nurse b. Placenta previa

include
c. Hyperemesis gravidarum
when describing the pathophysiologv of
d. Abruption placentae
gestational
Situation 15 - One important toot a community
diabetes?
health
a. Glucose levels decrease to accommodate
nurse uses in the conduct of his/her activities is
fetal growth
the CHN
b. Hypoinsulinemia develops early in the first
Bag. Which of the following BEST DESCRIBES the
trimester
use of
c. Pregnancy fosters the development of
this vital facility for our practice?
carbohydrate
71. The Community/Public Health Bag is: b. The bag should contain all necessary supplies
and
208
equipment ready for use
a. a requirement for home visits
c. Be sure to thoroughly clean your bag
b. an essential and indispensable equipment of
especially when
the
exposed to communicable disease cases
community health nurse
d. Minimize if not totally prevent the spread of
c. contains basic medications and articles used
infection
by the
74. This is an important procedure of the nurse
community health nurse
during
d. a tool used by the Community health nurse is
home visits?
rendering effective nursing procedure during a
a. protection of the CHN bag
home
b. arrangement of the contents of the CHM bag
visit
c. cleaning of the CHN bag
72. What is the rationale in the use of bag
technique d. proper handwashing

during home visit? 75. In consideration of the steps in applying the

bag
a. It helps render effective nursing care to
clients or technique, which side of the paper lining of the
CHN
other members of the family
bag is considered clean to make a non-
b. It saves time and effort of the nurse in the
contaminated
performance of nursing procedures
work area?
c. It should minimize or prevent the spread of
a. The lower lip
infection
b. The outer surface
from individuals to families
c. The upper lip
d. It should not overshadow concerns for the
patient d. The inside surface

73. Which among the following is important in Situation 16 - As a Community Health Nurse
the use relating with

of the bag technique during home visit? people in different communities, and in the

a. Arrangement of the bag's contents must be implementation of health programs and

projects you
convenient to the nurse
experience vividly as well the varying forms of d. B, A, and C only
leadership
77. Management by Filipino values advocates
and management from the Barangay Level to the
the Local
consideration of the Filipino goals trilogy
Government/Municipal City Level. according to

76. The following statements can correctly be the Filipino priority-values which are:
made
a. Family goals, national goals, organizational
about Organization and management? goals

A. An organization (or company) is people. b. Organizational goats, national goals, family

Values make goals

people persons: values give vitality, meaning c. National goals, organizational goals, family
and goals

direction to a company. As the people of an d. Family goals, organizational goals, national

organization goals

value, so the company becomes. 78. Since the advocacy for the utilization of
Filipino
B. Management is the process by which
administration value-system in management has been
encouraged, the
achieves its mission, goals, and objectives
Nursing sector is no except, management needs
C. Management effectiveness can be measured
to
in terms
examine Filipino values and discover its positive
of accomplishment of the purpose of the
organization potentials and harness them to achieve:

while management efficiency is measured in a. Employee satisfaction

terms of
b. Organizational commits .ants, organizational
the satisfaction of individual motives
objectives and employee satisfaction
D. Management principles are universal
c. Employee objectives/satisfaction,
therefore one
commitments and
need not be concerned about people, culture,
organizational objectives
values,
d. Organizational objectives, commitments and
traditions and human relations.
employee objective/satisfaction
a. B and C only
79. The following statements can correctly be
b. A, B and D only
made
c. A and D only
about an effective and efficient community or and technical skills
even
C. Technical skills, budget and accounting skills,
agency managerial-leader. skills in

A. Considers the achievement and advancement fund-raising

of the
D. Manipulative skills, technical skills, resource
organization she/he represents as well as his
management skills
people
a. A and D are correct
209
b. B is correct
B. Considers the recognition of individual efforts
toward c. A is correct
the realization of organizational goals as well as d. C and D are correct
the
Situation 17 - You are actively practicing nurse
welfare of his people who just
C. Considers the welfare of the organization finished your Graduate Studies. You earned the
above all value of
other consideration by higher administration Research and would like to utilize the
knowledge and
D. Considers its own recognition by higher
skills gained in the application of research to
administration for purposes of promotion and
Nursing
prestige
service. The following questions apply to
a. Only C and D are correct
research.
b. A, C and D are correct
81. Which type of research Inquiry investigates
c. B, C, and D are correct the

d. Only A and B are correct issue of human complexity (e.g. understanding

the
80. Whether management at the community or
agency human expertise)

level, there are 3 essential types of skills a. Logical position

managers
b. Naturalistic inquiry
must have, these are:
c. Positivism
A. Human relation skills, technical skills, and
d. Quantitative Research
cognitive
82. Which of the following studies is based on
skills
quantitative research?
B. Conceptual skills, human relation/behavioral
skills,
a. A study examining the bereavement process taking care of me." Which client right is being
in violated?

spouses of clients with terminal cancer a. Right of self determination

b. A study exploring factors influencing weight b. Right to privacy and confidentiality

control
c. Right to full disclosure
behavior
d. Right not to be harmed
c. A study measuring the effects of sleep
85. "A supposition or system of ideas that is
deprivation on
proposed
wound healing
to explain a given phenomenon," best defines:
d. A study examining client's feelings before,
a. a paradigm
during and
b. a concept
after a bone marrow aspiration
c. a theory
83. Which of the following studies is based on
d. a conceptual framework
qualitative research?
Situation 18 - Nurse Michelle works with a
a. A study examining clients reactions to stress
Family
after
Nursing Team in Calbayog Province specifically
open heart surgery
handling
b. A study measuring nutrition and weight,
a UNICEF Project for Children. The following
loss/gain in
conditions
clients with cancer
pertain, to CARE OP THE FAMILIES
c. A study examining oxygen levels after PRESCHOOLERS.
endotracheal
86. Ronnie asks constant questions. How many
suctioning does a

d. A study measuring differences in blood typical 3-year-old ask in a day's time?

pressure
a. 1,200 or more
before during and after a procedure
b. Less than 50
84. An 85 year old client in a nursing home tells
c. 100-200
a nurse,
d. 300-400
"I signed the papers for that research study
because the 87. Ronnie will need to change to a new bed
because
doctor was so insistent and I want: him to
continue his baby sister will need Ronnie's old crib. What
measure would you suggest that his parents 90. As a nurse. You reviewed infant safety
take to procedures

help decrease sibling rivalry between Ronnie with Bryan's mother. What are two of the most
and his
common types of accidents among infants?
new sister?
a. Aspiration and falls
210
b. Falls and auto accidents
a. Move him to the new bed before the baby
c. Poisoning and burns
arrives
d. Drowning and homicide
b. Explain that new sisters grow up to become
best Situation 19 - Among common conditions found
in
friends
children especially among poor communities
c. Tell him he will have to share with the new
are ear
baby
infection/problems. The following questions
d. Ask him to get his crib ready for the new baby
apply.
88. Ronnie's parents want to know how to react
91. A child with ear problem should be assessed
to him
for the
when he begins to masturbate while watching
following EXCEPT:
television. What would you suggest?
a is there any fever?
a. They refuse to allow him to watch television
b. ear discharge
b. They schedule a health check-up for sex-
c. if discharge is present for how long?
related
d. ear pain
disease
92. If the child does not have ear problem, using
c. They remind him that some activities are
IMCI,
private
what should you as the nurse do?
d. They give him "timeout" when this begins
a. Check for ear discharge
89. How many words does a typical 12-month-
old b. Check for tender swellings, behind the ear
infant use? c. Check for ear pain
a. About 12 words d. Go to the next question, check for
malnutrition
b. Twenty or more words
93. An ear discharge that has been present for
c. About 50 words
more
d. Two, plus "mama" and "dada"
than 14 days can be classified as:
a. mastoditis 97. The child with no dehydration needs home

b. chronic ear infection treatment Which of the following is not

included the
c. acute ear infection
rules for home treatment in this case:
d. complicated ear infection
a. continue feeding the child
94. An ear discharge that has been present for
jess than b. give oresol every 4 hours

14 days can be classified as: c. know when to return to the health center

a. chronic ear infection d. give the child extra fluids

b. mastoditis 98. A child who has had diarrhea for 14 days but
has no
c. acute ear infection
sign of dehydration is classified as:
d. complicated ear infection
a. severe persistent diarrhea
95. If the child has severe classification because
of ear b. dysentery

problem, what would be the best thing that you c. severe dysentery b. dysentery
as the
d. persistent diarrhea
nurse can do?
211
a. instruct mother when to return immediately
99. If the child has sunken eyes, drinking
b. refer urgently eagerly,

c. give an antibiotic for 5 days thirsty and skin pinch goes back slowly, the

d. dry the ear by wicking classification would be:

Situation 20 - If a child with diarrhea registers a. no dehydration

one sign in
b. moderate dehydration
the pink row and one in the yellow; row in the
c. some dehydration
IMCI
d. severe dehydration
Chart.
100. Carlo has had diarrhea for 5 days. There is
96. We can classify the patient as:
no
a. moderate dehydration
blood in the stool, he is irritable. His eyes are
b. some dehydration sunken

c. no dehydration the nurse offers fluid to Carlo and he drinks

eagerly.
d. severe dehydration
When the nurse pinched the abdomen, it goes 21. C
back
22. C
slowly. How will you classify Carlo’s illness?
23. A
a. severe dehydration
24. C
b. no dehydration
25. A
c. some dehydration
26. B
d. moderate dehydration
27. A
ANSWER KEY: COMMUNITY HEALTH NURSING
28. C
AND CARE OF THE MOTHER AND CHILD
29. B
1. A
30. D
2. B
31. B
3. A
32. B
4. C
33. D
5. B
34. D
6. D
35. A
7. C
36. C
8. D
37. C
9. A
38. A
10. B
39. B
11. D
40. C
12. D
41. D
13. A
42. D
14. B
43. B
15. A
44. D
16. C
45. B
17. D
46. B
18. A
47. D
19. B
48. C
20. D
49. A
50. C 79. D

51. C 80. C

52. C 212

53. A 81. B

54. A 82. C

55. D 83. A

56. D 84. A

57. B 85. C

58. A 86. D

59. B 87. A

60. 88. C

61. A 89. A

62. B 90. A

63. D 91. A

64. C 92. D

65. A 93. B

66. A 94. C

67. C 95. B

68. D 96. D

69. C 97. B

70. C 98. D

71. B 99. C

72. A 100. C

73. D 213

74. D Comprehensive Exam 1

75. B Situation 1 - Concerted work efforts among

members of
76. D
the surgical team is essential to the success of
77. D
the
78. D
surgical procedure. orthopedic cases, what department is usually
informed
1. The sterile nurse or sterile personnel touch
only to be present in the OR?

sterile supplies and instruments. When there is a. Rehabilitation department

a need
b. Laboratory department
for sterile supply which is not in the sterile field,
c. Maintenance department
who
d. Radiology department
hands out these items by opening its outer
cover? 4. Minimally invasive surgery is very much into
a. Circulating nurse technology. Aside from the usual surgical team
who
b. Anesthesiologist
else to be present when a client undergoes
c. Surgeon
laparoscopic surgery?
d. Nursing aide
a. Information technician
2. The OR team performs distinct roles for one
surgical b. Biomedical technician
procedure to be accomplished within a c. Electrician
prescribed time
d. Laboratory technicial
frame and deliver a standard patient outcome.
White 5. In massive blood loss, prompt replacement of

the surgeon performs the surgical procedure, compatible blood is crucial. What department
who needs to

monitors the status of the client like urine be alerted to coordinate closely with the
output, patient's

blood loss? family for immediate blood component

therapy?
a. Scrub nurse
a. Security Division
b. Surgeon
b. Chaplaincy
c. Anesthesiologist
c. Social Service Section
d. Circulating nurse
d. Pathology department
3. Surgery schedules are communicated to the
OR Situation 2 - You are assigned in the Orthopedic
Ward
usually a day prior to the procedure by the
nurse of the where clients are complaining of pain in varying
degrees
floor or ward where the patient is confined. For
upon movement of body parts. c. The client can distract himself during pain
episodes
6. Troy is a one day post open reduction and
internal d. The client reports independence from
watchers
fixation (ORIF) of the left hip and is in pain.
Which of 9. Pain in Ortho cases may not be mainly due to
the
the following observation would prompt you to
call the surgery. There might be other factors such as
cultural
doctor?
or psychological that influence pain. How can
a. Dressing is intact but partially soiled
you alter
b. Left foot is cold to touch and pedal pulse is
these factors as the nurse?
absent
a. Explain all the possible interventions that may
c. Left leg in limited functional anatomic
cause
position
the client to worry.
d. BP 114/78, pulse of 82 beats/minute
b. Establish trusting relationship by giving his
7. There is an order of Demerol 50 mg I.M. now
medication
and
on time
every 6 hours p r n. You injected Demerol at 5
pm. The c. Stay with the client during pain episodes

next dose of Demerol 50 mg I.M. is given: d. Promote client's sense of control and
participation in
a. When the client asks for the next dose
pain control by listening to his concerns
b. When the patient is in severe pain
10. In some hip surgeries, an epidural catheter
c. At 11pm
for
d. At 12pm
214
8. You continuously evaluate the client's
Fentanyl epidural analgesia is given. What is
adaptation to
your
pain. Which of the following behaviors-indicate
nursing priority care in such a case?
appropriate adaptation?
a. Instruct client to observe strict bed rest
a. The client reports pain reduction and
b. Check for epidural catheter drainage
decreased
c. Administer analgesia through epidural
activity
catheter as
b. The client denies existence of pain
prescribed

d. Assess respiratory rate carefully

Situation 3 - Records are vital tools in any d. Medical records section
institution and
14. You readmitted a client who was in another
should be properly maintained for specific use
department a month ago. Since you will need
and time.
the
11. The patient's medical record can work as a
previous chart, from whom do you request the
doubleedged
old
swords. When can the medical record become
chart?
the doctor's/nurse worst enemy?
a. Central supply section
a. When the record is voluminous
b. Previous doctor's clinic
b. When a medical record is subpoenaed in
c. Department where the patient was previously
court
admitted
c. When it is missing
d. Medical records section
d. When the medical record is inaccurate,
incomplete, 15. Records Management and Archives Offices
of the
and inadequate
DOH is responsible for implementing its policies
12. Disposal of medical records in government
on
hospitals/institutions must be done in close
record, disposal. You know that your institution
coordination with what agency? is

a. Department of Interior and Local Government covered by this policy it;

(DILG)
a. Your hospital is considered tertiary
b. Metro Manila Development Authority
b. Your hospital is in Metro Manila
(MMDA)
c. It obtained permit to operate from DOH
c. Records Management Archives Office (RMAO)
d. Your hospital is Philhealth accredited
d. Depart of Health (DOH)
Situation 4 - In the OR, there are safety
13. In the hospital, when you need-the medical
protocols that
record
should be followed. The OR nurse should be
of a discharged patient for research, you will
well versed
request
with all these to safeguard the safety and
permission through:
quality to
a. Doctor in charge
patient delivery outcome.
b. The hospital director
16. Which of the following should be given
c. The nursing Service highest
priority when receiving patient in the OR? ankles and around the 2 hands around an arm
board
a. Assess level of consciousness
d. client is monitored throughout the surgery by
b. Verify patient identification and informed
the
consent
assistant anesthesiologist
c. Assess vital signs
19. Another nursing check that should not be
d. Check for jewelry, gown, manicure and
missed
dentures
before the induction of general anesthesia is:
17. Surgeries like I and D (incision and drainage)
and a. check for presence underwear

debribement are relatively short procedures but b. check for presence dentures

considered ‘dirty cases’. When are these; c. check patient's

procedures
d. check baseline vital signs
best scheduled?
215
a. Last case
20. Some different habits and hobbies affect
b. In between cases
postoperative respiratory function. If your client
c. According to availability of anesthesiologist
smokes 3 packs of cigarettes a day for the part
d. According to the surgeon's preference 10 years,

18. OR nurses should be aware that maintaining you will anticipate increased risk for:
the
a. perioperative anxiety and stress
client's safety is the overall goal of nursing care
b. delayed coagulation time
during
c. delayed wound healing
the intraoperative phase. As the circulating
nurse, you d. postoperative respiratory function
make certain that throughout the procedure... Situation 5 - Nurses hold a variety of roles when
a. the surgeon greets his client before induction providing care to a perioperative patient.
of
21. Which of the following role would be the
anesthesia
responsibility of the scrub nurse?
b. the surgeon and anestheriologist are in
tandem a. Assess the readiness of the client prior to
surgery
c. strap made of strong non-abrasive material
are b. Ensure that the airway is adequate

fastened securely around the joints of the knees c. Account for the number of sponges, needles,
and supplies,
Used during the surgical procedure impending infection?

d. Evaluate the type of anesthesia appropriate a. Localized heat and redness

for the
b. Serosanguinous exudates and skin blanching
surgical client
c. Separation of the incision
22. As a perioperative nurse, how can you best
d. Blood clots and scar tissue are visible
meet
25. Which of the following nursing intervention
the safety need of the client after administering
is done
preoperative narcotic?
when examining the incision wound and
a. Put side rails up and ask client not to get out changing the
of bed
dressing?
b. Send the client to ORD with the family
a. Observe the dressing and type and odor of
c. Allow client to get up to go to the comfort drainage if
room
any
d. Obtain consent form
b. Get patient's consent
23. It is the responsibility of the pre-op, nurse to
c. Wash hands
do
d. Request the client to expose the incision
skin prep for patients undergoing surgery. If hair
wound
at the
Situation 6 - Carlo, 16 years old, comes to the ER
operative site is not shaved, what should be
with
done to
acute asthmatic attack. RR is 46/min and he
make suturing easy and lessen chance of
appears to
incision
be in acute respiratory distress.
infection?
26. Which of She following nursing actions
a. Draped
should be
b. Pulled
initiated first?
c. Clipped
a. Promote emotional support
d. Shampooed
b. Administer oxygen at 6L/min
24. It is also the nurse's function to determine
c. Suction the client every 30 min
when
d. Administer bronchodilator by nebulizer
infection is developing in the surgical incision.
The 27. Aminophylline was ordered for acute
asthmatic
perioperative nurse should observe for what
signs of
attack. The mother asked the nurse, what its 216
indication
a. metabolic alkalosis
the nurse will say is:
b. respiratory acidosis
a. Relax smooth muscles of the bronchial airway
c. respiratory alkalosis
b. Promote expectoration
d. metabolic acidosis
c. Prevent thickening of secretions
Situation 7 - Joint Commission on Accreditation
d. Suppress cough of

28. You will give health instructions to Carlo, a Hospital Organization (JCAHP) patient safety
case of goals and

bronchial asthma. The health instruction will requirements include the care and efficient use
include of

the following EXCEPT: technology in the OR arid elsewhere in the

healthcare
a. Avoid emotional stress and extreme
temperature facility.

b. Avoid pollution like smoking 31. As the head nurse in the OR, how can you
improve
c. Avoid pollens, dust seafood
the effectiveness of clinical alarm systems?
d. Practice respiratory isolation
a. limit suppliers to a few so that quality is
29. The asthmatic client asked you what
maintained
breathing
b. implement a regular inventory of supplies
technique he can best practice when asthmatic
and
attack
equipment
starts. What will be the best position?
c. Adherence to manufacturer's
a. Sit in high-Fowler's position with extended
recommendation
legs
d. Implement a regular maintenance and testing
b. Sit-up with shoulders back
of alarm
c. Push on abdomen during exhalation
systems
d. Lean forward 30-40 degrees with each
32. Over dosage of medication or anesthetic can
exhalation
happen even with the aid of technology like
30. As a nurse you are always alerted to monitor
infusion
status
pump, sphymomanometer, and similar
asthmaticus who will likely and initially manifest
devices/machines. As a staff, how can you
symptoms of:
improve the
safety of using infusion pumps? patient's the following EXCEPT: medication
regimen
a. Check the functionality of the pump before
use b. Take action to address any identified risks
through
b. Select your brand of infusion pump like you
do with Incident Report (IR)

your cellphone c. Allow client to walk with relative to the OF?

C. Allow the technician to set the; infusion d. Assess and periodically reassess individual
pump before client's risk

use for falling

d. Verify the flow rate against your computation 35. As a nurse you know you can improve on
accuracy
33. JCAHOs universal protocol for surgical and
invasive of patient's identification by 2 patient
identifiers,
procedures to prevent wrong site, wrong
person, and EXCEPT:

wrong procedures/surgery includes the a. identify the client by his/her wrist tag and
following verify with

EXCEPT: family members

a. Mark the operative site if possible b. identify client by his/her wrist tag and call
his/her by
b. Conduct pre-procedure verification process
name
c. Take a video of the entire intra-operative
procedure c. call the client by his/her case and bed number

d. Conduct time out immediately before starting d. call the patient by his/her name and bed
the number

procedure Situation 8 - Team efforts is best demonstrated

in the OR
34. You identified a potential risk of pre and
post 36. If you are the nurse in charge for scheduling
surgical
operative clients. To reduce the risk of patient
harm cases, what important information do you need
to ask
resulting from fall, you can implement the
following the surgeon?

EXCEPT: a. Who is your internist

a. Assess potential risk of fail associated with b. Who is your assistant and anesthesiologist,
the and what
is your preferred time and type of surgery? activities outside, including the family?

c. Who are your anesthesiologist, internist, and 217

assistant
a. Orderly/clerk
d. Who is your anesthesiologist.
b. Nurse supervisor
37. In the OR, the nursing tandem for every
c. Circulating nurse
surgery is:
d. Anaesthesiologist
a. Instrument technician and circulating nurse
40. The breakdown in teamwork is often times a
b. Nurse anesthetist, nurse assistant, and
failure
instrument
in:
technician
a. Electricity
c. Scrub nurse and nurse anesthetist
b. Inadequate supply
d. Scrub and circulating nurses
c. Leg work
38. While team effort is needed in the OR for
efficient d. Communication
and quality patient care delivery, we should Situation 9 - Colostomy is a surgically created
limit the anus- It
number of people in the room for infection can be temporary or permanent, depending on
control. the
Who comprise this team? disease condition.
a. Surgeon, anesthesiologist, scrub nurse, 41. Skin care around the stoma is critical. Which
radiologist, of the
orderly following is not indicated as a skin care barriers?
b. Surgeon, assistants, scrub nurse, circulating a. Apply liberal amount of mineral oil to the
nurse, area
anesthesiologist b. Use karaya paste and rings around the stoma
c. Surgeon, assistant surgeon, anesthesiologist, c. Clean the area daily with soap and water
scrub before
nurse, pathologist applying bag
d. Surgeon, assistant surgeon, anesthesiologist, d. Apply talcum powder twice a day
intern,
42. What health instruction will enhance
scrub nurse regulation of a
39. When surgery is on-going, who coordinates colostomy (defecation) of clients?
the
a. Irrigate after lunch everyday Situation 10 - As a beginner in research, you are
aware
b. Eat fruits and vegetables in all three meals
that sampling is an essential element of the
c. Eat balanced meals at regular intervals
research
d. Restrict exercise to walking only
process.
43. After ileostomy, which of the following
46. What does a sample group represent?
condition is
a. Control group
NOT expected?
b. Study subjects
a. increased weight
c. General population
b. Irritation of skin around the stoma
d. Universe
c. Liquid stool
47. What is the most important characteristics
d. Establishment of regular bowel movement
of a
44. The following are appropriate nursing
sample?
interventions
a. Randomization
during colostomy irrigation EXCEPT:
b. Appropriate location
a. Increase the irrigating solution flow rate when
c. Appropriate number
abdominal cramps is felt
d. Representativeness
b. Insert 2-4 inches of an adequately lubricated
catheter 48. Random sampling ensures that each subject
has:
to the stoma
a. Been selected systematically
c. Position client in semi-Fowler
b. An equal change of selection
d. Hand the solution 18 inches above the stoma
c. Been selected based on set criteria
45. What sensation is used as a gauge so that
patients d. Characteristics that match other samples

with ileostomy can determine how often their 49. Which of the following sampling methods
pouch allows

should be drained? the use of any group of research subject?

a. Sensation of taste a. Purposive

b. Sensation of pressure b. Convenience

c. Sensation of smell c. Snow-bail

d. Urge to defecate d. Quota

50. You decided to include 5 barangays in your c. Peritoneum

municipality and chose a sampling method that d. Skin

would
53. Like sutures, needles also vary in shape and
get representative samples from each barangay. uses. If
What
you are the scrub nurse for a patient who is
should be the appropriate method for you to prone to
use in this
keloid formation and has a low threshold of
care? pain, what

a. Cluster sampling needle would you prepare?

b. Random sampling a. Round needle

c. Stratifies sampling b. A traumatic needle

d. Systematic sampling c. Reverse cutting needle

Situation 11 -After an abdominal surgery, the d. Tapered needle

circulating
54. Another alternative "suture" for skin closure
218 is the

and scrub nurses have critical responsibility use of _______________:

about
a. Staple
sponge and Instrument count.
b. Therapeutic glue
51. When is the first sponge/instrument count
c. Absorbent dressing
reported?
d. invisible suture
a. Before closing the subcutaneous layer
55. Like any nursing interventions, counts
b. Before peritoneum is closed should be

c. Before dosing the skin documented. To whom does the scrub nurse
report any
d. Before the fascia is sutured
discrepancy of country so that immediate 'and
52. What major supportive layer of the
abdominal wall appropriate action in instituted?

must be sutured with long tensile strength such a. Anesthesiologist

as
b. Surgeon
cotton or nylon or silk suture?
c. Or nurse supervisor
a. Fascia
d. Circulating nurse
b. Muscle
Situation 12 - As a nurse, you should be aware 59. As a nurse, what is one of the best way to
and reconcile

prepared of the different roles you play. medications across the continuum of care?

56. What role do you play, when you hold all a. Endorse on a case-to-case basis
clients’
b. Communication a complete list of the
information entrusted to you in the strictest patient's

confidence? medication to the next provider of service

a. Patient's advocate c. Endorse in writing

b. Educator d. Endorse the routine and 'stat' medications

every shift
c. Patient's Liaison
60. As a nurse, you protect yourself and co-
d. Patient's arbiter
workers
57. As a nurse, you can help improve the
from misinformation and misrepresentations
effectiveness
through
of communication among healthcare givers
the following EXCEPT:
a. Use of reminders of what to do
a. Provide information to clients about a variety
b. Using standardized list of abbreviations, of
acronyms,
services that can help alleviate the client's pain
and symbols and

c. One-on-one oral endorsement other conditions

d. Text messaging and e-mail b. Advising the client, by virtue of your

expertise, that
58. As a nurse, your primary focus in the
workplace is which can contribute to the client's well-being

the client's safety. However, personal safety is c. Health education among clients and
also a significant others

concern. You can communicate hazards to your regarding the use of chemical disinfectant
coworkers
d. Endorsement thru trimedia to advertise your
through the use of the following EXCEPT: favorite

a. Formal training disinfectant solution

b. Posters 61. A one-day postoperative abdominal surgery

client
c. Posting IR in the bulletin board
has been complaining of severe throbbing
d. Use of labels and signs abdominal
pain described as 9 in a 1-10 pain rating. Your 64. Surgical pain might be minimized by which
nursing
assessment reveals bowel sounds on all
quadrants and action in the OR:

219 a. Skill of surgical team and lesser manipulation

the dressing is dry and intact. What nursing b. Appropriate preparation For the scheduled
procedure
intervention would you take?
c. Use of modem technology in closing the
a. Medicate client as prescribed
wound
b. Encourage client to do imagery
d. Proper positioning and draping of clients
c. Encourage deep breathing and turning
65. One very common cause of postoperative
d. Call surgeon stat pain is:

62. Pentoxicodone 5 mg IV every 8 hours was a. Forceful traction during surgery

prescribed for post abdominal pain. Which will b. Prolonged surgery

be your
c. Break in aseptic technique
priority nursing action?
d. Inadequate anesthetic
a. Check abdominal dressing for possible
Situation 14 - You were on duty at the medical
swelling
ward
b. Explain the proper use of PCA to alleviate
when Zeny came in for admission for tiredness,
anxiety
cold
c. Avoid overdosing to prevent
intolerance, constipation, and weight gain. Upon
dependence/tolerance
examination, the doctor's diagnosis was
d. Monitor VS, more importantly RR .
hypothyroidism.
63. The client complained of abdominal and
66. Your independent nursing care for
pain. Your
hypothyroidism
nursing intervention that can alleviate pain is:
includes:
a. Instruct client to go to sleep and relax
a. administer sedative round the clock
b. Advice the client to close the lips and avoid
b. administer thyroid hormone replacement
deep
c. providing a cool, quiet, and comfortable
breathing and talking
environment
c. Offer hot and clear soup
d. encourage to drink 6-8 glasses of water
d. Turn to sides frequently and avoid too much
67. As the nurse, you should anticipate to
talking
administer
which of the following medications to Zeny who a. thyroxine
is
b. thyrotropin
diagnosed to be suffering from hypothyroidism?
c. iron
a. Levothyroxine
d. iodine
b. Lidocaine
Situation 15 - Mrs. Pichay is admitted to your
c. Lipitor ward. The

d. Levophed MD ordered "Prepared for thoracentesis this pm

to
68. Your appropriate nursing diagnosis for Zeny
who is remove excess air from the pleural cavity."

suffering from hypothyroidism would probably 71. Which of the following nursing responsibility
include is

which of the following? essential in Mrs. Pichay who will undergo

a. Activity intolerance related to tiredness thoracentesis?

associated
a. Support, and reassure client during the
with disorder procedure

b. Risk to injury related to incomplete eyelid b. Ensure that informed consent has been
closure signed

c. Imbalance nutrition related to c. Determine if client has allergic reaction to

hypermetabolism local

d. Deficient fluid volume related to diarrhea anesthesia

69. Myxedema coma is a life threatening d. Ascertain if chest x-rays and other tests have
complication been

of long standing and untreated hypothyroidism prescribed and completed

with
72. Mrs. Pichay who is for thoracentesis is
one of the following characteristics. assisted by

a. Hyperglycemia 220

b. hypothermia the nurse to any of the following positions,

EXCEPT:
c. hyperthermia
a. straddling a chair with arms and head resting
d. hypoglycemia
on the
70. As a nurse, you know that the most common
back of the chair
type
b. lying on the unaffected side with the bed
of goiter is related to a deficiency
elevated 30-
40 degrees a. to rule out pneumothorax

c. lying prone with the head of the bed lowered b. to rule out any possible perforation
15-30
c. to decongest
degrees
d. to rule out any foreign: body
d. sitting on the edge of the bed with her feet
Situation 16 - In the hospital, you are aware that
supported
we are
and arms and head on a padded overhead table
helped by the .use of a variety of
73. During thoracentesis, which of the following equipment/devices to
nursing
enhance quality patient care delivery;
intervention will be most crucial?
76. You are initiate an IV line to your patient,
a. Place patient in a quiet and cool room Kyle, 5,

b. Maintain strict aseptic technique who is febrile. What IV administration set will
you
c. Advice patient to sit perfectly still during
needle prepare?

insertion until it has been withdrawn from the a. Blood transfusion set
chest
b. Macroset
d. Apply pressure over the puncture site as soon
c. Volumetric chamber
as the
d. Microset
needle is withdrawn
77. Kyle is diagnosed to have measles. What will
74. To prevent leakage of fluid in the thoracic
your
cavity,
protective personal attire include?
how wilt you position the client after
thoracentesis? a. Gown
a. Place flat in bed b. Eyewear
b. Turn on the unaffected side c. Face mask
c. Turn on the affected side d. Gloves
d. On bed rest 78. What will you do to ensure that Kyle, who is
febrile,
75. Chest x-ray was ordered after thoracentesis.
When will have a liberal oral fluid intake?
you client asks what is the reason for another a. Provide a glass of fruit every meal
chest xray,
b. Regulate his IV to 30 drops per minute
you will explain:
c. Provide a calibrated pitcher of drinking water d. general anesthesia
and juice
82. Mothers of children undergoing
at the bedside and monitor intake and output tonsillectomy and

d. Provide a writing pad to record his intake adenoidectomy usually ask what food prepared
and
79. Before bedtime, you went to ensure Kyle's
safety in give their children after surgery. You as the
nurse will
'bed. You will do which of the following:
say:
a. Put the lights on
a. balanced diet when fully awake
b. Put the side rails up
b. hot soup when awake
c. Test the call system
c. ice cream when fully awake
d. Lock the doors
d. soft diet when fully awake
80. Kyle's room is fully mechanized. What do
you teach 221

the watcher and Kyle to alert the nurse for help? 83. The RR nurse should monitor for the most
common
a. How to lock side rails
postoperative complication of:
b. Number of the telephone operator
a. hemorrhage
c. Call system
b. endotracheal tube perforation
d. Remote control
c. esopharyngeal edema
Situation 17 - Tony, 11 years old, has 'kissing
tonsils' and d. epiglottis

is scheduled for tonsillectomy and 84. The PACU nurse will maintain postoperative
adenoidectomy or T T and A

and A. client in what position?

81. You are the nurse of Tony who will undergo a. Supine with neck hyperextended and
T and A supported with

in the morning. His mother asked you if Tony pillow

will be
b. Prone with the head on pillow and tuned to
put to sleep. Your teaching will focus on: the side

a. spinal anesthesia c. Semi-Fowler's with neck flexed

b. anesthesiologist’s preference d. Reverse trendelenburg with extended neck

c. local anesthesia 85. Tony is to be discharged in the afternoon of

the
same day after tonsillectomy and a. Recommend protein of high biologic value
adenoidectomy. You like eggs,

as the RN will make sure that the family knows poultry and lean meat
to:
b. Encourage client to include raw cucumbers,
a. offer osteorized feeding carrot,

b. offer soft foods for a week to minimize cabbage, and tomatoes

discomfort
c. Allowing the client cheese, canned foods, and
while swallowing other

c. supplement his diet with vitamin C rich juices processed food

to
d. Bananas, cantaloupe, orange and other fresh
enhance heating fruits

d. offer clear liquid for 3 days to prevent can be included in the diet
irritation
88. Rudy undergoes hemodialysis for the first
Situation 18 - Rudy was diagnosed to have time and
chronic renal
was scared of disequilibrium syndrome. He
failure. Hemodialysis is ordered that an A-V asked you
shunt was
how this can be prevented. Your response is:
surgically created.
a. maintain a conducive comfortable and cool
86. Which of the following action would be of
environment
highest
b. maintain fluid and electrolyte balance
priority with regards to the external shunt?
c. initial hemodialysis shall be done for 30
a. Avoid taking BP or blood sample from the
minutes only
arm with
so as not to rapidly remove the waste from the
shunt
blood
b. Instruct the client not to exercise the arm
than from the brain
with the
d. maintain aseptic technique throughout the
shunt
hemodialysis
c. Heparinize the shunt daily
89. You are assisted by a nursing aide with the
d. Change dressing of the shunt daily
care of
87. Diet therapy for Rudy, who has acute renal
the client with renal failure. Which delegated
failure,
function
is tow-protein, low potassium and sodium. The
to the aide would you particularly check?
nutrition instruction should include:
a. Monitoring and recording I and O 92. What will the nurse monitor and instruct the
client
b. Checking bowel movement
and significant others, post IVP?
c. Obtaining vital signs
222
d. Monitoring diet
a. Report signs and symptoms for delayed
90. A renal failure patient was ordered for
allergic
creatinine
reactions
clearance. As the nurse you will collect
b. Observe NPO for 6 hours
a. 48 jour urine specimen
c. Increase fluid intake
b. first morning urine
d. Monitor intake and output
c. 24 hour urine specimen
93. Post IVP, Fe should excrete the contrast
d. random urine specimen
medium.
Situation 19 - Fe is experiencing left sharp pain
You instructed the family to include more
and
vegetables in
occasional hematuria. She was advised to
the diet and
undergo IVP
a. increase fluid intake
by her physician.
b. barium enema
91. Fe was so anxious about the procedure and
c. cleansing enema
particularly expressed her low pain threshold.
Nursing d. gastric lavage

health instruction will include: 94. The IVP reveals that Fe has small renal
calculus that
a. assure the client that the pain is associated
with the can be passed out spontaneously. To increase
the
warm sensation during the administration of the
chance of passing the stones, you instructed her
Hypaque by IV
to
b. assure the client that the procedure painless
force fluids and do which of the following?
c. assure the client that contrast medium will be
a. Balanced diet
given
b. Ambulance more
orally
c. Strain all urine
d. assure the client that x-ray procedure like IVP
is only d. Bed rest

done by experts 95. The presence of calculi in the urinary tract is

called:
a. Colelithiasis b. Inject the drugs as close to the IV injection
site
b. Nephrolithiasis
c. Incorporate to the IV solution
c. Ureterolithiasis
d. Use volumetric chamber
d. Urolithiasis
98. One patient has a 'runaway' IV of 50%
Situation 20 - At the medical-surgical ward, the
dextrose. To
nurse
prevent temporary excess of insulin transient
must also be concerned about drug interactions.
hyperinsulin reaction, what solution should you
96. You have a client with TPN. You know that in
TPN, prepare in anticipation of the doctors order?

like blood transfusion, there should be no drug a. Any IV solution available to KVO

incorporation. However, the MD's order read; b. Isotonic solution

incorporate insulin to present TPN. Will you c. Hypertonic solution

follow the
d. Hypotonic solution
order?
99. How can nurse prevent drug interaction
a. No, because insulin will induce hyperglycemia including
in
absorption?
patients with TPN
a. Always flush with NSS after IV administration
b. Yes, because insulin is chemically stable with
b. Administering drugs with more diluents
TPN and
c. Improving on preparation techniques
can enhance blood glucose level
d. Referring to manufacturer's guidelines
c. No, because insulin is not compatible with
TPN 100. In insulin administration, it should be
understood
d. Yes, because it was ordered by the MD
that our body normally releases insulin
97. The RN should also know that some drugs
according to our
have
blood glucose level. When is insulin and glucose
increased absorption when infused in PVC
level
container.
highest?
How will you administer drugs such as insulin,
a. After excitement
nitroglycerine hydralazine to promote better
b. After a good night's rest
therapeutic drug effects?
c. After an exercise
a. Administer by fast drip
d. After ingestion of food
CARE OF CLIENTS WITH PHYSIOLOGIC AND bums on his trunk, right upper extremities ad
right
PSYCHOSOCIAL ALTERATIONS
lower extremities. His wife asks what that
Situation 1 - Because of the serious
means. Your
consequences of
most accurate response would be:
severe burns management requires a multi
disciplinary a. Structures beneath the skin are damaged

approach. You have important responsibilities as b. Dermis is partially damaged

a
c. Epidermis and dermis are both damaged
nurse.
d. Epidermis is damaged
1. While Sergio was lighting a barbecue grill with
4. During the first 24 hours after thermal injury,
a
you
lighter fluid, his shirt burst into flames. The most
should assess Sergio for
effective way to extinguish the flames with as
a. hypokalemia and hypernatremia
little
b. hypokalemia and hyponatremia
further damage as possible is to:
c. hyperkalemia and hyponatremia
a. log roll on the grass/ground
d. hyperkalemia and hypernatremia
b. slap the flames with his hands
5. Teddy, who sustained deep partial thickness
c. remove the burning clothes
and full
d. pour cold liquid over the flames
thickness burns of the face, whole anterior
223 chest and

2. Once the flames are extinguished, it is most both upper extremities two days ago, begins to
exhibit
important to:
extreme restlessness. You recognize that this
a. cover Sergio with a warm blanket
most
b. give him sips of water
likely indicates that Teddy is developing:
c. calculate the extent of his burns
a. Cerebral hypoxia
d. assess the Sergio's breathing
b. Hypervolemia
3. Sergio is brought to the Emergency Room
c. Metabolic acidosis
after the
d. Renal failure .
barbecue grill accident. Based on the
assessment of the Situation 2 - You are now working as a staff
nurse in a
physician, Sergio sustained superficial partial
thickness
general hospital. You have to be prepared to a. Make and incident report
handle
b. Call security to report the incident
situations with ethico-legal and moral
c. Wait for 2 hours before reporting
implications.
d. Report the incident to your supervisor
6. You are on night duty in the surgical ward.
One of 8. You are on duty in the medical ward. You
were asked
our patients Martin is prisoner who sustained
an to check the narcotics cabinet. You found out
that what
abdominal gunshot wound. He is being guarded
by is on record does not tally with the drugs used.
Which
policemen from the local police unit. During
your among the following will you do first?
rounds you heard a commotion. You saw the a. Write an incident report and refer the matter
policeman to the
trying to hit Martin. You asked why he was nursing director
trying to
b. Keep your findings to yourself
hurt Martin. He denied the matter. Which
among the c. Report the matter to your supervisor

following activities will you do first? d. Find out from the endorsement any patient
who
a. Write an incident report
might have been given narcotics
b. Call security officer and report the incident
9. You are on duty in the medical ward. The
c. Call your nurse supervisor and report the mother of
incident :
your patient who is also a nurse came running
d. Call the physician on duty to the
7. You are on morning duty in the medical ward. nurse station and informed you that Fiolo went
You into
have 10 patients assigned to you. During your cardiopulmonary arrest. Which among the
following
endorsement rounds, you found out that one of
your will you do first?
patients was not in bed. The patient next to him a. Start basic life support measures
informed you that he went home without b. Call for the Code
notifying the
c. Bring the crush cart to the room
nurses. Which among the following will you do
first?
d. Go to see Fiolo and assess for airway patency 12. To confirm his impression of colorectal
and cancer, Larry

breathing problems will require which diagnostic study?

10. You are admitting Jorge to the ward and you a. carcinoembryonic antigen
found
b. proctosigmoidbscopy
out that he is positive for HIV. Which among the
c. stool hematologic test
following will you do first?
d. abdominal computed tomography (CT) test
a. Take note of it and plan to endorse this to
13. The following are risk factors for colorectal
next shift
cancer,
b. Keep this matter to your self
EXCEPT:
c. Write an incident report
a. inflammatory bowels
d. Report the matter to your head nurse
b. high fat, high fiver diet
Situation 3 - Colorectal cancer can affect old and
c. smoking
younger people. Surgical procedures and other
d. genetic factors-familial adenomatous
modes of
polyposis
treatment are done to ensure quality of life. You
14. Symptoms associated with cancer of the
are
colon
assigned in the Cancer institute to care of
include:
patients with
a. constipation, ascites and mucus in the stool
224
b. diarrhea, heartburn and eructation
this type of cancer.
c. blood in the stools, anemia, and pencil-
11. Larry, 55 years old, who is suspected of
shaped, stools
having
d. anorexia, hematemesis, and increased
colorectal cancer, is admitted to the CI. After
peristalsis
taking the
15. Several days prior to bowel surgery, Larry
history and vital signs the physician does which
may be
test as
given sulfasuxidine and neomycin primarily to:
a screening test for colorectal cancer.
a. promote rest of the bowel by minimizing
a. Barium enema
peristalsis
b. Carcinoembryonig antigen
b. reduce the bacterial content of the colon
c. Annual digital rectal examination
c. empty the bowel of solid waste
d. Proctosigmoidoscopy
d. soften the stool by retaining water in the a. Lubricates the tip of the catheter prior to
colon inserting

Situation 4 - ENTEROSTOMAL THERAPY is now into the stoma

considered especially in nursing. You are b. Hands the irrigating bag on the bathroom
participating in door doth

the OSTOMY CARE CLASS. hook during fluid insertion

16. You plan to teach Fermin how to irrigate the c. Discontinues the insertion of fluid after only
500 ml of
colostomy when:
fluid had been insertion
a. The perineal wound heals and Fermin can sit
d. Clamps off the flow of fluid when feeling
comfortably on the commode
uncomfortable
b. Fermin can lie on the side comfortably, about
the 3rd 19. You are aware that teaching about
colostomy care
postoperative day
is understood when Fermin states, "I will
c. The abdominal incision is close and
contact my
contamination is
physician and report:
no longer a danger
a. If I have any difficulty inserting the irrigating
d. The stool starts to become formed, around
tub into
the 7th
the stoma.”
postoperative day
b. If I notice a loss of sensation to touch in the
17. When preparing to teach Fermin how to
stoma
irrigate his
tissue."
colostomy, you should plan to do the procedure:
c. The expulsion of flatus while the irrigating
a. When Fermin would have normal bowel
fluid is
movement
running out."
b. At least 2 hours before visiting hours
d. When mucus is passed from the stoma
c. Prior to breakfast and morning care
between
d. After Fermin accepts alteration in body image
irrigation."
18. When observing a rectum demonstration of
20. You would know after teaching. Fermin that
colostomy irrigation, you know that more dietary
teaching is
instruction for him is effective when he states,
required if Fermin: "It is

important that I eat:

a. Soft foods that are easily digested and b. a pitting edema of the ankle
absorbed by my
c. a reddened area at the ankle
large intestine."
d. pruritus on the calf and ankle
b. Bland food so that my intestines do not
23. To prevent recurrent attacks on Terry who
become
has
irritate."
acute glumerulonephritis, you should instruct
c. Food low in fiber so that there is less stool." her to:

d. Everything that I ate before the operation, a. seek early treatment for respiratory infections
while
b. take showers instead of tub bath
avoiding foods that cause gas."
c. continue to take the same restrictions on fluid
225 intake

Situation 5 - Ensuring safety is one of your most d. avoid situations that involve physical activity

important responsibilities. You will need to 24. Herbert has a laryngectomy and he is now
provide for

instructions and information to your clients to discharge. Re verbalized his concern regarding
prevent his

complications. laryngectomy tube being dislodged. What

should you
21. Randy has chest tubes attached to a pleural
teach him first?
drainage system. When caring for him you
should: a. Recognize that prompt closure of the tracheal
opening
a. empty the drainage system at the end of the
shift may occur

b. clamp the chest tube when auctioning b. Keep calm because there is no immediate
emergency
c. palpate the surrounding areas for crepitus
c. Reinsert another tubing immediately
d. change the dressing daily using aseptic
techniques d. Notify the physician at once

22. Fanny came in from PACU after pelvic 25. When caring for Larry after an exploratory
surgery. As chest

Fanny's nurse you know that the sign that would surgery and pneumonectomy, your priority
be would be to

indicative of a developing thrombophlebitis maintain:

would be:
a. supplementary oxygen
a. a tender, painful area on the leg
b. ventilation exchange 27. Voltaire develops a nosocomial respiratory
tract
c. chest tube drainage
infection. He asks you what that means.
d. blood replacement
a. "You acquired the infection after you have
Situation 6 - Infection can cause debilitating
been
consequences when host resistance is
admitted to the hospital."
compromised and
b. "This is a highly contagious infection requiring
virulence of microorganisms and environmental
factors complete isolation."

are favorable. Infection control is one important c. "The infection you had prior to hospitalization
flared
responsibility of the nurse to ensure quality of
care. up."

26. Honrad, who has been complaining of d. "As a result of medical treatment, you have
anorexia and acquired a

feeling tired, develops jaundice. After a workup secondary infection.''

he is
28. As a nurse you know that one of the
diagnosed of having Hepatitis A. His wife asks complications
you
that you have to watch out for when caring for
about gamma globulin for herself and her Omar
household
who is receiving total parenteral nutrition is:
help. Your most appropriate response would be:
a. stomatitis
a. "Don't worry your husband's type of hepatitis
b. hepatitis
is no
c. dysrhythmia
longer communicable"
d. infection
b. "Gamma globulin provides passive immunity
for 29. A solution used to treat Pseudomonas
would
Hepatitis B"
infection is:
c. "You should contact your physician
immediately about a. Dakin's solution
getting gamma globulin." b. Half-strength hydrogen peroxide
d. "A vaccine has been developed for this type b. Acetic acid
of
d. Betadine
hepatitis"
30. Which of the following is most reliable in
diagnosing
a wound infection? c. Tell her family who are in the room not to talk

a. Culture and sensitivity d. Speak softly then hold her hands gently

b. Purulent drainage from a wound 33. Which among the following interventions
should
c. WBC count of 20,000/pL
you consider as the highest priority when caring
226
for
d. Gram stain testing
June who has hemiparersis secondary to stroke?
Situation 7 - As a nurse you need to anticipate
a. Place June on an upright lateral position
the
b. Perform range of motion exercises
occurrence of complications of stroke so that
life c. Apply antiembolic stocking

threatening situations can be prevented. d. Use hand rolls or pillows for support

31. Wendy is admitted to the hospital with signs 34. Ivy, age 40, was admitted to the hospital
and with a

symptoms of stroke. Her Glasgow Coma Scale is severe headache, stiff neck and photophobia.
6 on She was

admission. A central venous catheter was diagnosed with a subarachnoid hemorrhage

inserted and secondary

an I.V. infusion was started. As a nurse assigned to ruptured aneurysm. While waiting for
to surgery, you

Wendy what will he your priority goal? can provide a therapeutic by doing which of the

a. Prevent skin breakdown following?

b. Preserve muscle function a. honoring her request for a television

c. Promote urinary elimination b. placing her bed near the window

d. Maintain a patent airway c. dimming the light in her room

32. Knowing that for a comatose patient hearing d. allowing the family unrestricted visiting
is the privileges

best last sense to be lost, as Judy's nurse, what 35. When performing a neurological assessment
should on

you do? Walter, you find that his pupils are fixed and
dilated.
a. Tell her family that probably she can't hear
them This indicated that he:

b. Talk loudly so that Wendy can hear you a. probably has meningitis
b. is going to be blind because of trauma b. a visual problem

c. is permanently paralyzed c. functional decline

d. has received a significant brain injury d. drug toxicity

Situation 8 - With the improvement in life 39. Cardiac ischemia in an older patient usually
expectancies
produces:
and the emphasis in the quality of life it is
a. ST-T wave changes
important to
b. Very high creatinine kinase level
provide quality care to our older patients. There
are c. chest pain radiating to the left arm
frequently encountered situations and issues d. acute confusion
relevant to
40. The most dependable sign of infection in the
the older, patients. older
36. Hypoxia may occur in the older patients patient is:
because of
a. change in mental status pain
which of the following physiologic changer
associated b. fever

with aging. c. pain

a Ineffective airway clearance d. decreased breath sound with crackles

b. Decreased alveolar surface area Situation 9 - A "disaster" is a large-scale

emergency—
c. Decreased anterior-posterior chest diameter
even a small emergency left unmanaged may
d. Hyperventilation turn into a
37. The older patient is at higher risk for in disaster. Disaster preparedness is crucial and is
inconvenience because of: 227
a. dilated urethra everybody's business. There are agencies that
are in
b. increased glomerular filtration rate
charge of ensuring prompt response.
c. diuretic use
Comprehensive
d. decreased bladder capacity
Emergency Management (CEM) is an integrated
38. Merle, age 86, is complaining of dizziness
approach to the management of emergency
when she
program
stands up. This may indicate:
and activities for all four emergency phases
a. dementia (mitigation,
preparedness, response, and recovery), for all c. Aggregate care prevention
type of
d. Secondary prevention
emergencies and disasters (natural, man-made,
43. During the disaster you see a victim with a
and
green
attack) and for all levels of government and the
tag, you know that the person:
private
a. has injuries that are significant and require
sector.
medical
41. Which of the four phases of emergency
care but can wait hours will threat to life or limb
management is defined as "sustained action
b. has injuries that are life threatening but
that
survival is
reduces or eliminates long-term risk to people
good with minimal intervention
and
c. indicates injuries that are extensive and
properly from natural hazards and the effect"?
chances of
a. Recovery
survival are unlikely even with definitive care
b. Mitigation
d. has injuries that are minor and treatment can
c. Response be

d. Preparedness delayed from hours to days

42. You are a community health nurse 44. The term given to a category of triage that
collaborating refers to

with the Red Cross and working with disaster life threatening or potentially life threatening
relief injury or

following a typhoon which flooded and illness requiring immediate treatment:

devastated the
a. Immediate
whole province. Finding safe housing for
b. Emergent
survivors,
c. Non-acute
organizing support for the family, organizing
counseling d. Urgent
debriefing sessions and securing physical care 45. Which of the following terms refer to a
are the process by
services you are involved with. To which type of which the individual receives education about
prevention are these activities included. recognition of stress reactions and management
a. Tertiary prevention strategies for handling stress which may be
instituted
b. Primary prevention
after a disaster? patients had positive blood and wound culture).
What
a. Critical incident stress management
is your priority activity?
b. Follow-up
a. Establish policies for surveillance and
c. Defriefing
monitoring
d. Defusion
b. Do data gathering about the possible sources
Situation 10 - As a member of the health and of
nursing
infection (observation, chart review, interview)
team you have a crucial role to play in ensuring
c. Assign point persons who can implement
that all
policies
the members participate actively is the various
d. Meet with the nursing group working in the
tasks
burn unit
agreed upon,
and discuss problem with them feel
46. While eating his meal, Matthew accidentally
48. Part of your responsibility as a member of
dislodges his IV line and bleeds. Blood oozes on the
the
diabetes core group is to get referrals from the
surface of the over-bed table. It is most various
appropriate
wards regarding diabetic patients needing
that you instruct the housekeeper to clean the diabetes
table
education. Prior to discharge today 4 patients
with: are

a. Acetone referred to you. How would you start prioritizing

your
b. Alcohol
activities?
c. Ammonia
a. Bring your diabetes teaching kit and start
d. Bleach your session
47. You are a member of the infection control taking into consideration their distance from
team, of your office
the hospital. Based on a feedback during the b. Contact the nurse-in-charge and find out
meeting of from her the
the committee there is an increased incidence 228
of
reason for the referral
pseudomonas infection in the Burn Unit (3 out
of 10 c. Determine their learning needs then prioritize
d. involve the whole family in the teaching class important role where you can demonstrate the
impact
49. You have been designated as a member of
the task of nursing health?

force to plan activities for the Cancer a. Conduct health education on healthy lifestyle
Consciousness
b. Be a triage nurse
Week. Your committee has 4 months to plan
c. Take the initial history and document findings
and
d. Act as a coordinator
implement the plan. You are assigned to contact
the Situation 11 - One of the realities that we are
confronted
various cancer support groups in your hospital.
What with is'6w mortality. It is important for us nurses
to be
will be your priority activity?
aware of how we view suffering, pain, illness,
a. Find out if there is a budget for this activity
and even
b. Clarify objectives of the activity with the task
our death as well as its meaning. That way we
force
can help
before contacting the support groups
our patients cope with death and dying.
c. Determine the VIPs and Celebrities who will
51. Irma is terminally ill she speaks to you in
be invited
confidence. You now feel that Irma's family
d. Find out how many support groups there are
could be
in the
helpful if they knew what Irma has told you.
hospital and get the contact number of their
What
president
should you do first?
50. You are invited to participate in the medical
mission a. Tell the physician who in turn could tell the
family
activity of your alumni association. In the
planning b. Obtain Irma's permission to share the
information
stage everybody is expected to identify what
they can with the family
do during the medical mission and what c. Tell Irma that she has to tell her family what
resources are she told
needed. You though it is also your chance to you
share what
d. Make an appointment to discuss the situation
you can do for others. What will be your most with

the family
52. Ruby who has been told she has terminal b. "I have resigned myself to dying"
cancer
c. "What's the use"?
turns away aha refuses to respond to you. You
d: "I'm giving up"
can best
55. Maria, 90 years old has planned ahead for
help her by:
herdeath-
a. Coming back periodically and indicating your
philosophically, socially, financially and
availability if she would like you to sit with her
emotionally. This is recognized as:
b. Insisting that Ruby should talk with you
a. Acceptance that death is inevitable
because it is
b Avoidance of the true sedation
not good to Keep everything inside
c. Denial with planning for continued life
c. Leaving her atone because she is
uncooperative and d. Awareness that death will soon occur
unpleasant to be with Situation 12 - Brain tumor, whether malignant
or benign,
d. Encouraging her to be physically active as
possible has serious management implications nurse,
you should
53. Leo who is terminally ill and recognizes that
he is in be able to understand the consequences of the
disease
the process of losing, everything and everybody
he and the treatment.
loves, is depressed. Which of the following 56. You are caring for Conrad who has a brain
would best tumor
help him during depression? and increased intracranial Pressure (ICP). Which
a. Arrange for visitors who might cheer him intervention should you include in your plan to
reduce
b. Sit down and talk with him for a while
ICP?
c. Encourage him to look at the brighter side of
things a. Administer bowel! Softener
d. Sit silently with him b. Position Conrad with his head turned toward
the side
54. Which of the following statements would
best of the tumor
indicate that Ruffy; who is dying has accepted c. Provide sensory stimulation
this
d. Encourage coughing and deep breathing
impending death?
229
a. "I'm ready to do."
57. Keeping Conrad's head and neck in b. yellowish drainage
alignment
c. Greenish drainage
results in:
d. Bloody drainage
a. increased intrathoracic pressure
Situation 13 -As a Nurse, you have specific
b. increased venous outflow
responsibilities as professional. You have to
c. decreased venous outflow demonstrate

d. increased intra abdominal pressure specific competencies.

58. Which of the following activities may 61. The essential components of professional
increase nursing

intracranial pressure (ICP)? practice are all the following EXCEPT:

a. Raising the head of the bed a. Culture

b. Manual hyperventilation b. Care

c. Use of osmotic Diuretics c. Cure

d. Valsava's maneuver d. Coordination

59. After you assessed Conrad, you suspected 62. You are assigned to care for four (4)
increased patients. Which

ICP! Your most appropriate respiratory goal is of the following patients should you give first
to: priority?

a. maintain partial pressure of arterial 02 (PaO2) a. Grace, who is terminally ill with breast cancer
above
b. Emy, who was previously lucid but is now
80 mmHg unarousable

b. lower arterial pH c. Aris, who is newly admitted and is scheduled

for an
c. prevent respiratory alkalosis
executive check-up
d. promote CO2 elimination
d. Claire, who has cholelithiasis and is for
60. Conrad underwent craniotomy. As his nurse;
operation on
you
call
know that drainage on a craniotomy dressing
must be 63. Brenda, the Nursing Supervisor of the
intensive care
measured and marked. Which findings should
you unit (ICU) is not on duty when a staff nurse
committed
report immediately to the surgeon?

a. Foul-smelling drainage
a serious medication error. Which statement b. Assign the same nurse to him when possible
accurately
c. Allow Vincent uninterrupted period of time
reflects the accountability of the nursing
d. Limit Vincent's visitors to coincide with CCU
supervisor?
policies
a. Brenda should be informed when she goes
Situation 14 - As a nurse in the Oncology Unit,
back on
you have
duty
to be prepared to provide efficient and effective
b. Although Brenda is not on duty, the nursing care to
supervisor
your patients.
on duty decides to call her if time permits
66. Which one of the following nursing
c. The nursing supervisor on duty will notify interventions
Brenda at
would be most helpful in preparing the patient
home for

d. Brenda is not duty therefore it is not radiation therapy?

necessary to
a. Offer tranquilizers and antiemetics
inform her
b. Instruct the patient of the possibility of
64. Which barrier should you avoid, to manage radiation burn
your
c. Emphasis on the therapeutic value of the
time wisely? treatment

a. Practical planning d. Map out the precise course of treatment

b. Procrastination 67. What side effects are most apt to occur to

patient
c. Setting limits
during radiation therapy to the pelvis?
d. Realistic personal expectation
230
65. You are caring for Vincent who has just been
a. Urinary retention
transferred to the private room. He is anxious
because b. Abnormal vaginal or perineal discharge

he fears he won't be monitored as closely as he c. Paresthesia of the lower extremities

was in
d. Nausea and vomiting and diarrhea
the Coronary Care Unit. How can you allay his
68. Which of the following can be used on the
fear?
irradiated skin during a course of radiation
a. Move his bed to a room far from nurse's
therapy?
station to
a. Adhesive tape
reduce
b. Mineral oil c. Morgue management

c. Talcum powder d. Transport group

d. Zinc oxide ointment 72. There are important principles that should
guide
69. Earliest sign of skin reaction to radiation
therapy is: the triage team in disaster management that
you have
a. desquamation
to know if you were to volunteer as part of the
b. erythema
triage
c. atrophy
team. The following principles should be
d. pigmentation observed in

70. What is the purpose of wearing a film badge disaster triage, EXCEPT:
while
a. any disaster plan should have resource
caring for the patient who is radioactive? available to

a. Identify the nurse who is assigned to care for triage at each facility and at the disaster site if
such a possible

patient b. make the most efficient use of available

resources
b. Prevent radiation-induced sterility
c. training on disaster is not important to the
c. Protect the nurse from radiation effects response in
d. Measure the amount of exposure to radiation the event of a real disaster because each
Situation 15 - In a disaster there must be a chain disaster is
of unique in itself
command in place that defines the roles of each d. do the greatest good for the greatest number
member of the response team. Within the of
health care casualties
group there are pre-assigned roles based on 73. Which of the following categories of
education, conditions
experience and training on disaster. should be considered first priority in a disaster?
71. As a nurse to which of the following groups a. Intracranial pressure and mental status
are you
b. Lower gastrointestinal problems
best prepared to join?
c. Respiratory infection
a. Treatment group
d. Trauma
b. Triage group
74. A guideline that is utilized in determining 77. Late signs and symptoms of cervical cancer
priorities include

is to assess the status of the following, EXCEPT? the following EXCEPT:

a. perfusion a. urinary/bowel changes

b. locomotion b. pain in pelvis, leg of flank

c. respiration c. uterine bleeding

d. mentation d. lymph edema of lower extremities

75. The most important component of 231

neurologic
78. When a panhysterectomy is performed due
assessment is: to

a. pupil reactivity cancer of the cervix, which of the following

organs are
b. vital sign assessment
moved?
c. cranial nerve assessment
a. the uterus, cervix, and one ovary
d. level of consciousness/responsiveness
b. the uterus, cervix, and two-thirds of the
Situation 16 - You are going to participate in a
vagina
Cancer
c. the uterus, cervix, tubes and ovaries
Consciousness Week. You are assigned to take
charge of d. the uterus and cervix

the women to make them aware of cervical 79. The primary modalities of treatment for
cancer. You Stage 1 and

reviewed its manifestations and management. IIA cervical cancer include the following:

76. The following are risk factors for cervical a. surgery, radiation therapy and hormone
Cancer therapy

EXCEPT: b. surgery

a. immunisuppressive therapy c. radiation therapy

b. sex at an early age, multiple partners, d. surgery and radiation therapy

exposure to
80. A common complication of hysterectomy is:
socially transmitted diseases, male partner's
a. thrombophlebitis of the pelvic and thigh
sexual
vessels
habits
b. diarrhea due to over stimulating
c. viral agents like the Human Papilloma Virus
c. atelectasis
d. smoking
d. wound dehiscence d. Two ampules of sodium bicarbonate

Situation 17 - The body has regulatory 83. Which of the following nursing interventions
mechanism to is

maintain the needed electrolytes. However appropriate after a total thyroidectomy?

there are
a. Place pillows under your patient's shoulders
conditions/surgical interventions that could
b. Raise the knee-gatch to 30 degrees
compromise
c. Keep your patient in a high-fowler's position
life. You have to understand how management
of these d. Support the patient's head and neck with
pillows and
conditions are done.
sandbags
81. You are caring for Leda who is scheduled to
undergo 84. If there is an accidental injury to the
parathyroid
total thyroidectomy because of a diagnosis of
thyroid gland during a thyroidectomy which of the
following
cancer. Prior to total thyroidectomy, you should
might Leda develops postoperative?
instruct Leda to:
a. Cardiac arrest
a. Perform range and motion exercises on the
head and b. Dyspnea
neck c. Respiratory failure
b. Apply gentle pressure against the incision d. Tetany
when
85. After surgery Leda develops peripheral
swallowing numbness,
c. Cough and deep breath every 2 hours tingling and muscle twitching and spasm. What
would
d. Support head with the hands when changing
position you anticipate to administer?
82. As Leda's nurse, you plan to set up an a. Magnesium sulfate
emergency
b. Calcium gluconate
equipment at her beside following
thyroidectomy. You c. Potassium iodine

should include: d. Potassium chloride

a An airway and rebreathing tube Situation 18 - NURSES are involved in

maintaining a safe
b. A tracheostomy set and oxygen
and health environment. This is part of quality
c. A crush cart .with bed board care
management. present or incubating at the time of hospital

86. The first step in decontamination is: admission?

a. to immediately apply a chemical a. Secondary bloodstream infection

decontamination
b. Nosocomial infection
foam to the area of contamination
c. Emerging infectious disease
b. a thorough soap and water was and rinse of
d. Primary bloodstream infection
the
90. Which of the following guidelines is not
patient
appropriate
c. to immediately apply personal protective
to helping family members cope with sudden
equipment
death?
d. removal of the patients clothing and jewelry
a. Obtain orders for sedation of family members
and then
b. Provide details of the factors attendant to the
rinsing the patient with water
sudden
87. For a patient experiencing pruritus, you
death
recommend
c. Show acceptance of the body by touching it
which type of bath:
and giving
a. Water
the family permission to touch
b. colloidal (oatmeal)
d. Inform the family that the patient has passed
c. saline on

d. sodium bicarbonate Situation 19 - As a nurse you are expected to

participate
88. Induction of vomiting is indicated for the
accidental in initiating or participating in the conduct of
research
poisoning patient who has ingested.
studies to improve nursing practice. You have to
a. rust remover
be
b. gasoline
updated on the latest trends and issues
c. toilet bowl cleaner affecting

232 profession and the best practices arrived at by

the
d. aspirin
profession
89. Which of the following term most precisely
refer to 91. You are interested to study the effects of

an infection acquired in the hospital that was meditation and relaxation on the pain
not experienced by
cancer patients. What type of variable is pain? b. Descriptive

a. Dependant c. Experimental

b. Correlational d. Quasi-experimental

c. Independent 94. You are shown a Likert Scale that will be

used in
d. Demographic
evaluating your performance in the clinical area.
92. You would like to compare the support
Which
system of
of the following questions will you not use in
patients with chronic illness to those with acute
critiquing
illness.
the Likert Scale?
How will you best state your problem?
a. Are the techniques to complete and score the
a. A descriptive study to compare the support
scale
system of
provided?
patients with chronic illness and those with
acute illness b. Are the reliability and validity information on
the scale
in terms of demographic data and knowledge
about described?

interventions c. If the Likert Scale is to be used for a study,

was the
b. The effect of the Type of Support system of
patients development process described?

with chronic illness and those with acute illness d. Is the instrument clearly described?

c. A comparative analysis of the support: system 95. In any research study where individual
of persons are

patients with chronic illness and those with involves, it is important that an informed
acute illness consent for

d. A study to compare the support system of the Study is obtained. The following are
patients essential

with chronic illness and those with acute illness information about the consent that you should
disclose
93. You would like to compare the support,
system of to the prospective subjects EXCEPT:

patients with chronic illness to those with acute a. Consent to incomplete disclosure
illness.
b. Description of benefits, risks and discomforts
What type of research it this?
c. Explanation of procedure
a. Correlational
d. Assurance of anonymity and confidentiality, burn wounds is:

Situation 20 - Because severe burn can affect a. patient hypothermia

the
b. cross contamination of wound
person's totality it is important that you apply
c. patient discomfort
interventions focusing on the various
d. excessive manpower requirement
dimensions of
100. Oral analgecis are most frequently used to
man. You also have to understand the rationale
control
of the
burn injury pain:
treatment.
a. upon patient request
96. What type of debribement involves
proteolytic b. during the emergent phase
enzymes? c. after hospital discharge
a. Interventional d. during the cute phase
b. Mechanical 234
c. Surgical ANSWER KEY: CARE OF CLIENTS WITH
PHYSIOLOGIC
d Chemical
AND PSYCHOSOCIAL ALTERATIONS
97. Which topical antimicrobial is most
frequently used 1. A
in burn wound care? 2. D
a. Neosporin 3. D
b. Silver nitrate 4. B
c. Silver sulfadiazine 5. D
233 6. A
d. Sulfamylon 7. B
98. Hypertrophic burns scars are caused by: 8. A
a. exaggerated contraction 9. D
b. random layering of collagen 10. A
c. wound ischemia 11. B
d. delayed epithelialization 12. B
99. The major disadvantage of whirlpool 13. B
cleansing of
14. C 43. D

15. B 44. D

16. C 45. A

17. C 46. D

18. C 47. A

19. A 48. C

20. C 49. B

21. C 50. A

22. A 51. C

23. A 52. A

24. D 53. D

25. A 54. A

26. D 55. D

27. A 56. A

28 D 57. B

29. C 58. B

30. D 59. D

31. D 60. A

32. D 61. A

33. B 62. B

34. C 63. A

35. D 64. B

36. B 65. B

37. D 66. C

38. B 67. A

39. C 68. D

40. C 69. B

41. B 70. C

42. C 71. B
72. C 235

73. D Nursing Practice Test V

74. B Situation: The nurse is interviewing a handsome

man. He
75. D
is intelligent and very charming. When asked
76. A
about his
77. B
family, he states he has been married four
78. C times. He says

79. D three of those marriages were "shotgun"

weddings. He
80. A
states he never really loved any of his wives. He
81. C doesn't
82. B know much about his three children. "I've lost
83. C track," he

84. D states.

85. B 1. If a patient is very resistant in taking

responsibility of
86. C
his action and asks, "Can you just give me some
87. B
medication?" the best response is:
88. D
a. "The medication has too many side effects."
89. B
b. You don't want to take medication, do you?"
90. A
c. Medication is given only as a East resort."
91. A
d. "There is no medication specific for your
92. C condition."
93. A 2. The patient asks the nurse, "What is this
94. A therapy for

95. A anyway. I just don't understand it." the best

reply is:
96. D
a. "It keeps you from being put on medications."
97. B
b. "It helps you to change others in the family."
98. A
c. "The purpose of therapy is to help you
99. A change."
100. C
d. "No one but professionals can really b. They are borderline mentally retarded
understand
c. They are too psychotic to see what’s going on
3. For patient in group therapy, the goal is:
d. They do not learn from past mistakes
a. Exchanging information and ideas
7. The nurse recognizes that these are traits of:
b. Developing insight by relating to others
a. Bipolar disorder
c. Learning that everyone has problems
b. Alcoholic personality
d. All of the above
c. Antisocial personality
4. In planning care for the patient with a
d. Borderline personality
personality
Situation: The patient with bipolar disorder is
disorder, the nurse realizes that this patient will
pacing
most
continuously and is skipping meals.
likely:
8. Blood levels are drawn on the patient who
a. Not need long-term therapy
has been
b. Not require medication
taking Lithium for about six months. The
c. Require anti-anxiety medication present level

d. Resist any change in behavior is 2.1 meq/L. The nurse evaluates this level as:

5. The person with an antisocial personality is a. Therapeutic

participating in therapy while a patient at a b. Below therapeutic

psychiatric
c. Potentially dangerous
hospital. The nurse’s expectations are that he
d. Fatally toxic
will:
9. The priority in working with patient a thought
a. Make a complete recovery
disorder is:
b. Make significant changes
a. Get him to understand what you're saying
c. Begin the slow process of change
b. Get him to do his ADLs
d. Make few changes, if any
c. Reorient him to reality
6. One of the reasons that persons with
antisocial d. Administer antipsychotic medications
personalities may marry repeatedly or get into 10. The most recent Lithium level on bipolar
trouble patient
with legal authorities is: indicates a drop non-therapeutic level. What
associated
a. They usually just don't care
behavior does the nurse assess? 14. Supportive therapy to the rape victim is
directed at
a. Ataxia
overwhelming feeling that the victim
b. Confusion
experiences just
c. Hyperactivity
after the rape has occurred?
d. Lethargy
a. Guilt
11. Adequate fluid intake for a patient on
b. Rage
Lithium is:
c. Damaged
a. 1,000 ml per day
d. Despair
b. 1,500 ml per day
15. Anna asks, "Why do I need to have pelvic
c. 2,000 ml per day
exam?"
d. 3,600 ml per day
The nurse explains:
12. The physician orders Lithium carbonate for
a. "To make sure you're not pregnant."
the
b. "To see if you got an infection."
bipolar patient. The nurse is aware that:
c. "To make sure you were really raped."
236
d. "To gather legal evidence that is required."
a. The patient should be put on a special diet
16. In providing support therapy, the nurse
b. The medication should be given only at night
explains
c. A salt-free should be provided for the patient
that rape has nothing to do with sexual desires
d. The drug level should be monitored regularly or

13. The nursing plan should emphasize: heeds. The two most common elements in rape
are:
a. Offering him finger foods
a. Guilt and shame
b. Telling him he must sit down and eat
b. Shame and jealousy
c. Serving food in his room and staying with him
c. Embarrassment and envy
d. Telling him to order fast food of he wants to
eat d. Power and anger

Situation: Anna, 25 years old was raped six 17. The rape victim will not talk, is withdrawn
months ago and

states, "I just can't seem to get over this. My depressed. The defensive mechanism being
husband used is:

and I don't even have sex anymore. What can I a. Rationalization

do?"
b. Denial
c. Repression increases the ritual behavior at bedtime. She
cannot
d. Regression
sleep. The treatment plan should include:
18. The composite picture of rape victim reveals
that a. Recommending a sedative medication

most victimized women are: b. Modifying the routine to diminish her

bedtime anxiety
a. Secretaries
c. Reminding her to perform rituals early in the
b. Elderly
evening
c. Students
d. Limit the amount of time she spends washing
d. Professionals her

19. The best intervention is: hands

a. Tell her it just takes a long time 22. A patient has been diagnosed with a
personality
b. Ask her if her husband is angry
disorder with .compulsive traits. Of the
c. Refer her and her husband to sex therapy following
d. Tell her she is suffering PTSD behavior's, which one would you expect the
Situation: Obsessions are recurring thoughts patient to
that exhibit?
become prevalent in the consciousness and may a. Inability to make decisions
be
b. Spontaneous playfulness
considered as senseless or repulsive white
compulsion c. Inability to alter plans

are the repetitive acts that follow obsessive d. Insistence that things be done his way
thoughts.
23. The patient will not be able to stop her
20. To understand the meaning of the cleaning compulsive
rituals,
washing routines until she:
the nurse must realize:
a. Acquires more superego
a. The patient cannot help herself
b. Recognizes the behavior is unrealistic
b. The patient cannot change
c. No longer needs them to manage her feelings
c. Rituals relieve intense anxiety of

d. Medications cannot help anxiety

21. Upon admission to the hospital the patient 237

d. Regains contact with reality

24. A 48-year-old female patient is brought to c. Work with her to develop limits of behavior
the
d. Restrain her from the rituals
hospital by her husband because her behavior is
27. After the patient entered the hospital she
blocking her ability to meet her family's needs. began to
She has
increase her ritualistic hand washing at bedtime
uncontrollable and constant desire to scrub her and
hands,
could; not sleep. The nurse plans care around
the walls, floors and sofa. She keeps repeating," the fact

Everything is dirty." This is an example of: that this patient needs:

a. Compulsion a. A substitute activity to relieve anxiety

b. Obsession b. Medication for sleeping

c. Delusion c. Anti-anxiety medication such as Xanax

d. Hallucination d. More scheduled activities during the day

25. The female patient is preoccupied with rules 28. The patient states, "I know all this scrubbing
and is silly

regulations. She becomes upset if others do not but I can’t help it:'', this statement indicates that
follow the

her lead and adhere to the rules exactly. This is patient does not recognize:
a
a. What she is doing
characteristic of which of the following
b. Why she is cleaning
personality?
c. Her level of anxiety
a. Compulsive
d. Need for medication
b. Borderline
Situation: Substance, abuse is a common,
c. Antisocial
growing health
d. Schizoid
problem in this country.
26. In planning care focused on decreasing the
29. The nurse is monitoring a drug abuser who
patient's
states
anxiety, what plan should the nurse have in
he was given cocaine and heroine that war cut
regards to
with
the rituals?
cornstarch or some other kind of powder. He
a. Encourage the routines states, "It

b. Ignore rituals
was really bad stuff." Which complication is irritation of eyes, nose and mouth, she suspects
most
inhalants. Which sign is most indicative of
threatening to this patient? inhalant

a. Endocarditis abuse?

b. Gangrene a. Vomiting

c. Pulmonary abscess b. Bad breath

d. Pulmonary embolism c. Bad trip

30. The chronic drug abuser is suffering d. Sudden fear

lymphedema in
33. An impaired nurse has been admitted for
all extremities, but particularly in the arm where treatment
the
of Demerol addiction. She asks, "When will the
drug was obviously injected. There is severe
withdrawal begin?" the best response is:
obstruction of veins and lymphatics. The nurse
a. "It varies, with each individual."
suspects
b. "There is no way to tell."
the patient used:
c. "Withdrawal begins soon after the last dose."
a. A dull, contaminated needle
d. "It depends upon how well the Demerol
b. A needle contaminated with AIDS
works."
c. Contaminated drugs
238
d. Cocaine mixed with uncut heroin
34. The patient has a blood pressure of
31. The nurse is assessing a heroin user who 180/100, heart
injected
rate of 120, associated with extreme
the drug into an artery instead of a vein. Which restlessness. He is

complication is the nurse most likely to expect? very suspicious of the hospital environment and
actions
a. Infection
of healthcare workers. The nurse should
b. Cardiac dysrhythmias
confront this
c. Gangrene
patient on abuse of;
d. Thrombophlebitis
a. Marijuana
32. The nurse is assessing a 16-year-old patient
b. Cocaine
for drug
c. Barbiturates
abuse. The patient is incoherent. Because she
notes d. Tranquilizers
35. The nursing interventions most effective in nonsexual, socially accepted way is using the
working coping

with substance dependent patients are: mechanism of.

a. Firm and directive a. Projection

b. Instillation of values b. Conversion

c. Helpful and advisory c. Sublimation

d Subjective and non-judgmental d. Compensation

36. An adolescent patient has bloodshot eyes, a 39. "The reason I did not do well on the exam is
that I
voracious appetite (especially for junk foods),
and a dry was tired." This is an example of:

mouth. Which drug of abuse would the nurse a. Rationalization

most
b. Projection
likely suspect?
c. Compensation
a. Marijuana
d. Substitution
b. Amphetamines
40. An unattractive girl becomes a very good
c. Barbiturates student.

d. Anxiolytics This is an example of:

Situation: Defense mechanisms are unconscious a. displacement

intrapsychic process implemented to cope with b. Regression

anxiety.
c. Compensation
The use of some of these mechanisms is
d. Projection
healthy, while
41. A patient has been sharing a painful
she use of others is unhealthy.
experience of
37. A patient cries and curls in a fetal position
sexual abuse during his childhood. Suddenly he
refusing
stops
to move or talk. This is an example of:
and says, “l can't remember any more." The
a. Regression nurse

b. Suppression assesses his behavior as:

c. Conversion a. Stubbornness

d. Sublimation b. Forgetfulness

38. A person who expands sexual energy in a c. Blocking

d. Transference d. The client has a more realistic self-concept

42. The patient has a phobia about walking 45. The nurse is caring for a client with anorexia
down in
nervosa who is to be placed on behavioral
dark halls. The nurse recognizes that the coping
modification. Which is appropriate to include in
mechanism usually associated with phobia is: (he

a. Compensation nursing care plan?

b. Denial a. Remind the client frequently to eat all the

food served
c. Conversion
on the tray
d. Displacement
b. Increased phone calls allowed for client by
43. The patient is denying that he is an alcoholic
one per day
He
for each pound gained
states that his wife is an alcoholic. The defense
c. Include the family of the client in therapy
mechanism he is utilizing is: v
sessions two
a. Sublimation
times per week
b. Projection
d. Weigh the client each day at 6:00 am in
c. Suppression hospital gown

d. Displacement and slippers after she voids

Situation: Ms. Dwane, 17 years old, is admitted 46. A nursing intervention based on the
with behavior

anorexia nervosa. You have been assigned to sit modification model of treatment for anorexia
with her nervosa

while she eats her dinner. Ms. Dwane says "My would be:
primary
a. Role playing the client's interaction with her
nurse trusts me. I don't see why you don't." parents

44. Which observation of the client with b. Encouraging the client to vent her feelings
anorexia through

nervosa indicates the client is improving? exercise

a. The client eats meats in the dining room c. Providing a high-calorie, high protein diet
with
b. The client gains one pound per week
between meals snacks
c. The client attends group therapy sessions
d. Restricting the client's privileges until she
239 gains three
pounds experiencing increasing anxiety related to
recent
47. While admitting Ms. Dwane, the nurse
discovers a accident. She notes an increase in vital signs
from
bottle of pills that Ms. Dwane calls antacids. She
takes 130/70 to 160/30, pulse rate of 120, respiration
36. He
them because her stomach hurts. The nurse's
best is having difficulty communicating. His level of
anxiety
initial response is:
is:
a. Tell me more about your stomach pain
a. Mild
b. These do not look like antacids. I need to get
an order b. Moderate

for you to have them c. Severe

c. Tell me more about you drug use d. Panic

d. Some girls take pills to help them lose weight 51. The patient who suffers panic attacks is
prescribed
48. The primary objective in the treatment of
the a medication for short-term therapy. The nurse

hospitalized anorexic client is to: prepares to administer.

a. Decrease the client's anxiety a. Elavil

b. Increase the insight into the disorder b. Librium

c. Help the mother to gain control c. Xanax

d. Get the client to ea and gain weight d. Mellaril

49. Your best response for Ms. Dwane is: 52. In attempting to control a patient who is
suffering
a. I do trust you, but I was assigned to be with
you panic attack, the nursing priority is:

b. It sounds as if you are manipulating me a. Provide safely

c. Ok, when I return, you should have eaten b. Hold the patient
everything
c. Describe crisis in detail
d. Who is your primary nurse?
d. Demonstrate ADLs frequently
Situation: The nurse suspects a client is denying
53. Which assessment would the nurse most
his
likely find
feelings of anxiety
in a person who is suffering increased anxiety?
50. The nurse is monitoring a patient who is
a. Increasing BP, increasing heart rate and action should the nurse take next?
respirations
a. Reassure the client that someone will help
b. Decreasing BP, heart rate and respirations him soon

c. Increased BP and decreased respirations b. Assess the client's insurance coverage

d. Increased respirations and decreased heart c. Find out more about what is happening to the
rate client

54. A patient who suffers an acute anxiety d. Call the client's family to come and provide
disorder support

approaches the nurse and while clutching at his 57. Mr. Juan is admitted for panic attack. He
shirt frequently

states "I think I'm having a heart attack." The experiences shortness of breath, palpitations,
priority nausea,

nursing action is: diaphoresis, and terror. What should the nurse
include
a. Reassure him he is OK
in the care plan for Mr. Juan? When he is
b. Take vital signs stat
shaving a
c. Administer Valium IM
panic attack?
d. Administer Xanax PO
a. Calm reassurance, deep breathing and
55. In teaching stress management, the goal of medications as
therapy
ordered
is to:
b. Teach Mr. Juan problem solving in relation to
240 his

a. Get rid of the major stressor anxiety

b. Change lifestyle completely c. Explain the physiologic responses of anxiety

c. Modify responses to stress d. Explore alternate methods for dealing with

the cause
d. Learn new ways of thinking
of his anxiety
56. Another client walks in to the mental health
58. Ms. Wendy is pacing about the unit and
outpatient center and States, "I've had it. I can't wringing
go on
his hands. She is breathing rapidly and
any longer. You've got to help me. "The nurse complains of
asks the
palpitations and nausea, and she has difficulty
client to be seated in a private interview room. focusing
Which
on what the nurse is saying. She says she is a. Assign someone to watch Mr. Pat until he is
having a calm

heart attack but refuses to rest. The nurse b. Ask Mr. Pat to sit down and orient him to the
would nurse's

interpret her level of anxiety as: name and the need for information

a. Mild c. Check Mr. Pat's vital signs, ask him about

allergies, and
b. Moderate
call the physician for sedation
c. Severe
d. Explain the importance of accurate
d. Panic
assessment data
59. When assessing this client, the nurse must
to Mr. Pat .
be
61. If Raul will say "I'm so afraid! Where I am?
particularly alert to:
Where is
a. Restlessness
my family'?" How should the nurse respond?
b. Tapping of the feet
a. "You are in the hospital and you're safe here.
c. Wringing of the hands Your

d. His or her own anxiety level family will return at 10 o'clock, which is one
hour from
Situation: Raul aged 70 was recently admitted to
a now"

nursing home because of confusion, b. "You know were you are. You were admitted
disorientation, and here 2

negativistic behavior. Her family states that Raul weeks ago. Don’t worry your family will be back
is in soon."

good health. Raul asks you, "Where am I?" c. "I just told you that you're in the hospital and
your
60. Another patient, Mr. Pat, has been brought
to the family will be here soon."

psychiatric unit and is pacing up and down the d. "The name of the hospital is on the sigh over
hall. The the door.

nurse is to admit him to the hospital. To Let's go read it again."

establish a
62. Raul has had difficulty sleeping since
nurse-client relationship, which approach admission.
should the
Which of the following would be the best
nurse try first? intervention?
a. Provide him with glass of warm milk department. He has been locked in his
apartment for the
b. Ask the physician for a mild sedative
past 3 days, making frequent calls to the police
c. Do not allow Raul to take naps during the day
and
d. Ask him family what they prefer
emergency services and stating that people are
63. Which activity would you engage in Raul at trying to
the
kill him.
nursing home?
66. A client on an inpatient psychiatric unit
a. Reminiscence groups refuses to

b. Sing-along eat and states that the staff is poisoning her

food.
d. Discussion groups
Which action should the nurse include in the
c. Exercise class client's
64. Which of the following would be an care plan?
appropriate
a. Explain to the client that the staff can be
strategy in reorienting a confused client to trusted
where her
b. Show the client that others eat the food
room is? without harm
a. Place pictures of her family on the bedside c. Offer the client factory-sealed foods and
stand beverages
b. Put her name in large letters on her forehead d. Institute behavioral modification with
c. Remind the client where her room is privileges

241 dependent on intake

d. Let the other residents know where the 67. The client tells the nurse that he can't eat
client’s room because

is his food has been poisoned. This statement is an

65. The best response for the nurse to make is: indication of which of the following?

a. Don't worry, Raul. You're safe here a. Paranoia

b. Where do you think you are? b. Delusion of persecution

c. What did your family tell you? c. Hallucination

d. You're at the community nursing home d. Illusion

Situation: The police bring a patient to the 68. The client on antipsychotic drugs begins to
emergency exhibit
signs and symptoms of which disorder? a. Loose of associations

a. Akinesia b. Delusion of reference

b. Pseudoparkinsonism c. Paranoid speech

c. Tardive dyskinesia d. Flight of ideas

d. Oculogyric crisis 72. What type of delusions is the patient

experiencing?
69. During a patient history, a patient state that
she a. Persecutory

used to believe she was God. But she knows this b. Grandiose
isn't
c. Jealous
true. Which of the following would be your best
d. Somatic
response?"
Situation: Helen, with a diagnosis of
a. "Does it bother you that you used to believe disorganized
that
schizophrenia is creating a disturbance in the
about yourself?" day room.

b. "Your thoughts are now more appropriate" She is yelling and pointing at another patient,
accusing
c. "Many people have these delusions."
him to stealing her purse. Several patients are in
d. "What caused you to think you were God?"
the day
70. The nurse is caring for a client who is
room when this incident starts.
experiencing
73. The nurse is preparing to care for a client
auditory hallucination. What would be most
diagnosed
crucial for
with catatonic schizophrenia. In anticipation of
the nurse to assess?
this
a. Possible hearing impairment
client's arrival, what should the nurse do?
b. Family history of psychosis
a. Notify security
c. Content of the hallucination
b. Prepare a magnesium sulfate drip
d. Otitis media
c. Place a specialty mattress overlay on the bed
71. A patient with schizophrenia reports that
d. Communicable the client's nothing-by-mouth
the
status to
newscaster on the radio has a divine message
the dietary department
especially for her. You would interpret this as
74. The nurse is caring for a client whom she
indicating. suspects is
paranoid. How would the nurse confirm this 77. A 23-year-old patient is receiving
antipsychotic
assessment?
medication to treat his schizophrenia. He's
a. indirect questioning
experiencing some motor abnormalities called
b. Direct questioning
extrapyramidal effects. Which of the following
c. Les-ad-in-sentences
extrapyramidal effects occurs most frequently in
d. Open-ended sentences
younger make patients?
242
a. Akathisia
75. Which of the following is an example of a
negative b. Akinesia

symptom of schizophrenia? c. Dystonia

a. Delusions d. Pseudoparkinsonism

b. Disorganized speech 78. Which of the following should you do next?

c. Flat affect a. Firmly redirect the patient to her room to

discuss the
d. Catatonic behavior
incident
76. The patient tells you that a "voice" keeps
laughing b. Call the assistance and place the patient in
locked
at him and tells him he must crawl on his hands
and seclusion

knees like a dog. Which of the following would c. Help the patient look for her purse
be the
d. Don't intervene - the patients need a little bit
most appropriate response? of room

a. "They are imaginary voices and we're here to in which to work out differences
make
Situation: John is admitted with a diagnosis of
them go, away." paranoid

b. "If it makes you feel better, do what the schizophrenia.

voices tell
79. You're reaching a community group about
you."
schizophrenia disorders. You explain the
c. "The voices can't hurt you here in the different types
hospital"
of schizophrenia and delusional disorders. You
d. "Even though I don't hear the voices, I also
understand that
explain that, unlike schizophrenia, delusional
you do." disorders:
a. Tend to begin in early childhood patient with schizophrenia, you should be sure
to
b. Affect more men than women
inform them about which of the following
c. Affect more women than men
characteristics of the disorder?
d. May be related to certain medical conditionsa
a. Relapse can be prevented if the patient takes
80. A patient with schizophrenia (catatonic type)
is medication

mute and can't perform activities of daily living. b. Support is available to help family members
The meet their

patient stares out the window for hours. What is own needs
your
c. Improvement should occur if the patient's
first priority in this situation?
environment is carefully maintained
a. Assist the patient with feeding
d. Stressful situations in the family in the family
b. Assist the patient with showering and tasks can
for
precipitate a relapse in the patient
hygiene
83. While caring for John, the nurse knows that
c. Reassure the patient about safely, and try to John
orient
may have trouble with:
him to his surroundings
a. Staff who are cheerful
d. Encourage, socialization with peers, and
b. Simple direct sentences
provide a
c. Multiple commands
stimulating environment
d. Violent behaviors
81. Which of the following would you suspect in
a 84 Which nursing diagnosis is most likely to be
patient receiving Chlorpromazine (Thorazine) associated with a person who has a medical
who diagnosis
complains of a sore throat and has a fever? of schizophrenia, paranoid type?
a. An allergic reaction a. Fear of being along
b. Jaundice b. Perceptual disturbance related to delusion of
c. Dyskinesia 243
d. Agranulocytosis persecution
82. While providing information for the family of c. Social isolation related to impaired ability to
a trust
d. Impaired social skills related to inadequate 88. It is an, emotional response to a consciously
developed
recognized threat.
superego
a. Fear
85. Which of the following behaviors can the
b. Anxiety
nurse
c. Antisocial
anticipate with this client?
d. Schizoid
a. Negative cognitive distortions
89. All but one is an example of situational
b. Impaired psychomotor development
crisis:
c. Delusions of grandeur and hyperactivity
a. Menstruation
d. Alteration of appetite and sleep pattern
b. Role changes
Situation: A client is admitted to the hospital.
c. Rape
During the
d. Divorce
assessment the nurse notes that the client has
not slept 90. What would be the highest priority in
formulating a
for a week. The client is talking rapidly, and
throwing his nursing care plan for this client?
arms around randomly. a. Isolate the client until he or she adjusts to
'the
86. When writing an assessment of a client with
mood hospital
disorder, the nurse should specify: b. Provide nutritious food and a quite place to
rest
a. How flat the client's affect
c. Protect the client and others from harm
b. How suicidal the client is
d. Create a structured environment
c. How grandiose the client is
Situation: Wendell, 24 year-old student with a
d. How the client is behaving
primary
87. It is an apprehensive anticipation of an
sleep disorder, is unable to initiate maintenance
unknown
of
danger:
sleep. Primary sleep disorders may be
a. Fear categorized as

b. Anxiety dyssomnias or parasomnias.

c. Antisocial 91. The nurse is caring for a client who

complains; of
d. Schizoid
fat?gue, inability to concentrate, and a. Eating unlimited spicy foods, and limiting
palpitations. The caffeine and

client stales that she has been experiencing alcohol

these
b. Exercising 1 hour before bedtime to promote
symptoms for the past 6 months. Which factor sleep
in the
c. Importance of steeping whenever the client
client’s history has most likely contributed tires
to.these
d. Drinking warm milk before bed to induce
symptoms? sleep

a. History of recent fever 94. Examples of dyssomnia includes:

b. Shift work a. Insomnia, hypersomnia, narcolepsy

c. Hyperthyroidism b. Sleepwalking, nightmare

d. Fear c. Snoring while sleeping

92. If Wendell complains of experiencing an d. Non-rapid eye movement

overwhelming urge to sleep and states that he's Situation: The following questions refer to
been therapeutic

falling asleep while studying and reports that communication.

these
244
episodes occur about 5 times daily Wendell is
95. When preparing to conduct group therapy,
most
the
likely experiencing which sleep disorder?
nurse keeps in mind that the optimal number of
a. Breathing-related sleep disorder clients

b. Narcolepsy in a group would be:

c. Primary hypersomnia a. 6 to 8

d. Circadian rhythm disorder b. 10 to 12

93. The nurse is preparing a teaching plan for a c. 3 to 5

client
d. Unlimited
diagnosed with primary insomnia. Which of the
96. What occurs during the working phase of
following teaching topics should be included in the-nurseclient
the
relationship?
plan?
a. The nurse assesses the client's needs and
develops a
plan of care 98. A client on the unit tells the nurse that his
wife's
b. The nurse and client together evaluate and
modify the nagging really gets on his nerves. He asks the
nurse if
goals of the relationship
she will talk with his wife about nagging during
c. The nurse and client discuss their feelings
their
about
family session tomorrow afternoon. Which of
terminating the relationship
the
d. The nurse and client explore each other's
following would be most therapeutic response
expectations
to
of-the relationship
client?
97. A 42 year-old homemaker arrives at the
a. "Tell me more specifically about her
emergency
complaints"
department with uncomfortable crying and
b. "Can you think why she might nag you so
anxiety.
much?"
Her husband of 17 years has recently asked her
c. "I'll help you think about how to bring this up
for a
yourself
divorce. The patient is sitting in a chair, rocking
tomorrow."
back
d. "Why do you want me to initiate this
and forth. Which is the best response for the
discussion in
nurse to
tomorrow's session rather than you?"
make?
99. The nurse is working with a client who has
a. "You must stop crying so that we can discuss
just
your
stimulated her anger by using a condescending
feelings about the divorce."
tone of
b. "Once you find a job, you will feel much
voice. Which of the following responses by the
better and
nurse
more secure."
would be the most therapeutic?
c. "I can see how upset you are. Let's sit in the
a. "I feel angry when I hear that tone of voice"
office so
b. "You make me so angry when you talked to
that we can talk about how you're feeling."
me that
d. "Once you have a lawyer looking out for your
way."
interests, you will feel better."
c. "Are you trying to make me angry?"
d. "Why do you use that condescending tone of 1. If a patient is very resistant in taking
voice responsibility of

with me?" his action and asks, "Can you just give me some

100. A 35 year-old client tells the nurse that he medication?" the best response is:
never
a. "The medication has too many side effects."
disagrees with anyone and that he has loved
b. You don't want to take medication, do you?"
everyone
c. Medication is given only as a East resort."
he's ever known. What would be the nurse's
best d. "There is no medication specific for your
condition."
response to this client?
2. The patient asks the nurse, "What is this
a. "How do you manage to do that?"
therapy for
b. "That's hard to believe. Most people couldn't
anyway. I just don't understand it." the best
to that."
reply is:
c. "What do you do with your feelings of
a. "It keeps you from being put on medications."
dissatisfaction
b. "It helps you to change others in the family."
or anger?"
c. "The purpose of therapy is to help you
d. "How did you come to adopt such a way of
change."
life?"
d. "No one but professionals can really
245
understand
Nursing Practice Test V
3. For patient in group therapy, the goal is:
Situation: The nurse is interviewing a handsome
a. Exchanging information and ideas
man. He
b. Developing insight by relating to others
is intelligent and very charming. When asked
about his c. Learning that everyone has problems
family, he states he has been married four d. All of the above
times. He says
4. In planning care for the patient with a
three of those marriages were "shotgun" personality
weddings. He
disorder, the nurse realizes that this patient will
states he never really loved any of his wives. He most
doesn't
likely:
know much about his three children. "I've lost
track," he a. Not need long-term therapy

states. b. Not require medication

c. Require anti-anxiety medication

d. Resist any change in behavior is 2.1 meq/L. The nurse evaluates this level as:

5. The person with an antisocial personality is a. Therapeutic

participating in therapy while a patient at a b. Below therapeutic

psychiatric
c. Potentially dangerous
hospital. The nurse’s expectations are that he
d. Fatally toxic
will:
9. The priority in working with patient a thought
a. Make a complete recovery
disorder is:
b. Make significant changes
a. Get him to understand what you're saying
c. Begin the slow process of change
b. Get him to do his ADLs
d. Make few changes, if any
c. Reorient him to reality
6. One of the reasons that persons with
antisocial d. Administer antipsychotic medications
personalities may marry repeatedly or get into 10. The most recent Lithium level on bipolar
trouble patient
with legal authorities is: indicates a drop non-therapeutic level. What
associated
a. They usually just don't care
behavior does the nurse assess?
b. They are borderline mentally retarded
a. Ataxia
c. They are too psychotic to see what’s going on
b. Confusion
d. They do not learn from past mistakes
c. Hyperactivity
7. The nurse recognizes that these are traits of:
d. Lethargy
a. Bipolar disorder
11. Adequate fluid intake for a patient on
b. Alcoholic personality
Lithium is:
c. Antisocial personality
a. 1,000 ml per day
d. Borderline personality
b. 1,500 ml per day
Situation: The patient with bipolar disorder is
c. 2,000 ml per day
pacing
d. 3,600 ml per day
continuously and is skipping meals.
12. The physician orders Lithium carbonate for
8. Blood levels are drawn on the patient who
the
has been
bipolar patient. The nurse is aware that:
taking Lithium for about six months. The
present level 246
a. The patient should be put on a special diet d. "To gather legal evidence that is required."

b. The medication should be given only at night 16. In providing support therapy, the nurse
explains
c. A salt-free should be provided for the patient
that rape has nothing to do with sexual desires
d. The drug level should be monitored regularly
or
13. The nursing plan should emphasize:
heeds. The two most common elements in rape
a. Offering him finger foods are:

b. Telling him he must sit down and eat a. Guilt and shame

c. Serving food in his room and staying with him b. Shame and jealousy

d. Telling him to order fast food of he wants to c. Embarrassment and envy

eat
d. Power and anger
Situation: Anna, 25 years old was raped six
17. The rape victim will not talk, is withdrawn
months ago
and
states, "I just can't seem to get over this. My
depressed. The defensive mechanism being
husband
used is:
and I don't even have sex anymore. What can I
a. Rationalization
do?"
b. Denial
14. Supportive therapy to the rape victim is
directed at c. Repression

overwhelming feeling that the victim d. Regression

experiences just
18. The composite picture of rape victim reveals
after the rape has occurred? that

a. Guilt most victimized women are:

b. Rage a. Secretaries

c. Damaged b. Elderly

d. Despair c. Students

15. Anna asks, "Why do I need to have pelvic d. Professionals

exam?"
19. The best intervention is:
The nurse explains:
a. Tell her it just takes a long time
a. "To make sure you're not pregnant."
b. Ask her if her husband is angry
b. "To see if you got an infection."
c. Refer her and her husband to sex therapy
c. "To make sure you were really raped."
d. Tell her she is suffering PTSD
Situation: Obsessions are recurring thoughts exhibit?
that
a. Inability to make decisions
become prevalent in the consciousness and may
b. Spontaneous playfulness
be
c. Inability to alter plans
considered as senseless or repulsive white
compulsion d. Insistence that things be done his way
are the repetitive acts that follow obsessive 23. The patient will not be able to stop her
thoughts. compulsive
20. To understand the meaning of the cleaning washing routines until she:
rituals,
a. Acquires more superego
the nurse must realize:
b. Recognizes the behavior is unrealistic
a. The patient cannot help herself
c. No longer needs them to manage her feelings
b. The patient cannot change of
c. Rituals relieve intense anxiety anxiety
d. Medications cannot help 247
21. Upon admission to the hospital the patient d. Regains contact with reality
increases the ritual behavior at bedtime. She 24. A 48-year-old female patient is brought to
cannot the
sleep. The treatment plan should include: hospital by her husband because her behavior is
a. Recommending a sedative medication blocking her ability to meet her family's needs.
She has
b. Modifying the routine to diminish her
bedtime anxiety uncontrollable and constant desire to scrub her
hands,
c. Reminding her to perform rituals early in the
evening the walls, floors and sofa. She keeps repeating,"
d. Limit the amount of time she spends washing Everything is dirty." This is an example of:
her
a. Compulsion
hands
b. Obsession
22. A patient has been diagnosed with a
personality c. Delusion

disorder with .compulsive traits. Of the d. Hallucination

following 25. The female patient is preoccupied with rules
behavior's, which one would you expect the and
patient to
regulations. She becomes upset if others do not but I can’t help it:'', this statement indicates that
follow the

her lead and adhere to the rules exactly. This is patient does not recognize:
a
a. What she is doing
characteristic of which of the following
b. Why she is cleaning
personality?
c. Her level of anxiety
a. Compulsive
d. Need for medication
b. Borderline
Situation: Substance, abuse is a common,
c. Antisocial
growing health
d. Schizoid
problem in this country.
26. In planning care focused on decreasing the
29. The nurse is monitoring a drug abuser who
patient's
states
anxiety, what plan should the nurse have in
he was given cocaine and heroine that war cut
regards to
with
the rituals?
cornstarch or some other kind of powder. He
a. Encourage the routines states, "It

b. Ignore rituals was really bad stuff." Which complication is

most
c. Work with her to develop limits of behavior
threatening to this patient?
d. Restrain her from the rituals
a. Endocarditis
27. After the patient entered the hospital she
began to b. Gangrene

increase her ritualistic hand washing at bedtime c. Pulmonary abscess

and
d. Pulmonary embolism
could; not sleep. The nurse plans care around
30. The chronic drug abuser is suffering
the fact
lymphedema in
that this patient needs:
all extremities, but particularly in the arm where
a. A substitute activity to relieve anxiety the

b. Medication for sleeping drug was obviously injected. There is severe

c. Anti-anxiety medication such as Xanax obstruction of veins and lymphatics. The nurse
suspects
d. More scheduled activities during the day
the patient used:
28. The patient states, "I know all this scrubbing
is silly a. A dull, contaminated needle
b. A needle contaminated with AIDS d. "It depends upon how well the Demerol
works."
c. Contaminated drugs
248
d. Cocaine mixed with uncut heroin
34. The patient has a blood pressure of
31. The nurse is assessing a heroin user who
180/100, heart
injected
rate of 120, associated with extreme
the drug into an artery instead of a vein. Which
restlessness. He is
complication is the nurse most likely to expect?
very suspicious of the hospital environment and
a. Infection actions

b. Cardiac dysrhythmias of healthcare workers. The nurse should

confront this
c. Gangrene
patient on abuse of;
d. Thrombophlebitis
a. Marijuana
32. The nurse is assessing a 16-year-old patient
for drug b. Cocaine

abuse. The patient is incoherent. Because she c. Barbiturates

notes
d. Tranquilizers
irritation of eyes, nose and mouth, she suspects
35. The nursing interventions most effective in
inhalants. Which sign is most indicative of working
inhalant
with substance dependent patients are:
abuse?
a. Firm and directive
a. Vomiting
b. Instillation of values
b. Bad breath
c. Helpful and advisory
c. Bad trip
d Subjective and non-judgmental
d. Sudden fear
36. An adolescent patient has bloodshot eyes, a
33. An impaired nurse has been admitted for
voracious appetite (especially for junk foods),
treatment
and a dry
of Demerol addiction. She asks, "When will the
mouth. Which drug of abuse would the nurse
withdrawal begin?" the best response is: most

a. "It varies, with each individual." likely suspect?

b. "There is no way to tell." a. Marijuana

c. "Withdrawal begins soon after the last dose." b. Amphetamines

c. Barbiturates
d. Anxiolytics This is an example of:

Situation: Defense mechanisms are unconscious a. displacement

intrapsychic process implemented to cope with b. Regression

anxiety.
c. Compensation
The use of some of these mechanisms is
d. Projection
healthy, while
41. A patient has been sharing a painful
she use of others is unhealthy.
experience of
37. A patient cries and curls in a fetal position
sexual abuse during his childhood. Suddenly he
refusing
stops
to move or talk. This is an example of:
and says, “l can't remember any more." The
a. Regression nurse

b. Suppression assesses his behavior as:

c. Conversion a. Stubbornness

d. Sublimation b. Forgetfulness

38. A person who expands sexual energy in a c. Blocking

nonsexual, socially accepted way is using the d. Transference

coping
42. The patient has a phobia about walking
mechanism of. down in

a. Projection dark halls. The nurse recognizes that the coping

b. Conversion mechanism usually associated with phobia is:

c. Sublimation a. Compensation

d. Compensation b. Denial

39. "The reason I did not do well on the exam is c. Conversion

that I
d. Displacement
was tired." This is an example of:
43. The patient is denying that he is an alcoholic
a. Rationalization He

b. Projection states that his wife is an alcoholic. The defense

c. Compensation mechanism he is utilizing is: v

d. Substitution a. Sublimation

40. An unattractive girl becomes a very good b. Projection

student.
c. Suppression d. Weigh the client each day at 6:00 am in
hospital gown
d. Displacement
and slippers after she voids
Situation: Ms. Dwane, 17 years old, is admitted
with 46. A nursing intervention based on the
behavior
anorexia nervosa. You have been assigned to sit
with her modification model of treatment for anorexia
nervosa
while she eats her dinner. Ms. Dwane says "My
primary would be:

nurse trusts me. I don't see why you don't." a. Role playing the client's interaction with her
parents
44. Which observation of the client with
anorexia b. Encouraging the client to vent her feelings
through
nervosa indicates the client is improving?
exercise
a. The client eats meats in the dining room
c. Providing a high-calorie, high protein diet
b. The client gains one pound per week
with
c. The client attends group therapy sessions
between meals snacks
249
d. Restricting the client's privileges until she
d. The client has a more realistic self-concept gains three

45. The nurse is caring for a client with anorexia pounds

nervosa who is to be placed on behavioral 47. While admitting Ms. Dwane, the nurse
discovers a
modification. Which is appropriate to include in
(he bottle of pills that Ms. Dwane calls antacids. She
takes
nursing care plan?
them because her stomach hurts. The nurse's
a. Remind the client frequently to eat all the best
food served
initial response is:
on the tray
a. Tell me more about your stomach pain
b. Increased phone calls allowed for client by
one per day b. These do not look like antacids. I need to get
an order
for each pound gained
for you to have them
c. Include the family of the client in therapy
sessions two c. Tell me more about you drug use

times per week d. Some girls take pills to help them lose weight
48. The primary objective in the treatment of 51. The patient who suffers panic attacks is
the prescribed

hospitalized anorexic client is to: a medication for short-term therapy. The nurse

a. Decrease the client's anxiety prepares to administer.

b. Increase the insight into the disorder a. Elavil

c. Help the mother to gain control b. Librium

d. Get the client to ea and gain weight c. Xanax

49. Your best response for Ms. Dwane is: d. Mellaril

a. I do trust you, but I was assigned to be with 52. In attempting to control a patient who is
you suffering

b. It sounds as if you are manipulating me panic attack, the nursing priority is:

c. Ok, when I return, you should have eaten a. Provide safely

everything
b. Hold the patient
d. Who is your primary nurse?
c. Describe crisis in detail
Situation: The nurse suspects a client is denying
d. Demonstrate ADLs frequently
his
53. Which assessment would the nurse most
feelings of anxiety
likely find
50. The nurse is monitoring a patient who is
in a person who is suffering increased anxiety?
experiencing increasing anxiety related to
a. Increasing BP, increasing heart rate and
recent
respirations
accident. She notes an increase in vital signs
b. Decreasing BP, heart rate and respirations
from
c. Increased BP and decreased respirations
130/70 to 160/30, pulse rate of 120, respiration
36. He d. Increased respirations and decreased heart
rate
is having difficulty communicating. His level of
anxiety 54. A patient who suffers an acute anxiety
disorder
is:
approaches the nurse and while clutching at his
a. Mild
shirt
b. Moderate
states "I think I'm having a heart attack." The
c. Severe priority

d. Panic nursing action is:

a. Reassure him he is OK
b. Take vital signs stat in the care plan for Mr. Juan? When he is
shaving a
c. Administer Valium IM
panic attack?
d. Administer Xanax PO
a. Calm reassurance, deep breathing and
55. In teaching stress management, the goal of
medications as
therapy
ordered
is to:
b. Teach Mr. Juan problem solving in relation to
250
his
a. Get rid of the major stressor
anxiety
b. Change lifestyle completely
c. Explain the physiologic responses of anxiety
c. Modify responses to stress
d. Explore alternate methods for dealing with
d. Learn new ways of thinking the cause

56. Another client walks in to the mental health of his anxiety

outpatient center and States, "I've had it. I can't 58. Ms. Wendy is pacing about the unit and
go on wringing

any longer. You've got to help me. "The nurse his hands. She is breathing rapidly and
asks the complains of

client to be seated in a private interview room. palpitations and nausea, and she has difficulty
Which focusing

action should the nurse take next? on what the nurse is saying. She says she is
having a
a. Reassure the client that someone will help
him soon heart attack but refuses to rest. The nurse
would
b. Assess the client's insurance coverage
interpret her level of anxiety as:
c. Find out more about what is happening to the
client a. Mild

d. Call the client's family to come and provide b. Moderate

support
c. Severe
57. Mr. Juan is admitted for panic attack. He
d. Panic
frequently
59. When assessing this client, the nurse must
experiences shortness of breath, palpitations,
be
nausea,
particularly alert to:
diaphoresis, and terror. What should the nurse
include a. Restlessness
b. Tapping of the feet a. "You are in the hospital and you're safe here.
Your
c. Wringing of the hands
family will return at 10 o'clock, which is one
d. His or her own anxiety level
hour from
Situation: Raul aged 70 was recently admitted to
now"
a
b. "You know were you are. You were admitted
nursing home because of confusion,
here 2
disorientation, and
weeks ago. Don’t worry your family will be back
negativistic behavior. Her family states that Raul
soon."
is in
c. "I just told you that you're in the hospital and
good health. Raul asks you, "Where am I?"
your
60. Another patient, Mr. Pat, has been brought
family will be here soon."
to the
d. "The name of the hospital is on the sigh over
psychiatric unit and is pacing up and down the
the door.
hall. The
Let's go read it again."
nurse is to admit him to the hospital. To
establish a 62. Raul has had difficulty sleeping since
admission.
nurse-client relationship, which approach
should the Which of the following would be the best
intervention?
nurse try first?
a. Provide him with glass of warm milk
a. Assign someone to watch Mr. Pat until he is
calm b. Ask the physician for a mild sedative

b. Ask Mr. Pat to sit down and orient him to the c. Do not allow Raul to take naps during the day
nurse's
d. Ask him family what they prefer
name and the need for information
63. Which activity would you engage in Raul at
c. Check Mr. Pat's vital signs, ask him about the
allergies, and
nursing home?
call the physician for sedation
a. Reminiscence groups
d. Explain the importance of accurate
b. Sing-along
assessment data
d. Discussion groups
to Mr. Pat .
c. Exercise class
61. If Raul will say "I'm so afraid! Where I am?
Where is 64. Which of the following would be an
appropriate
my family'?" How should the nurse respond?
strategy in reorienting a confused client to a. Explain to the client that the staff can be
where her trusted

room is? b. Show the client that others eat the food
without harm
a. Place pictures of her family on the bedside
stand c. Offer the client factory-sealed foods and
beverages
b. Put her name in large letters on her forehead
d. Institute behavioral modification with
c. Remind the client where her room is
privileges
251
dependent on intake
d. Let the other residents know where the
67. The client tells the nurse that he can't eat
client’s room
because
is
his food has been poisoned. This statement is an
65. The best response for the nurse to make is:
indication of which of the following?
a. Don't worry, Raul. You're safe here
a. Paranoia
b. Where do you think you are?
b. Delusion of persecution
c. What did your family tell you?
c. Hallucination
d. You're at the community nursing home
d. Illusion
Situation: The police bring a patient to the
68. The client on antipsychotic drugs begins to
emergency
exhibit
department. He has been locked in his
signs and symptoms of which disorder?
apartment for the
a. Akinesia
past 3 days, making frequent calls to the police
and b. Pseudoparkinsonism

emergency services and stating that people are c. Tardive dyskinesia

trying to
d. Oculogyric crisis
kill him.
69. During a patient history, a patient state that
66. A client on an inpatient psychiatric unit she
refuses to
used to believe she was God. But she knows this
eat and states that the staff is poisoning her isn't
food.
true. Which of the following would be your best
Which action should the nurse include in the
response?"
client's
a. "Does it bother you that you used to believe
care plan?
that
about yourself?" schizophrenia is creating a disturbance in the
day room.
b. "Your thoughts are now more appropriate"
She is yelling and pointing at another patient,
c. "Many people have these delusions."
accusing
d. "What caused you to think you were God?"
him to stealing her purse. Several patients are in
70. The nurse is caring for a client who is the day
experiencing
room when this incident starts.
auditory hallucination. What would be most
73. The nurse is preparing to care for a client
crucial for
diagnosed
the nurse to assess?
with catatonic schizophrenia. In anticipation of
a. Possible hearing impairment this

b. Family history of psychosis client's arrival, what should the nurse do?

c. Content of the hallucination a. Notify security

d. Otitis media b. Prepare a magnesium sulfate drip

71. A patient with schizophrenia reports that c. Place a specialty mattress overlay on the bed
the
d. Communicable the client's nothing-by-mouth
newscaster on the radio has a divine message status to

especially for her. You would interpret this as the dietary department

indicating. 74. The nurse is caring for a client whom she

suspects is
a. Loose of associations
paranoid. How would the nurse confirm this
b. Delusion of reference
assessment?
c. Paranoid speech
a. indirect questioning
d. Flight of ideas
b. Direct questioning
72. What type of delusions is the patient
experiencing? c. Les-ad-in-sentences

a. Persecutory d. Open-ended sentences

b. Grandiose 252

c. Jealous 75. Which of the following is an example of a

negative
d. Somatic
symptom of schizophrenia?
Situation: Helen, with a diagnosis of
disorganized a. Delusions

b. Disorganized speech
c. Flat affect a. Firmly redirect the patient to her room to
discuss the
d. Catatonic behavior
incident
76. The patient tells you that a "voice" keeps
laughing b. Call the assistance and place the patient in
locked
at him and tells him he must crawl on his hands
and seclusion

knees like a dog. Which of the following would c. Help the patient look for her purse
be the
d. Don't intervene - the patients need a little bit
most appropriate response? of room

a. "They are imaginary voices and we're here to in which to work out differences
make
Situation: John is admitted with a diagnosis of
them go, away." paranoid

b. "If it makes you feel better, do what the schizophrenia.

voices tell
79. You're reaching a community group about
you."
schizophrenia disorders. You explain the
c. "The voices can't hurt you here in the different types
hospital"
of schizophrenia and delusional disorders. You
d. "Even though I don't hear the voices, I also
understand that
explain that, unlike schizophrenia, delusional
you do." disorders:

77. A 23-year-old patient is receiving a. Tend to begin in early childhood

antipsychotic
b. Affect more men than women
medication to treat his schizophrenia. He's
c. Affect more women than men
experiencing some motor abnormalities called
d. May be related to certain medical conditionsa
extrapyramidal effects. Which of the following
80. A patient with schizophrenia (catatonic type)
extrapyramidal effects occurs most frequently in is

younger make patients? mute and can't perform activities of daily living.
The
a. Akathisia
patient stares out the window for hours. What is
b. Akinesia
your
c. Dystonia
first priority in this situation?
d. Pseudoparkinsonism
a. Assist the patient with feeding
78. Which of the following should you do next?
b. Assist the patient with showering and tasks d. Stressful situations in the family in the family
for can

hygiene precipitate a relapse in the patient

c. Reassure the patient about safely, and try to 83. While caring for John, the nurse knows that
orient John

him to his surroundings may have trouble with:

d. Encourage, socialization with peers, and a. Staff who are cheerful

provide a
b. Simple direct sentences
stimulating environment
c. Multiple commands
81. Which of the following would you suspect in
d. Violent behaviors
a
84 Which nursing diagnosis is most likely to be
patient receiving Chlorpromazine (Thorazine)
who associated with a person who has a medical
diagnosis
complains of a sore throat and has a fever?
of schizophrenia, paranoid type?
a. An allergic reaction
a. Fear of being along
b. Jaundice
b. Perceptual disturbance related to delusion of
c. Dyskinesia
253
d. Agranulocytosis
persecution
82. While providing information for the family of
a c. Social isolation related to impaired ability to
trust
patient with schizophrenia, you should be sure
to d. Impaired social skills related to inadequate
developed
inform them about which of the following
superego
characteristics of the disorder?
85. Which of the following behaviors can the
a. Relapse can be prevented if the patient takes
nurse
medication
anticipate with this client?
b. Support is available to help family members
a. Negative cognitive distortions
meet
b. Impaired psychomotor development
their own needs
c. Delusions of grandeur and hyperactivity
c. Improvement should occur if the patient's
d. Alteration of appetite and sleep pattern
environment is carefully maintained
Situation: A client is admitted to the hospital. c. Rape
During the
d. Divorce
assessment the nurse notes that the client has
90. What would be the highest priority in
not slept
formulating a
for a week. The client is talking rapidly, and
nursing care plan for this client?
throwing his
a. Isolate the client until he or she adjusts to
arms around randomly.
'the
86. When writing an assessment of a client with
hospital
mood
b. Provide nutritious food and a quite place to
disorder, the nurse should specify:
rest
a. How flat the client's affect
c. Protect the client and others from harm
b. How suicidal the client is
d. Create a structured environment
c. How grandiose the client is
Situation: Wendell, 24 year-old student with a
d. How the client is behaving primary

87. It is an apprehensive anticipation of an sleep disorder, is unable to initiate maintenance

unknown of

danger: sleep. Primary sleep disorders may be

categorized as
a. Fear
dyssomnias or parasomnias.
b. Anxiety
91. The nurse is caring for a client who
c. Antisocial
complains; of
d. Schizoid
fat?gue, inability to concentrate, and
88. It is an, emotional response to a consciously palpitations. The

recognized threat. client stales that she has been experiencing

these
a. Fear
symptoms for the past 6 months. Which factor
b. Anxiety in the
c. Antisocial client’s history has most likely contributed
d. Schizoid to.these

89. All but one is an example of situational symptoms?

crisis: a. History of recent fever
a. Menstruation b. Shift work
b. Role changes c. Hyperthyroidism
d. Fear d. Non-rapid eye movement

92. If Wendell complains of experiencing an Situation: The following questions refer to

therapeutic
overwhelming urge to sleep and states that he's
been communication.

falling asleep while studying and reports that 254

these
95. When preparing to conduct group therapy,
episodes occur about 5 times daily Wendell is the
most
nurse keeps in mind that the optimal number of
likely experiencing which sleep disorder? clients

a. Breathing-related sleep disorder in a group would be:

b. Narcolepsy a. 6 to 8

c. Primary hypersomnia b. 10 to 12

d. Circadian rhythm disorder c. 3 to 5

93. The nurse is preparing a teaching plan for a d. Unlimited

client
96. What occurs during the working phase of
diagnosed with primary insomnia. Which of the the-nurseclient

following teaching topics should be included in relationship?

the
a. The nurse assesses the client's needs and
plan? develops a

a. Eating unlimited spicy foods, and limiting plan of care

caffeine and
b. The nurse and client together evaluate and
alcohol modify

b. Exercising 1 hour before bedtime to promote the goals of the relationship

sleep
c. The nurse and client discuss their feelings
c. Importance of steeping whenever the client about
tires
terminating the relationship
d. Drinking warm milk before bed to induce
d. The nurse and client explore each other's
sleep
expectations
94. Examples of dyssomnia includes:
of-the relationship
a. Insomnia, hypersomnia, narcolepsy
97. A 42 year-old homemaker arrives at the
b. Sleepwalking, nightmare emergency

c. Snoring while sleeping

department with uncomfortable crying and b. "Can you think why she might nag you so
anxiety. much?"

Her husband of 17 years has recently asked her c. "I'll help you think about how to bring this up
for a
yourself tomorrow."
divorce. The patient is sitting in a chair, rocking
d. "Why do you want me to initiate this
back
discussion in
and forth. Which is the best response for the
tomorrow's session rather than you?"
nurse to
99. The nurse is working with a client who has
make?
just
a. "You must stop crying so that we can discuss
stimulated her anger by using a condescending
your
tone of
feelings about the divorce."
voice. Which of the following responses by the
b. "Once you find a job, you will feel much nurse
better and
would be the most therapeutic?
more secure."
a. "I feel angry when I hear that tone of voice"
c. "I can see how upset you are. Let's sit in the
b. "You make me so angry when you talked to
office so
me that
that we can talk about how you're feeling."
way."
d. "Once you have a lawyer looking out for your
c. "Are you trying to make me angry?"
interests, you will feel better."
d. "Why do you use that condescending tone of
98. A client on the unit tells the nurse that his voice
wife's
with me?"
nagging really gets on his nerves. He asks the
100. A 35 year-old client tells the nurse that he
nurse if
never
she will talk with his wife about nagging during
disagrees with anyone and that he has loved
their
everyone
family session tomorrow afternoon. Which of
he's ever known. What would be the nurse's
the
best
following would be most therapeutic response
response to this client?
to
a. "How do you manage to do that?"
client?
b. "That's hard to believe. Most people couldn't
a. "Tell me more specifically about her
to that."
complaints"
c. "What do you do with your feelings of administering the medication, Nurse Trish
dissatisfaction
should avoid which route?
or anger?"
a. I.V
d. "How did you come to adopt such a way of
b. I.M
life?"
c. Oral
255
d. S.C
TEST I - Foundation of Professional Nursing
3. Dr. Garcia writes the following order for the
Practice
client who has been recently admitted “Digoxin
1. The nurse In-charge in labor and delivery unit
.125 mg P.O. once daily.” To prevent a dosage
administered a dose of terbutaline to a client
error, how should the nurse document this
without checking the client’s pulse. The
order
standard
onto the medication administration record?
that would be used to determine if the nurse
a. “Digoxin .1250 mg P.O. once daily”
was negligent is:
b. “Digoxin 0.1250 mg P.O. once daily”
a. The physician’s orders.
c. “Digoxin 0.125 mg P.O. once daily”
b. The action of a clinical nurse specialist
d. “Digoxin .125 mg P.O. once daily”
who is recognized expert in the field.
4. A newly admitted female client was
c. The statement in the drug literature
diagnosed
about administration of terbutaline.
with deep vein thrombosis. Which nursing
d. The actions of a reasonably prudent
diagnosis should receive the highest priority?
nurse with similar education and
a. Ineffective peripheral tissue perfusion
experience.
related to venous congestion.
2. Nurse Trish is caring for a female client with a
b. Risk for injury related to edema.
history of GI bleeding, sickle cell disease, and a
c. Excess fluid volume related to peripheral
platelet count of 22,000/μl. The female client is
vascular disease.
dehydrated and receiving dextrose 5% in
d. Impaired gas exchange related to
halfnormal
increased blood flow.
saline solution at 150 ml/hr. The client
5. Nurse Betty is assigned to the following
complains of severe bone pain and is scheduled
clients.
to receive a dose of morphine sulfate. In
The client that the nurse would see first after
endorsement? 8. The doctor orders hourly urine output

a. A 34 year-old post-operative measurement for a postoperative male client.

appendectomy client of five hours who The nurse Trish records the following amounts
of
is complaining of pain.
output for 2 consecutive hours: 8 a.m.: 50 ml; 9
b. A 44 year-old myocardial infarction (MI)
a.m.: 60 ml. Based on these amounts, which
client who is complaining of nausea.
action should the nurse take?
c. A 26 year-old client admitted for
a. Increase the I.V. fluid infusion rate
dehydration whose intravenous (IV) has
b. Irrigate the indwelling urinary catheter
infiltrated.
c. Notify the physician
d. A 63 year-old post operative’s
d. Continue to monitor and record hourly
abdominal hysterectomy client of three
urine output
days whose incisional dressing is
9. Tony, a basketball player twist his right ankle
saturated with serosanguinous fluid.
while playing on the court and seeks care for
6. Nurse Gail places a client in a four-point
restraint ankle pain and swelling. After the nurse applies

following orders from the physician. The client ice to the ankle for 30 minutes, which statement

care plan should include: by Tony suggests that ice application has been

a. Assess temperature frequently. effective?

b. Provide diversional activities. a. “My ankle looks less swollen now”.

c. Check circulation every 15-30 minutes. b. “My ankle feels warm”.

d. Socialize with other patients once a shift. c. “My ankle appears redder now”.

7. A male client who has severe burns is 256

receiving
d. “I need something stronger for pain
H2 receptor antagonist therapy. The nurse
relief”
Incharge
10. The physician prescribes a loop diuretic for a
knows the purpose of this therapy is to:
client. When administering this drug, the nurse
a. Prevent stress ulcer
anticipates that the client may develop which
b. Block prostaglandin synthesis
electrolyte imbalance?
c. Facilitate protein synthesis.
a. Hypernatremia
d. Enhance gas exchange
b. Hyperkalemia 14. A female client with a fecal impaction
frequently
c. Hypokalemia
exhibits which clinical manifestation?
d. Hypervolemia
a. Increased appetite
11. She finds out that some managers have
b. Loss of urge to defecate
benevolent-authoritative style of management.
c. Hard, brown, formed stools
Which of the following behaviors will she exhibit
d. Liquid or semi-liquid stools
most likely?
15. Nurse Linda prepares to perform an
a. Have condescending trust and
otoscopic
confidence in their subordinates.
examination on a female client. For proper
b. Gives economic and ego awards.
visualization, the nurse should position the
c. Communicates downward to staffs.
client's ear by:
d. Allows decision making among
a. Pulling the lobule down and back
subordinates.
b. Pulling the helix up and forward
12. Nurse Amy is aware that the following is
c. Pulling the helix up and back
true
d. Pulling the lobule down and forward
about functional nursing
16. Which instruction should nurse Tom give to
a. Provides continuous, coordinated and
a
comprehensive nursing services.
male client who is having external radiation
b. One-to-one nurse patient ratio.
therapy:
c. Emphasize the use of group
a. Protect the irritated skin from sunlight.
collaboration.
b. Eat 3 to 4 hours before treatment.
d. Concentrates on tasks and activities.
c. Wash the skin over regularly.
13. Which type of medication order might read
d. Apply lotion or oil to the radiated area
"Vitamin K 10 mg I.M. daily × 3 days?"
when it is red or sore.
a. Single order
17. In assisting a female client for immediate
b. Standard written order
surgery, the nurse In-charge is aware that she
c. Standing order
should:
d. Stat order
a. Encourage the client to void following

preoperative medication.
b. Explore the client’s fears and anxieties b. Height and weight.

about the surgery. c. Calcium and potassium levels

c. Assist the client in removing dentures d. Hgb and Hct levels.

and nail polish. 21. Nurse Michelle witnesses a female client

sustain
d. Encourage the client to drink water prior
a fall and suspects that the leg may be broken.
to surgery.
The nurse takes which priority action?
18. A male client is admitted and diagnosed
with a. Takes a set of vital signs.

acute pancreatitis after a holiday celebration of 257

excessive food and alcohol. Which assessment b. Call the radiology department for X-ray.

finding reflects this diagnosis? c. Reassure the client that everything will

a. Blood pressure above normal range. be alright.

b. Presence of crackles in both lung fields. d. Immobilize the leg before moving the

c. Hyperactive bowel sounds client.

d. Sudden onset of continuous epigastric 22. A male client is being transferred to the
nursing
and back pain.
unit for admission after receiving a radium
19. Which dietary guidelines are important for
nurse implant for bladder cancer. The nurse in-charge

Oliver to implement in caring for the client with would take which priority action in the care of

burns? this client?

a. Provide high-fiber, high-fat diet a. Place client on reverse isolation.

b. Provide high-protein, high-carbohydrate b. Admit the client into a private room.

diet. c. Encourage the client to take frequent

c. Monitor intake to prevent weight gain. rest periods.

d. Provide ice chips or water intake. d. Encourage family and friends to visit.

20. Nurse Hazel will administer a unit of whole 23. A newly admitted female client was
diagnosed
blood, which priority information should the
with agranulocytosis. The nurse formulates
nurse have about the client?
which priority nursing diagnosis?
a. Blood pressure and pulse rate.
a. Constipation
b. Diarrhea a. .5 cc

c. Risk for infection b. 5 cc

d. Deficient knowledge c. 1.5 cc

24. A male client is receiving total parenteral d. 2.5 cc

nutrition suddenly demonstrates signs and 27. A child of 10 years old is to receive 400 cc of
IV
symptoms of an air embolism. What is the
fluid in an 8 hour shift. The IV drip factor is 60.
priority action by the nurse?
The IV rate that will deliver this amount is:
a. Notify the physician.
a. 50 cc/ hour
b. Place the client on the left side in the
b. 55 cc/ hour
Trendelenburg position.
c. 24 cc/ hour
c. Place the client in high-Fowlers position.
d. 66 cc/ hour
d. Stop the total parenteral nutrition.
28. The nurse is aware that the most important
25. Nurse May attends an educational
conference nursing action when a client returns from

on leadership styles. The nurse is sitting with a surgery is:

nurse employed at a large trauma center who a. Assess the IV for type of fluid and rate of

states that the leadership style at the trauma flow.

center is task-oriented and directive. The nurse b. Assess the client for presence of pain.

determines that the leadership style used at the c. Assess the Foley catheter for patency

trauma center is: and urine output

a. Autocratic. d. Assess the dressing for drainage.

b. Laissez-faire. 29. Which of the following vital sign

assessments
c. Democratic.
that may indicate cardiogenic shock after
d. Situational
myocardial infarction?
26. The physician orders DS 500 cc with KCl 10
a. BP – 80/60, Pulse – 110 irregular
mEq/liter at 30 cc/hr. The nurse in-charge is
b. BP – 90/50, Pulse – 50 regular
going to hang a 500 cc bag. KCl is supplied 20
c. BP – 130/80, Pulse – 100 regular
mEq/10 cc. How many cc’s of KCl will be added
d. BP – 180/100, Pulse – 90 irregular
to the IV solution?
30. Which is the most appropriate nursing health professional in arriving at a diagnosis or
action in
determining the person’s needs?
obtaining a blood pressure measurement?
a. Diagnostic test results
a. Take the proper equipment, place the
b. Biographical date
client in a comfortable position, and
c. History of present illness
record the appropriate information in
d. Physical examination
the client’s chart.
33. In preventing the development of an
b. Measure the client’s arm, if you are not external

sure of the size of cuff to use. rotation deformity of the hip in a client who

c. Have the client recline or sit comfortably must remain in bed for any period of time, the

in a chair with the forearm at the level of most appropriate nursing action would be to

the heart. use:

d. Document the measurement, which a. Trochanter roll extending from the crest

extremity was used, and the position of the ileum to the mid-thigh.

that the client was in during the b. Pillows under the lower legs.

measurement. c. Footboard

31. Asking the questions to determine if the d. Hip-abductor pillow

person
34. Which stage of pressure ulcer development
understands the health teaching provided by does
the
the ulcer extend into the subcutaneous tissue?
nurse would be included during which step of
a. Stage I
the nursing process?
b. Stage II
a. Assessment
c. Stage III
b. Evaluation
d. Stage IV
c. Implementation
35. When the method of wound healing is one
258 in

d. Planning and goals which wound edges are not surgically

32. Which of the following item is considered approximated and integumentary continuity is
the
restored by granulations, the wound healing is
single most important factor in assisting the
termed
a. Second intention healing metric system.

b. Primary intention healing b. It’s the basis for solids in the avoirdupois

c. Third intention healing system.

d. First intention healing c. It’s the smallest measurement in the

36. An 80-year-old male client is admitted to the apothecary system.

hospital with a diagnosis of pneumonia. Nurse d. It’s a measure of effect, not a standard

Oliver learns that the client lives alone and measure of weight or quantity.

hasn’t been eating or drinking. When assessing 39. Nurse Oliver measures a client’s
temperature at
him for dehydration, nurse Oliver would expect
102° F. What is the equivalent Centigrade
to find:
temperature?
a. Hypothermia
a. 40.1 °C
b. Hypertension
b. 38.9 °C
c. Distended neck veins
c. 48 °C
d. Tachycardia
d. 38 °C
37. The physician prescribes meperidine
(Demerol), 40. The nurse is assessing a 48-year-old client
who
75 mg I.M. every 4 hours as needed, to control a
has come to the physician’s office for his annual
client’s postoperative pain. The package insert is
physical exam. One of the first physical signs of
“Meperidine, 100 mg/ml.” How many milliliters
aging is:
of meperidine should the client receive?
a. Accepting limitations while developing
a. 0.75
assets.
b. 0.6
b. Increasing loss of muscle tone.
c. 0.5
c. Failing eyesight, especially close vision.
d. 0.25
d. Having more frequent aches and pains.
38. A male client with diabetes mellitus is
receiving 41. The physician inserts a chest tube into a
female
insulin. Which statement correctly describes an
client to treat a pneumothorax. The tube is
insulin unit?
connected to water-seal drainage. The nurse
a. It’s a common measurement in the
incharge
can prevent chest tube air leaks by: b. Call another nurse

a. Checking and taping all connections. c. Call the physician

b. Checking patency of the chest tube. d. Apply a dry sterile dressing to the site.

c. Keeping the head of the bed slightly 45. A female client was recently admitted. She
has
elevated.
fever, weight loss, and watery diarrhea is being
d. Keeping the chest drainage system
admitted to the facility. While assessing the
below the level of the chest.
client, Nurse Hazel inspects the client’s
42. Nurse Trish must verify the client’s identity
abdomen
before administering medication. She is aware
and notice that it is slightly concave. Additional
that the safest way to verify identity is to:
assessment should proceed in which order:
a. Check the client’s identification band.
a. Palpation, auscultation, and percussion.
b. Ask the client to state his name.
b. Percussion, palpation, and auscultation.
259
c. Palpation, percussion, and auscultation.
c. State the client’s name out loud and
d. Auscultation, percussion, and palpation.
wait a client to repeat it.
46. Nurse Betty is assessing tactile fremitus in a
d. Check the room number and the client’s
client with pneumonia. For this examination,
name on the bed.
nurse Betty should use the:
43. The physician orders dextrose 5 % in water,
a. Fingertips
1,000 ml to be infused over 8 hours. The I.V.
b. Finger pads
tubing delivers 15 drops/ml. Nurse John should
c. Dorsal surface of the hand
run the I.V. infusion at a rate of:
d. Ulnar surface of the hand
a. 30 drops/minute
47. Which type of evaluation occurs
b. 32 drops/minute continuously

c. 20 drops/minute throughout the teaching and learning process?

d. 18 drops/minute a. Summative

44. If a central venous catheter becomes b. Informative

disconnected accidentally, what should the c. Formative

nurse in-charge do immediately? d. Retrospective

a. Clamp the catheter 48. A 45 year old client, has no family history of
breast cancer or other risk factors for this 51. When caring for a male client with a 3-cm
stage I
disease. Nurse John should instruct her to have
pressure ulcer on the coccyx, which of the
mammogram how often?
following actions can the nurse institute
a. Twice per year
independently?
b. Once per year
a. Massaging the area with an astringent
c. Every 2 years
every 2 hours.
d. Once, to establish baseline
b. Applying an antibiotic cream to the area
49. A male client has the following arterial blood
gas three times per day.

values: pH 7.30; Pao2 89 mmHg; Paco2 50 c. Using normal saline solution to clean the

mmHg; and HCO3 26mEq/L. Based on these ulcer and applying a protective dressing

values, Nurse Patricia should expect which as necessary.

condition? d. Using a povidone-iodine wash on the

a. Respiratory acidosis ulceration three times per day.

b. Respiratory alkalosis 52. Nurse Oliver must apply an elastic bandage

to a
c. Metabolic acidosis
client’s ankle and calf. He should apply the
d. Metabolic alkalosis
bandage beginning at the client’s:
50. Nurse Len refers a female client with
terminal a. Knee

cancer to a local hospice. What is the goal of b. Ankle

this
c. Lower thigh
referral?
d. Foot
a. To help the client find appropriate
53. A 10 year old child with type 1 diabetes
treatment options. develops

b. To provide support for the client and diabetic ketoacidosis and receives a continuous

family in coping with terminal illness. insulin infusion. Which condition represents the

c. To ensure that the client gets counseling greatest risk to this child?

regarding health care costs. a. Hypernatremia

d. To teach the client and family about b. Hypokalemia

cancer and its treatment. c. Hyperphosphatemia

260 d. Behind the client.

d. Hypercalcemia 57. Nurse Janah is monitoring the ongoing care

54. Nurse Len is administering sublingual given to the potential organ donor who has
nitrglycerin been

(Nitrostat) to the newly admitted client. diagnosed with brain death. The nurse

Immediately afterward, the client may determines that the standard of care had been

experience: maintained if which of the following data is

a. Throbbing headache or dizziness observed?

b. Nervousness or paresthesia. a. Urine output: 45 ml/hr

c. Drowsiness or blurred vision. b. Capillary refill: 5 seconds

d. Tinnitus or diplopia. c. Serum pH: 7.32

55. Nurse Michelle hears the alarm sound on d. Blood pressure: 90/48 mmHg
the
58. Nurse Amy has an order to obtain a
telemetry monitor. The nurse quickly looks at urinalysis

the monitor and notes that a client is in a from a male client with an indwelling urinary

ventricular tachycardia. The nurse rushes to the catheter. The nurse avoids which of the

client’s room. Upon reaching the client’s following, which contaminate the specimen?

bedside, the nurse would take which action a. Wiping the port with an alcohol swab

first? before inserting the syringe.

a. Prepare for cardioversion b. Aspirating a sample from the port on the

b. Prepare to defibrillate the client drainage bag.

c. Call a code c. Clamping the tubing of the drainage bag.

d. Check the client’s level of consciousness d. Obtaining the specimen from the urinary

56. Nurse Hazel is preparing to ambulate a drainage bag.

female
59. Nurse Meredith is in the process of giving a
client. The best and the safest position for the
client a bed bath. In the middle of the
nurse in assisting the client is to stand:
procedure, the unit secretary calls the nurse on
a. On the unaffected side of the client.
the intercom to tell the nurse that there is an
b. On the affected side of the client.
emergency phone call. The appropriate nursing
c. In front of the client.
action is to: pieces, and then walks into it.

a. Immediately walk out of the client’s b. Puts weight on the hand pieces, moves

room and answer the phone call. the walker forward, and then walks into

b. Cover the client, place the call light it.

within reach, and answer the phone call. c. Puts weight on the hand pieces, slides

c. Finish the bed bath before answering the walker forward, and then walks into

the phone call. it.

d. Leave the client’s door open so the client d. Walks into the walker, puts weight on

can be monitored and the nurse can the hand pieces, and then puts all four

answer the phone call. points of the walker flat on the floor.

60. Nurse Janah is collecting a sputum specimen 62. Nurse Amy has documented an entry
for regarding

culture and sensitivity testing from a client who client care in the client’s medical record. When

has a productive cough. Nurse Janah plans to checking the entry, the nurse realizes that

implement which intervention to obtain the 261

specimen? incorrect information was documented. How

a. Ask the client to expectorate a small does the nurse correct this error?

amount of sputum into the emesis basin. a. Erases the error and writes in the correct

b. Ask the client to obtain the specimen information.

after breakfast. b. Uses correction fluid to cover up the

c. Use a sterile plastic container for incorrect information and writes in the

obtaining the specimen. correct information.

d. Provide tissues for expectoration and c. Draws one line to cross out the incorrect

obtaining the specimen. information and then initials the change.

61. Nurse Ron is observing a male client using a d. Covers up the incorrect information

walker. The nurse determines that the client is completely using a black pen and writes

using the walker correctly if the client: in the correct information

a. Puts all the four points of the walker flat 63. Nurse Ron is assisting with transferring a
client
on the floor, puts weight on the hand
from the operating room table to a stretcher. To b. Single straight-legged cane

provide safety to the client, the nurse should: c. Quad cane

a. Moves the client rapidly from the table d. Walker

to the stretcher. 66. A male client with a right pleural effusion

noted
b. Uncovers the client completely before
on a chest X-ray is being prepared for
transferring to the stretcher.
thoracentesis. The client experiences severe
c. Secures the client safety belts after
dizziness when sitting upright. To provide a safe
transferring to the stretcher.
environment, the nurse assists the client to
d. Instructs the client to move self from the
which position for the procedure?
table to the stretcher.
a. Prone with head turned toward the side
64. Nurse Myrna is providing instructions to a
supported by a pillow.
nursing assistant assigned to give a bed bath to
a b. Sims’ position with the head of the bed

client who is on contact precautions. Nurse flat.

Myrna instructs the nursing assistant to use c. Right side-lying with the head of the bed

which of the following protective items when elevated 45 degrees.

giving bed bath? d. Left side-lying with the head of the bed

a. Gown and goggles elevated 45 degrees.

b. Gown and gloves 67. Nurse John develops methods for data

c. Gloves and shoe protectors gathering. Which of the following criteria of a

d. Gloves and goggles good instrument refers to the ability of the

65. Nurse Oliver is caring for a client with instrument to yield the same results upon its
impaired
repeated administration?
mobility that occurred as a result of a stroke.
a. Validity
The
b. Specificity
client has right sided arm and leg weakness. The
c. Sensitivity
nurse would suggest that the client use which of
d. Reliability
the following assistive devices that would
68. Harry knows that he has to protect the
provide the best stability for ambulating?
rights of
a. Crutches
human research subjects. Which of the a. Field study
following
b. Quasi-experiment
actions of Harry ensures anonymity?
c. Solomon-Four group design
a. Keep the identities of the subject secret
262
b. Obtain informed consent
d. Post-test only design
c. Provide equal treatment to all the
72. Cherry notes down ideas that were derived
subjects of the study. from

d. Release findings only to the participants the description of an investigation written by

the
of the study
person who conducted it. Which type of
69. Patient’s refusal to divulge information is a
reference source refers to this?
limitation because it is beyond the control of
a. Footnote
Tifanny”. What type of research is appropriate
b. Bibliography
for this study?
c. Primary source
a. Descriptive- correlational
d. Endnotes
b. Experiment
73. When Nurse Trish is providing care to his
c. Quasi-experiment
patient, she must remember that her duty is
d. Historical
bound not to do doing any action that will cause
70. Nurse Ronald is aware that the best tool for
data the patient harm. This is the meaning of the

gathering is? bioethical principle:

a. Interview schedule a. Non-maleficence

b. Questionnaire b. Beneficence

c. Use of laboratory data c. Justice

d. Observation d. Solidarity

71. Monica is aware that there are times when 74. When a nurse in-charge causes an injury to a
only
female patient and the injury caused becomes
manipulation of study variables is possible and
the proof of the negligent act, the presence of
the elements of control or randomization are
the injury is said to exemplify the principle of:
not attendant. Which type of research is
a. Force majeure
referred to this?
b. Respondeat superior a new method of pain assessment scale. Which

c. Res ipsa loquitor of the following is the second step in the

d. Holdover doctrine conceptualizing phase of the research process?

75. Nurse Myrna is aware that the Board of a. Formulating the research hypothesis
Nursing
b. Review related literature
has quasi-judicial power. An example of this
c. Formulating and delimiting the research
power is:
problem
a. The Board can issue rules and
d. Design the theoretical and conceptual
regulations that will govern the practice
framework
of nursing
78. The leader of the study knows that certain
b. The Board can investigate violations of
patients who are in a specialized research
the nursing law and code of ethics setting

c. The Board can visit a school applying for tend to respond psychologically to the

a permit in collaboration with CHED conditions of the study. This referred to as :

d. The Board prepares the board a. Cause and effect

examinations b. Hawthorne effect

76. When the license of nurse Krina is revoked, c. Halo effect

it
d. Horns effect
means that she:
79. Mary finally decides to use judgment
a. Is no longer allowed to practice the sampling

profession for the rest of her life on her research. Which of the following actions

b. Will never have her/his license re-issued of is correct?

since it has been revoked a. Plans to include whoever is there during

c. May apply for re-issuance of his/her his study.

license based on certain conditions b. Determines the different nationality of

stipulated in RA 9173 patients frequently admitted and

d. Will remain unable to practice decides to get representations samples

professional nursing from each.

77. Ronald plans to conduct a research on the c. Assigns numbers for each of the
use of
patients, place these in a fishbowl and b. Sr. Callista Roy

draw 10 from it. c. Florence Nightingale

d. Decides to get 20 samples from the d. Jean Watson

admitted patients 84. Ms. Garcia is responsible to the number of

80. The nursing theorist who developed personnel reporting to her. This principle refers

transcultural nursing theory is: to:

a. Florence Nightingale a. Span of control

b. Madeleine Leininger b. Unity of command

c. Albert Moore c. Downward communication

d. Sr. Callista Roy d. Leader

81. Marion is aware that the sampling method 85. Ensuring that there is an informed consent
that on

gives equal chance to all units in the population the part of the patient before a surgery is done,

to get picked is: illustrates the bioethical principle of:

a. Random a. Beneficence

b. Accidental b. Autonomy

c. Quota c. Veracity

d. Judgment d. Non-maleficence

263 86. Nurse Reese is teaching a female client with

82. John plans to use a Likert Scale to his study peripheral vascular disease about foot care;
to
Nurse Reese should include which instruction?
determine the:
a. Avoid wearing cotton socks.
a. Degree of agreement and disagreement
b. Avoid using a nail clipper to cut toenails.
b. Compliance to expected standards
c. Avoid wearing canvas shoes.
c. Level of satisfaction
d. Avoid using cornstarch on feet.
d. Degree of acceptance
87. A client is admitted with multiple pressure
83. Which of the following theory addresses the
ulcers. When developing the client's diet plan,
four
the nurse should include:
modes of adaptation?
a. Fresh orange slices
a. Madeleine Leininger
b. Steamed broccoli d. Intradependent

c. Ice cream 91. A female client is to be discharged from an

acute
d. Ground beef patties
care facility after treatment for right leg
88. The nurse prepares to administer a cleansing
thrombophlebitis. The Nurse Betty notes that
enema. What is the most common client
the client's leg is pain-free, without redness or
position used for this procedure?
edema. The nurse's actions reflect which step of
a. Lithotomy
the nursing process?
b. Supine
a. Assessment
c. Prone
b. Diagnosis
d. Sims’ left lateral
c. Implementation
89. Nurse Marian is preparing to administer a
blood d. Evaluation

transfusion. Which action should the nurse take 92. Nursing care for a female client includes

first? removing elastic stockings once per day. The

a. Arrange for typing and cross matching of Nurse Betty is aware that the rationale for this

the client’s blood. intervention?

b. Compare the client’s identification a. To increase blood flow to the heart

wristband with the tag on the unit of b. To observe the lower extremities

blood. c. To allow the leg muscles to stretch and

c. Start an I.V. infusion of normal saline relax

solution. d. To permit veins in the legs to fill with

d. Measure the client’s vital signs. blood.

90. A 65 years old male client requests his 93. Which nursing intervention takes highest
priority
medication at 9 p.m. instead of 10 p.m. so that
when caring for a newly admitted client who's
he can go to sleep earlier. Which type of nursing
receiving a blood transfusion?
intervention is required?
a. Instructing the client to report any
a. Independent
itching, swelling, or dyspnea.
b. Dependent
b. Informing the client that the transfusion
c. Interdependent
usually take 1 ½ to 2 hours. female client?

c. Documenting blood administration in a. Secure the elastic band tightly around

the client care record. the client's head.

264 b. Assist the client to the semi-Fowler

d. Assessing the client’s vital signs when position if possible.

the transfusion ends. c. Apply the face mask from the client's

94. A male client complains of abdominal chin up over the nose.

discomfort
d. Loosen the connectors between the
and nausea while receiving tube feedings.
oxygen equipment and humidifier.
Which
97. The maximum transfusion time for a unit of
intervention is most appropriate for this
packed red blood cells (RBCs) is:
problem?
a. 6 hours
a. Give the feedings at room temperature.
b. 4 hours
b. Decrease the rate of feedings and the
c. 3 hours
concentration of the formula.
d. 2 hours
c. Place the client in semi-Fowler's position
98. Nurse Monique is monitoring the
while feeding.
effectiveness
d. Change the feeding container every 12
of a client's drug therapy. When should the
hours.
nurse Monique obtain a blood sample to
95. Nurse Patricia is reconstituting a powdered
measure the trough drug level?
medication in a vial. After adding the solution to
a. 1 hour before administering the next
the powder, she nurse should:
dose.
a. Do nothing.
b. Immediately before administering the
b. Invert the vial and let it stand for 3 to 5
next dose.
minutes.
c. Immediately after administering the
c. Shake the vial vigorously.
next dose.
d. Roll the vial gently between the palms.
d. 30 minutes after administering the next
96. Which intervention should the nurse Trish
dose.
use

when administering oxygen by face mask to a

99. Nurse May is aware that the main advantage 2. Answer: (B) I.M
of
Rationale: With a platelet count of 22,000/μl,
using a floor stock system is:
the clients tends to bleed easily. Therefore,
a. The nurse can implement medication
the nurse should avoid using the I.M. route
orders quickly.
because the area is a highly vascular and can
b. The nurse receives input from the
bleed readily when penetrated by a needle.
pharmacist.
The bleeding can be difficult to stop.
c. The system minimizes transcription
3. Answer: (C) “Digoxin 0.125 mg P.O. once
errors. daily”

d. The system reinforces accurate Rationale: The nurse should always place a

calculations. zero before a decimal point so that no one

100. Nurse Oliver is assessing a client's misreads the figure, which could result in a
abdomen.
dosage error. The nurse should never insert a
Which finding should the nurse report as
zero at the end of a dosage that includes a
abnormal?
decimal point because this could be misread,
a. Dullness over the liver.
possibly leading to a tenfold increase in the
b. Bowel sounds occurring every 10
dosage.
seconds.
4. Answer: (A) Ineffective peripheral tissue
c. Shifting dullness over the abdomen.
perfusion related to venous congestion.
d. Vascular sounds heard over the renal
Rationale: Ineffective peripheral tissue
arteries.
perfusion related to venous congestion takes
265
the highest priority because venous
Answers and Rationale – Foundation of
inflammation and clot formation impede blood
Professional Nursing Practice
flow in a client with deep vein thrombosis.
1. Answer: (D) The actions of a reasonably
5. Answer: (B) A 44 year-old myocardial
prudent
infarction (MI) client who is complaining of
nurse with similar education and experience.
nausea.
Rationale: The standard of care is determined
Rationale: Nausea is a symptom of impending
by the average degree of skill, care, and
myocardial infarction (MI) and should be
diligence by nurses in similar circumstances.
assessed immediately so that treatment can and increased warmth are signs of

be instituted and further damage to the heart inflammation that shouldn't occur after ice

is avoided. application

6. Answer: (C) Check circulation every 15-30 10. Answer: (B) Hyperkalemia

minutes. Rationale: A loop diuretic removes water and,

Rationale: Restraints encircle the limbs, which along with it, sodium and potassium. This may

place the client at risk for circulation being result in hypokalemia, hypovolemia, and

restricted to the distal areas of the hyponatremia.

extremities. Checking the client’s circulation 11. Answer:(A) Have condescending trust and

every 15-30 minutes will allow the nurse to confidence in their subordinates

adjust the restraints before injury from Rationale: Benevolent-authoritative managers

decreased blood flow occurs. pretentiously show their trust and confidence

7. Answer: (A) Prevent stress ulcer to their followers.

Rationale: Curling’s ulcer occurs as a 12. Answer: (A) Provides continuous,

coordinated
generalized stress response in burn patients.
and comprehensive nursing services.
This results in a decreased production of
Rationale: Functional nursing is focused on
mucus and increased secretion of gastric acid.
tasks and activities and not on the care of the
The best treatment for this prophylactic use of
patients.
antacids and H2 receptor blockers.
13. Answer: (B) Standard written order
8. Answer: (D) Continue to monitor and record
Rationale: This is a standard written order.
hourly urine output
Prescribers write a single order for
Rationale: Normal urine output for an adult is
medications given only once. A stat order is
approximately 1 ml/minute (60 ml/hour).
written for medications given immediately for
Therefore, this client's output is normal.
an urgent client problem. A standing order,
Beyond continued evaluation, no nursing
also known as a protocol, establishes
action is warranted.
guidelines for treating a particular disease or
9. Answer: (B) “My ankle feels warm”.
set of symptoms in special care areas such as
Rationale: Ice application decreases pain and
the coronary care unit. Facilities also may
swelling. Continued or increased pain, redness,
institute medication protocols that specifically dentures and nail polish.

designate drugs that a nurse may not give. Rationale: Dentures, hairpins, and combs must

14. Answer: (D) Liquid or semi-liquid stools be removed. Nail polish must be removed so

Rationale: Passage of liquid or semi-liquid that cyanosis can be easily monitored by

stools results from seepage of unformed observing the nail beds.

bowel contents around the impacted stool in 18. Answer: (D) Sudden onset of continuous

the rectum. Clients with fecal impaction don't epigastric and back pain.

pass hard, brown, formed stools because the Rationale: The autodigestion of tissue by the

feces can't move past the impaction. These pancreatic enzymes results in pain from

clients typically report the urge to defecate inflammation, edema, and possible

(although they can't pass stool) and a hemorrhage. Continuous, unrelieved epigastric

decreased appetite. or back pain reflects the inflammatory process

15. Answer: (C) Pulling the helix up and back in the pancreas.

266 19. Answer: (B) Provide high-protein,

highcarbohydrate
Rationale: To perform an otoscopic
diet.
examination on an adult, the nurse grasps the
Rationale: A positive nitrogen balance is
helix of the ear and pulls it up and back to
important for meeting metabolic needs, tissue
straighten the ear canal. For a child, the nurse
repair, and resistance to infection. Caloric
grasps the helix and pulls it down to straighten
goals may be as high as 5000 calories per day.
the ear canal. Pulling the lobule in any
20. Answer: (A) Blood pressure and pulse rate.
direction wouldn't straighten the ear canal for
Rationale: The baseline must be established to
visualization.
recognize the signs of an anaphylactic or
16. Answer: (A) Protect the irritated skin from
hemolytic reaction to the transfusion.
sunlight.
21. Answer: (D) Immobilize the leg before
Rationale: Irradiated skin is very sensitive and
moving
must be protected with clothing or sunblock.
the client.
The priority approach is the avoidance of
Rationale: If the nurse suspects a fracture,
strong sunlight.
splinting the area before moving the client is
17. Answer: (C) Assist the client in removing
imperative. The nurse should call for Rationale: The autocratic style of leadership is

emergency help if the client is not hospitalized a task-oriented and directive.

and call for a physician for the hospitalized 26. Answer: (D) 2.5 cc

client. Rationale: 2.5 cc is to be added, because only a

22. Answer: (B) Admit the client into a private 500 cc bag of solution is being medicated

room. instead of a 1 liter.

Rationale: The client who has a radiation 27. Answer: (A) 50 cc/ hour

implant is placed in a private room and has a Rationale: A rate of 50 cc/hr. The child is to

limited number of visitors. This reduces the receive 400 cc over a period of 8 hours = 50

exposure of others to the radiation. cc/hr.

23. Answer: (C) Risk for infection 28. Answer: (B) Assess the client for presence of

Rationale: Agranulocytosis is characterized by pain.

a reduced number of leukocytes (leucopenia) Rationale: Assessing the client for pain is a

and neutrophils (neutropenia) in the blood. very important measure. Postoperative pain is

The client is at high risk for infection because an indication of complication. The nurse

of the decreased body defenses against should also assess the client for pain to

microorganisms. Deficient knowledge related provide for the client’s comfort.

to the nature of the disorder may be 29. Answer: (A) BP – 80/60, Pulse – 110 irregular

appropriate diagnosis but is not the priority. Rationale: The classic signs of cardiogenic

24. Answer: (B) Place the client on the left side shock are low blood pressure, rapid and weak
in
irregular pulse, cold, clammy skin, decreased
the Trendelenburg position.
urinary output, and cerebral hypoxia.
Rationale: Lying on the left side may prevent
30. Answer: (A) Take the proper equipment,
air from flowing into the pulmonary veins. The place

Trendelenburg position increases intrathoracic the client in a comfortable position, and

pressure, which decreases the amount of record the appropriate information in the

blood pulled into the vena cava during client’s chart.

aspiration. Rationale: It is a general or comprehensive

25. Answer: (A) Autocratic. statement about the correct procedure, and it
includes the basic ideas which are found in the heart rate.

other options 37. Answer: (A) 0.75

31. Answer: (B) Evaluation Rationale: To determine the number of

Rationale: Evaluation includes observing the milliliters the client should receive, the nurse

person, asking questions, and comparing the uses the fraction method in the following

patient’s behavioral responses with the equation.

expected outcomes. 75 mg/X ml = 100 mg/1 ml

32. Answer: (C) History of present illness To solve for X, cross-multiply:

267 75 mg x 1 ml = X ml x 100 mg

Rationale: The history of present illness is the 75 = 100X

single most important factor in assisting the 75/100 = X

health professional in arriving at a diagnosis or 0.75 ml (or ¾ ml) = X

determining the person’s needs. 38. Answer: (D) it’s a measure of effect, not a

33. Answer: (A) Trochanter roll extending from standard measure of weight or quantity.
the
Rationale: An insulin unit is a measure of
crest of the ileum to the mid-thigh.
effect, not a standard measure of weight or
Rationale: A trochanter roll, properly placed,
quantity. Different drugs measured in units
provides resistance to the external rotation of
may have no relationship to one another in
the hip.
quality or quantity.
34. Answer: (C) Stage III
39. Answer: (B) 38.9 °C
Rationale: Clinically, a deep crater or without
Rationale: To convert Fahrenheit degreed to
undermining of adjacent tissue is noted.
Centigrade, use this formula
35. Answer: (A) Second intention healing
°C = (°F – 32) ÷ 1.8
Rationale: When wounds dehisce, they will
°C = (102 – 32) ÷ 1.8
allowed to heal by secondary Intention
°C = 70 ÷ 1.8
36. Answer: (D) Tachycardia
°C = 38.9
Rationale: With an extracellular fluid or plasma
40. Answer: (C) Failing eyesight, especially close
volume deficit, compensatory mechanisms
vision.
stimulate the heart, causing an increase in
Rationale: Failing eyesight, especially close
vision, is one of the first signs of aging in minute as follows:

middle life (ages 46 to 64). More frequent 125/60 minutes = X/1 minute

aches and pains begin in the early late years 60X = 125 = 2.1 ml/minute

(ages 65 to 79). Increase in loss of muscle tone To find the number of drops per minute:

occurs in later years (age 80 and older). 2.1 ml/X gtt = 1 ml/ 15 gtt

41. Answer: (A) Checking and taping all X = 32 gtt/minute, or 32 drops/minute

connections 44. Answer: (A) Clamp the catheter

Rationale: Air leaks commonly occur if the Rationale: If a central venous catheter

system isn’t secure. Checking all connections becomes disconnected, the nurse should

and taping them will prevent air leaks. The immediately apply a catheter clamp, if

chest drainage system is kept lower to available. If a clamp isn’t available, the nurse

promote drainage – not to prevent leaks. can place a sterile syringe or catheter plug in

42. Answer: (A) Check the client’s identification the catheter hub. After cleaning the hub with

band. alcohol or povidone-iodine solution, the nurse

Rationale: Checking the client’s identification must replace the I.V. extension and restart the

band is the safest way to verify a client’s infusion.

identity because the band is assigned on 45. Answer: (D) Auscultation, percussion, and

admission and isn’t be removed at any time. (If palpation.

it is removed, it must be replaced). Asking the Rationale: The correct order of assessment for

client’s name or having the client repeated his examining the abdomen is inspection,

name would be appropriate only for a client auscultation, percussion, and palpation. The

who’s alert, oriented, and able to understand reason for this approach is that the less

what is being said, but isn’t the safe standard intrusive techniques should be performed

of practice. Names on bed aren’t always before the more intrusive techniques.

reliable Percussion and palpation can alter natural

43. Answer: (B) 32 drops/minute findings during auscultation.

Rationale: Giving 1,000 ml over 8 hours is the 46. Answer: (D) Ulnar surface of the hand

same as giving 125 ml over 1 hour (60 Rationale: The nurse uses the ulnar surface, or

minutes). Find the number of milliliters per ball, of the hand to assess tactile fremitus,
268 normal. In metabolic acidosis, the pH and

thrills, and vocal vibrations through the chest bicarbonate (Hco3) values are below normal.

wall. The fingertips and finger pads best In metabolic alkalosis, the pH and Hco3 values

distinguish texture and shape. The dorsal are above normal.

surface best feels warmth. 50. Answer: (B) To provide support for the client

47. Answer: (C) Formative and family in coping with terminal illness.

Rationale: Formative (or concurrent) Rationale: Hospices provide supportive care

evaluation occurs continuously throughout the for terminally ill clients and their families.

teaching and learning process. One benefit is Hospice care doesn’t focus on counseling

that the nurse can adjust teaching strategies regarding health care costs. Most client

as necessary to enhance learning. Summative, referred to hospices have been treated for

or retrospective, evaluation occurs at the their disease without success and will receive

conclusion of the teaching and learning only palliative care in the hospice.

session. Informative is not a type of 51. Answer: (C) Using normal saline solution to

evaluation. clean the ulcer and applying a protective

48. Answer: (B) Once per year dressing as necessary.

Rationale: Yearly mammograms should begin Rationale: Washing the area with normal

at age 40 and continue for as long as the saline solution and applying a protective

woman is in good health. If health risks, such dressing are within the nurse’s realm of

as family history, genetic tendency, or past interventions and will protect the area. Using a

breast cancer, exist, more frequent povidone-iodine wash and an antibiotic cream

examinations may be necessary. require a physician’s order. Massaging with an

49. Answer: (A) Respiratory acidosis astringent can further damage the skin.

Rationale: The client has a below-normal 52. Answer: (D) Foot

(acidic) blood pH value and an above-normal Rationale: An elastic bandage should be

partial pressure of arterial carbon dioxide applied form the distal area to the proximal

(Paco2) value, indicating respiratory acidosis. area. This method promotes venous return. In

In respiratory alkalosis, the pH value is above this case, the nurse should begin applying the

normal and in the Paco2 value is below bandage at the client’s foot. Beginning at the
ankle, lower thigh, or knee does not promote in the event that there is a forward fall. The

venous return. client is instructed to look up and outward

53. Answer: (B) Hypokalemia rather than at his or her feet.

Rationale: Insulin administration causes 57. Answer: (A) Urine output: 45 ml/hr

glucose and potassium to move into the cells, Rationale: Adequate perfusion must be

causing hypokalemia. maintained to all vital organs in order for the

54. Answer: (A) Throbbing headache or client to remain visible as an organ donor. A
dizziness
urine output of 45 ml per hour indicates
Rationale: Headache and dizziness often occur
adequate renal perfusion. Low blood pressure
when nitroglycerin is taken at the beginning of
and delayed capillary refill time are circulatory
therapy. However, the client usually develops
system indicators of inadequate perfusion. A
tolerance
serum pH of 7.32 is acidotic, which adversely
55. Answer: (D) Check the client’s level of
affects all body tissues.
consciousness
58. Answer: (D ) Obtaining the specimen from
Rationale: Determining unresponsiveness is the

the first step assessment action to take. When urinary drainage bag.

a client is in ventricular tachycardia, there is a Rationale: A urine specimen is not taken from

significant decrease in cardiac output. the urinary drainage bag. Urine undergoes

However, checking the unresponsiveness chemical changes while sitting in the bag and

ensures whether the client is affected by the does not necessarily reflect the current client

decreased cardiac output. status. In addition, it may become

56. Answer: (B) On the affected side of the 269

client.
contaminated with bacteria from opening the
Rationale: When walking with clients, the
system.
nurse should stand on the affected side and
59. Answer: (B) Cover the client, place the call
grasp the security belt in the midspine area of
light within reach, and answer the phone call.
the small of the back. The nurse should
Rationale: Because telephone call is an
position the free hand at the shoulder area so
emergency, the nurse may need to answer it.
that the client can be pulled toward the nurse
The other appropriate action is to ask another
nurse to accept the call. However, is not one of change.

the options. To maintain privacy and safety, Rationale: To correct an error documented in a

the nurse covers the client and places the call medical record, the nurse draws one line

light within the client’s reach. Additionally, the through the incorrect information and then

client’s door should be closed or the room initials the error. An error is never erased and

curtains pulled around the bathing area. correction fluid is never used in the medical

60. Answer: (C) Use a sterile plastic container for record.

obtaining the specimen. 63. Answer: (C) Secures the client safety belts

Rationale: Sputum specimens for culture and after transferring to the stretcher.

sensitivity testing need to be obtained using Rationale: During the transfer of the client

sterile techniques because the test is done to after the surgical procedure is complete, the

determine the presence of organisms. If the nurse should avoid exposure of the client

procedure for obtaining the specimen is not because of the risk for potential heat loss.

sterile, then the specimen is not sterile, then Hurried movements and rapid changes in the

the specimen would be contaminated and the position should be avoided because these

results of the test would be invalid. predispose the client to hypotension. At the

61. Answer: (A) Puts all the four points of the time of the transfer from the surgery table to

walker flat on the floor, puts weight on the the stretcher, the client is still affected by the

hand pieces, and then walks into it. effects of the anesthesia; therefore, the client

Rationale: When the client uses a walker, the should not move self. Safety belts can prevent

nurse stands adjacent to the affected side. The the client from falling off the stretcher.

client is instructed to put all four points of the 64. Answer: (B) Gown and gloves

walker 2 feet forward flat on the floor before Rationale: Contact precautions require the use

putting weight on hand pieces. This will ensure of gloves and a gown if direct client contact is

client safety and prevent stress cracks in the anticipated. Goggles are not necessary unless

walker. The client is then instructed to move the nurse anticipates the splashes of blood,

the walker forward and walk into it. body fluids, secretions, or excretions may

62. Answer: (C) Draws one line to cross out the occur. Shoe protectors are not necessary.

incorrect information and then initials the 65. Answer: (C) Quad cane
Rationale: Crutches and a walker can be because this will hinder providing link between

difficult to maneuver for a client with the information given to whoever is its source.

weakness on one side. A cane is better suited 69. Answer: (A) Descriptive- correlational

for client with weakness of the arm and leg on Rationale: Descriptive- correlational study is

one side. However, the quad cane would the most appropriate for this study because it

provide the most stability because of the studies the variables that could be the

structure of the cane and because a quad cane antecedents of the increased incidence of

has four legs. nosocomial infection.

66. Answer: (D) Left side-lying with the head of 70. Answer: (C) Use of laboratory data

the bed elevated 45 degrees. Rationale: Incidence of nosocomial infection is

Rationale: To facilitate removal of fluid from best collected through the use of

the chest wall, the client is positioned sitting at biophysiologic measures, particularly in vitro

the edge of the bed leaning over the bedside 270

table with the feet supported on a stool. If the measurements, hence laboratory data is

client is unable to sit up, the client is essential.

positioned lying in bed on the unaffected side 71. Answer: (B) Quasi-experiment

with the head of the bed elevated 30 to 45 Rationale: Quasi-experiment is done when

degrees. randomization and control of the variables are

67. Answer: (D) Reliability not possible.

Rationale: Reliability is consistency of the 72. Answer: (C) Primary source

research instrument. It refers to the Rationale: This refers to a primary source

repeatability of the instrument in extracting which is a direct account of the investigation

the same responses upon its repeated done by the investigator. In contrast to this is a

administration. secondary source, which is written by

68. Answer: (A) Keep the identities of the someone other than the original researcher.
subject
73. Answer: (A) Non-maleficence
secret
Rationale: Non-maleficence means do not
Rationale: Keeping the identities of the
cause harm or do any action that will cause
research subject secret will ensure anonymity
any harm to the patient/client. To do good is
referred as beneficence. previous researchers.

74. Answer: (C) Res ipsa loquitor 78. Answer: (B) Hawthorne effect

Rationale: Res ipsa loquitor literally means the Rationale: Hawthorne effect is based on the

thing speaks for itself. This means in study of Elton Mayo and company about the

operational terms that the injury caused is the effect of an intervention done to improve the

proof that there was a negligent act. working conditions of the workers on their

75. Answer: (B) The Board can investigate productivity. It resulted to an increased

violations of the nursing law and code of ethics productivity but not due to the intervention

Rationale: Quasi-judicial power means that the but due to the psychological effects of being

Board of Nursing has the authority to observed. They performed differently because

investigate violations of the nursing law and they were under observation.

can issue summons, subpoena or subpoena 79. Answer: (B) Determines the different

duces tecum as needed. nationality of patients frequently admitted and

76. Answer: (C) May apply for re-issuance of decides to get representations samples from

his/her license based on certain conditions each.

stipulated in RA 9173 Rationale: Judgment sampling involves

Rationale: RA 9173 sec. 24 states that for including samples according to the knowledge

equity and justice, a revoked license maybe of the investigator about the participants in
reissued
the study.
provided that the following conditions
80. Answer: (B) Madeleine Leininger
are met: a) the cause for revocation of license
Rationale: Madeleine Leininger developed the
has already been corrected or removed; and,
theory on transcultural theory based on her
b) at least four years has elapsed since the
observations on the behavior of selected
license has been revoked.
people within a culture.
77. Answer: (B) Review related literature
81. Answer: (A) Random
Rationale: After formulating and delimiting the
Rationale: Random sampling gives equal
research problem, the researcher conducts a
chance for all the elements in the population
review of related literature to determine the
to be picked as part of the sample.
extent of what has been done on the study by
82. Answer: (A) Degree of agreement and
disagreement The client should be instructed to cut toenails

Rationale: Likert scale is a 5-point summated straight across with nail clippers.

scale used to determine the degree of 87. Answer: (D) Ground beef patties

agreement or disagreement of the 271

respondents to a statement in a study Rationale: Meat is an excellent source of

83. Answer: (B) Sr. Callista Roy complete protein, which this client needs to

Rationale: Sr. Callista Roy developed the repair the tissue breakdown caused by

Adaptation Model which involves the pressure ulcers. Oranges and broccoli supply

physiologic mode, self-concept mode, role vitamin C but not protein. Ice cream supplies

function mode and dependence mode. only some incomplete protein, making it less

84. Answer: (A) Span of control helpful in tissue repair.

Rationale: Span of control refers to the 88. Answer: (D) Sims’ left lateral

number of workers who report directly to a Rationale: The Sims' left lateral position is the

manager. most common position used to administer a

85. Answer: (B) Autonomy cleansing enema because it allows gravity to

Rationale: Informed consent means that the aid the flow of fluid along the curve of the

patient fully understands about the surgery, sigmoid colon. If the client can't assume this

including the risks involved and the alternative position nor has poor sphincter control, the

solutions. In giving consent it is done with full dorsal recumbent or right lateral position may

knowledge and is given freely. The action of be used. The supine and prone positions are

allowing the patient to decide whether a inappropriate and uncomfortable for the

surgery is to be done or not exemplifies the client.

bioethical principle of autonomy. 89. Answer: (A) Arrange for typing and cross

86. Answer: (C) Avoid wearing canvas shoes. matching of the client’s blood.

Rationale: The client should be instructed to Rationale: The nurse first arranges for typing

avoid wearing canvas shoes. Canvas shoes and cross matching of the client's blood to

cause the feet to perspire, which may, in turn, ensure compatibility with donor blood. The

cause skin irritation and breakdown. Both other options, although appropriate when

cotton and cornstarch absorb perspiration. preparing to administer a blood transfusion,

come later. promote venous return. The nurse needs to

90. Answer: (A) Independent remove them once per day to observe the

Rationale: Nursing interventions are classified condition of the skin underneath the stockings.

as independent, interdependent, or Applying the stockings increases blood flow to

dependent. Altering the drug schedule to the heart. When the stockings are in place, the

coincide with the client's daily routine leg muscles can still stretch and relax, and the

represents an independent intervention, veins can fill with blood.

whereas consulting with the physician and 93. Answer :(A) Instructing the client to report
any
pharmacist to change a client's medication
itching, swelling, or dyspnea.
because of adverse reactions represents an
Rationale: Because administration of blood or
interdependent intervention. Administering an
blood products may cause serious adverse
already-prescribed drug on time is a
effects such as allergic reactions, the nurse
dependent intervention. An intradependent
must monitor the client for these effects. Signs
nursing intervention doesn't exist.
and symptoms of life-threatening allergic
91. Answer: (D) Evaluation
reactions include itching, swelling, and
Rationale: The nursing actions described
dyspnea. Although the nurse should inform
constitute evaluation of the expected
the client of the duration of the transfusion
outcomes. The findings show that the
and should document its administration, these
expected outcomes have been achieved.
actions are less critical to the client's
Assessment consists of the client's history,
immediate health. The nurse should assess
physical examination, and laboratory studies.
vital signs at least hourly during the
Analysis consists of considering assessment
transfusion.
information to derive the appropriate nursing
94. Answer: (B) Decrease the rate of feedings
diagnosis. Implementation is the phase of the
and
nursing process where the nurse puts the plan
the concentration of the formula.
of care into action.
Rationale: Complaints of abdominal
92. Answer: (B) To observe the lower
discomfort and nausea are common in clients
extremities
receiving tube feedings. Decreasing the rate of
Rationale: Elastic stockings are used to
the feeding and the concentration of the connectors between the oxygen equipment

formula should decrease the client's and humidifier to ensure that they're airtight;

discomfort. Feedings are normally given at loosened connectors can cause loss of oxygen.

room temperature to minimize abdominal 97. Answer: (B) 4 hours

cramping. To prevent aspiration during Rationale: A unit of packed RBCs may be given

feeding, the head of the client's bed should be over a period of between 1 and 4 hours. It

elevated at least 30 degrees. Also, to prevent shouldn't infuse for longer than 4 hours

bacterial growth, feeding containers should be because the risk of contamination and sepsis

routinely changed every 8 to 12 hours. increases after that time. Discard or return to

95. Answer: (D) Roll the vial gently between the the blood bank any blood not given within this

palms. time, according to facility policy.

Rationale: Rolling the vial gently between the 98. Answer: (B) Immediately before
administering
palms produces heat, which helps dissolve the
the next dose.
medication. Doing nothing or inverting the vial
Rationale: Measuring the blood drug
wouldn't help dissolve the medication. Shaking
concentration helps determine whether the
the vial vigorously could cause the medication
dosing has achieved the therapeutic goal. For
to break down, altering its action.
measurement of the trough, or lowest, blood
96. Answer: (B) Assist the client to the semi-
level of a drug, the nurse draws a blood
Fowler position if possible.
sample immediately before administering the
Rationale: By assisting the client to the semi-
next dose. Depending on the drug's duration
Fowler position, the nurse promotes easier
of action and half-life, peak blood drug levels
chest expansion, breathing, and oxygen intake.
typically are drawn after administering the
The nurse should secure the elastic band so
next dose.
that the face mask fits comfortably and snugly
99. Answer: (A) The nurse can implement
rather than tightly, which could lead to
medication orders quickly.
272
Rationale: A floor stock system enables the
irritation. The nurse should apply the face
nurse to implement medication orders quickly.
mask from the client's nose down to the chin
It doesn't allow for pharmacist input, nor does
— not vice versa. The nurse should check the
it minimize transcription errors or reinforce risk for a spontaneous abortion?

accurate calculations. a. Age 36 years

100. Answer: (C) Shifting dullness over the b. History of syphilis

abdomen. c. History of genital herpes

Rationale: Shifting dullness over the abdomen d. History of diabetes mellitus

indicates ascites, an abnormal finding. The 3. Nurse Hazel is preparing to care for a client
who
other options are normal abdominal findings.
is newly admitted to the hospital with a possible
273
diagnosis of ectopic pregnancy. Nurse Hazel
TEST II - Community Health Nursing and Care of
develops a plan of care for the client and
the Mother and Child
determines that which of the following nursing
1. May arrives at the health care clinic and tells
the actions is the priority?

nurse that her last menstrual period was 9 a. Monitoring weight

weeks ago. She also tells the nurse that a home b. Assessing for edema

pregnancy test was positive but she began to c. Monitoring apical pulse

have mild cramps and is now having moderate d. Monitoring temperature

vaginal bleeding. During the physical 4. Nurse Oliver is teaching a diabetic pregnant

examination of the client, the nurse notes that client about nutrition and insulin needs during

May has a dilated cervix. The nurse determines pregnancy. The nurse determines that the client

that May is experiencing which type of understands dietary and insulin needs if the
abortion?
client states that the second half of pregnancy
a. Inevitable
requires:
b. Incomplete
a. Decreased caloric intake
c. Threatened
b. Increased caloric intake
d. Septic
c. Decreased Insulin
2. Nurse Reese is reviewing the record of a
d. Increase Insulin
pregnant client for her first prenatal visit. Which
5. Nurse Michelle is assessing a 24 year old
of the following data, if noted on the client’s client

record, would alert the nurse that the client is at with a diagnosis of hydatidiform mole. She is
aware that one of the following is unassociated 8. A pregnant client is receiving oxytocin
(Pitocin)
with this condition?
for induction of labor. A condition that warrant
a. Excessive fetal activity.
the nurse in-charge to discontinue I.V. infusion
b. Larger than normal uterus for
of Pitocin is:
gestational age.
a. Contractions every 1 ½ minutes lasting
c. Vaginal bleeding
70-80 seconds.
d. Elevated levels of human chorionic
b. Maternal temperature 101.2
gonadotropin.
c. Early decelerations in the fetal heart
6. A pregnant client is receiving magnesium
sulfate rate.

for severe pregnancy induced hypertension d. Fetal heart rate baseline 140-160 bpm.

(PIH). The clinical findings that would warrant 9. Calcium gluconate is being administered to a

use of the antidote , calcium gluconate is: client with pregnancy induced hypertension

a. Urinary output 90 cc in 2 hours. (PIH). A nursing action that must be initiated as

b. Absent patellar reflexes. the plan of care throughout injection of the

drug
c. Rapid respiratory rate above 40/min.
is:
d. Rapid rise in blood pressure.
a. Ventilator assistance
7. During vaginal examination of Janah who is in
b. CVP readings
labor, the presenting part is at station plus two.
c. EKG tracings
Nurse, correctly interprets it as:
d. Continuous CPR
a. Presenting part is 2 cm above the plane
10. A trial for vaginal delivery after an earlier
of the ischial spines.
caesarean, would likely to be given to a gravida,
b. Biparietal diameter is at the level of the
who had:
ischial spines.
274
c. Presenting part in 2 cm below the plane
a. First low transverse cesarean was for
of the ischial spines.
active herpes type 2 infections; vaginal
d. Biparietal diameter is 2 cm above the
culture at 39 weeks pregnancy was
ischial spines.
positive.
b. First and second caesareans were for a. Feed the infant when he cries.

cephalopelvic disproportion. b. Allow the infant to rest before feeding.

c. First caesarean through a classic incision c. Bathe the infant and administer

as a result of severe fetal distress. medications before feeding.

d. First low transverse caesarean was for d. Weigh and bathe the infant before

breech position. Fetus in this pregnancy feeding.

is in a vertex presentation. 14. Nurse Hazel is teaching a mother who plans

to
11. Nurse Ryan is aware that the best initial
discontinue breast feeding after 5 months. The
approach when trying to take a crying toddler’s
nurse should advise her to include which foods
temperature is:
in her infant’s diet?
a. Talk to the mother first and then to the
a. Skim milk and baby food.
toddler.
b. Whole milk and baby food.
b. Bring extra help so it can be done
c. Iron-rich formula only.
quickly.
d. Iron-rich formula and baby food.
c. Encourage the mother to hold the child.
15. Mommy Linda is playing with her infant,
d. Ignore the crying and screaming.
who is
12. Baby Tina a 3 month old infant just had a
sitting securely alone on the floor of the clinic.
cleft lip
The mother hides a toy behind her back and the
and palate repair. What should the nurse do to
infant looks for it. The nurse is aware that
prevent trauma to operative site?
estimated age of the infant would be:
a. Avoid touching the suture line, even
a. 6 months
when cleaning.
b. 4 months
b. Place the baby in prone position.
c. 8 months
c. Give the baby a pacifier.
d. 10 months
d. Place the infant’s arms in soft elbow
16. Which of the following is the most
restraints.
prominent
13. Which action should nurse Marian include in
feature of public health nursing?
the
a. It involves providing home care to sick
care plan for a 2 month old with heart failure?
people who are not confined in the
hospital. d. Any qualified physician

b. Services are provided free of charge to 20. Myra is the public health nurse in a
municipality
people within the catchments area.
with a total population of about 20,000. There
c. The public health nurse functions as part
are 3 rural health midwives among the RHU
of a team providing a public health
personnel. How many more midwife items will
nursing services.
the RHU need?
d. Public health nursing focuses on
a. 1
preventive, not curative, services.
b. 2
17. When the nurse determines whether
resources c. 3

were maximized in implementing Ligtas Tigdas, d. The RHU does not need any more

she is evaluating midwife item.

a. Effectiveness 275

b. Efficiency 21. According to Freeman and Heinrich,

community
c. Adequacy
health nursing is a developmental service.
d. Appropriateness
Which
18. Vangie is a new B.S.N. graduate. She wants
of the following best illustrates this statement?
to
a. The community health nurse
become a Public Health Nurse. Where should
continuously develops himself
she apply?
personally and professionally.
a. Department of Health
b. Health education and community
b. Provincial Health Office
organizing are necessary in providing
c. Regional Health Office
community health services.
d. Rural Health Unit
c. Community health nursing is intended
19. Tony is aware the Chairman of the Municipal
primarily for health promotion and
Health Board is:
prevention and treatment of disease.
a. Mayor
d. The goal of community health nursing is
b. Municipal Health Officer
to provide nursing services to people in
c. Public Health Nurse
their own places of residence.
22. Nurse Tina is aware that the disease a. Pre-pathogenesis
declared
b. Pathogenesis
through Presidential Proclamation No. 4 as a
c. Prodromal
target for eradication in the Philippines is?
d. Terminal
a. Poliomyelitis
26. The nurse is caring for a primigravid client in
b. Measles the

c. Rabies labor and delivery area. Which condition would

d. Neonatal tetanus place the client at risk for disseminated

23. May knows that the step in community intravascular coagulation (DIC)?

organizing that involves training of potential a. Intrauterine fetal death.

leaders in the community is: b. Placenta accreta.

a. Integration c. Dysfunctional labor.

b. Community organization d. Premature rupture of the membranes.

c. Community study 27. A fullterm client is in labor. Nurse Betty is

aware
d. Core group formation
that the fetal heart rate would be:
24. Beth a public health nurse takes an active
role in a. 80 to 100 beats/minute

community participation. What is the primary b. 100 to 120 beats/minute

goal of community organizing? c. 120 to 160 beats/minute

a. To educate the people regarding d. 160 to 180 beats/minute

community health problems 28. The skin in the diaper area of a 7 month old

b. To mobilize the people to resolve infant is excoriated and red. Nurse Hazel should

community health problems instruct the mother to:

c. To maximize the community’s resources a. Change the diaper more often.

in dealing with health problems. b. Apply talc powder with diaper changes.

d. To maximize the community’s resources c. Wash the area vigorously with each

in dealing with health problems. diaper change.

25. Tertiary prevention is needed in which stage d. Decrease the infant’s fluid intake to
of
decrease saturating diapers.
the natural history of disease?
29. Nurse Carla knows that the common cardiac b. Iron binding capacity

anomalies in children with Down Syndrome c. Blood typing

(trisomy
d. Serum Calcium
21) is:
33. Nurse Gina is aware that the most common
a. Atrial septal defect
condition found during the second-trimester of
b. Pulmonic stenosis
pregnancy is:
c. Ventricular septal defect
a. Metabolic alkalosis
d. Endocardial cushion defect
b. Respiratory acidosis
30. Malou was diagnosed with severe
c. Mastitis
preeclampsia
d. Physiologic anemia
is now receiving I.V. magnesium sulfate. The
34. Nurse Lynette is working in the triage area of
adverse effects associated with magnesium
an
sulfate is:
emergency department. She sees that several
a. Anemia
pediatric clients arrive simultaneously. The
b. Decreased urine output client

c. Hyperreflexia who needs to be treated first is:

d. Increased respiratory rate a. A crying 5 year old child with a

31. A 23 year old client is having her menstrual laceration on his scalp.

period every 2 weeks that last for 1 week. This b. A 4 year old child with a barking coughs

type of menstrual pattern is bets defined by: and flushed appearance.

a. Menorrhagia c. A 3 year old child with Down syndrome

b. Metrorrhagia who is pale and asleep in his mother’s

c. Dyspareunia arms.

d. Amenorrhea d. A 2 year old infant with stridorous

276 breath sounds, sitting up in his mother’s

32. Jannah is admitted to the labor and delivery arms and drooling.

unit. The critical laboratory result for this client 35. Maureen in her third trimester arrives at the

would be: emergency room with painless vaginal bleeding.

a. Oxygen saturation Which of the following conditions is suspected?

a. Placenta previa b. “I may need a different size of

b. Abruptio placentae diaphragm if I gain or lose weight more

c. Premature labor than 20 pounds”

d. Sexually transmitted disease c. “The diaphragm must be left in place for

36. A young child named Richard is suspected of atleast 6 hours after intercourse”

having pinworms. The community nurse collects d. “I really need to use the diaphragm and

a stool specimen to confirm the diagnosis. The jelly most during the middle of my

nurse should schedule the collection of this menstrual cycle”.

specimen for: 39. Hypoxia is a common complication of

a. Just before bedtime laryngotracheobronchitis. Nurse Oliver should

b. After the child has been bathe frequently assess a child with

c. Any time during the day laryngotracheobronchitis for:

d. Early in the morning a. Drooling

37. In doing a child’s admission assessment, b. Muffled voice

Nurse
c. Restlessness
Betty should be alert to note which signs or
d. Low-grade fever
symptoms of chronic lead poisoning?
40. How should Nurse Michelle guide a child
a. Irritability and seizures who is

b. Dehydration and diarrhea blind to walk to the playroom?

c. Bradycardia and hypotension a. Without touching the child, talk

d. Petechiae and hematuria continuously as the child walks down the

38. To evaluate a woman’s understanding about hall.

the
b. Walk one step ahead, with the child’s
use of diaphragm for family planning, Nurse
hand on the nurse’s elbow.
Trish asks her to explain how she will use the
c. Walk slightly behind, gently guiding the
appliance. Which response indicates a need for
child forward.
further health teaching?
d. Walk next to the child, holding the
a. “I should check the diaphragm carefully
child’s hand.
for holes every time I use it”
41. When assessing a newborn diagnosed with
ductus arteriosus, Nurse Olivia should expect d. Voided

that the child most likely would have an: 44. Nurse Carla should know that the most
common
a. Loud, machinery-like murmur.
causative factor of dermatitis in infants and
b. Bluish color to the lips.
younger children is:
c. Decreased BP reading in the upper
a. Baby oil
extremities
b. Baby lotion
d. Increased BP reading in the upper
c. Laundry detergent
extremities.
d. Powder with cornstarch
42. The reason nurse May keeps the neonate in
a 45. During tube feeding, how far above an
infant’s
neutral thermal environment is that when a
stomach should the nurse hold the syringe with
277
formula?
newborn becomes too cool, the neonate
a. 6 inches
requires:
b. 12 inches
a. Less oxygen, and the newborn’s
c. 18 inches
metabolic rate increases.
d. 24 inches
b. More oxygen, and the newborn’s
46. In a mothers’ class, Nurse Lhynnete
metabolic rate decreases.
discussed
c. More oxygen, and the newborn’s
childhood diseases such as chicken pox. Which
metabolic rate increases.
of the following statements about chicken pox is
d. Less oxygen, and the newborn’s
correct?
metabolic rate decreases.
a. The older one gets, the more susceptible
43. Before adding potassium to an infant’s I.V.
he becomes to the complications of
line,
chicken pox.
Nurse Ron must be sure to assess whether this
b. A single attack of chicken pox will
infant has:
prevent future episodes, including
a. Stable blood pressure
conditions such as shingles.
b. Patant fontanelles
c. To prevent an outbreak in the
c. Moro’s reflex
community, quarantine may be imposed
by health authorities. A week after the start of fever, the client noted

d. Chicken pox vaccine is best given when yellowish discoloration of his sclera. History

there is an impending outbreak in the showed that he waded in flood waters about 2

community. weeks before the onset of symptoms. Based on

47. Barangay Pinoy had an outbreak of German her history, which disease condition will you

measles. To prevent congenital rubella, what is suspect?

the BEST advice that you can give to women in a. Hepatitis A

the first trimester of pregnancy in the barangay b. Hepatitis B

Pinoy? c. Tetanus

a. Advise them on the signs of German d. Leptospirosis

measles. 50. Mickey a 3-year old client was brought to

the
b. Avoid crowded places, such as markets
health center with the chief complaint of severe
and movie houses.
diarrhea and the passage of “rice water” stools.
c. Consult at the health center where
The client is most probably suffering from which
rubella vaccine may be given.
condition?
d. Consult a physician who may give them
a. Giardiasis
rubella immunoglobulin.
b. Cholera
48. Myrna a public health nurse knows that to
c. Amebiasis
determine possible sources of sexually
d. Dysentery
transmitted infections, the BEST method that
51. The most prevalent form of meningitis
may be undertaken is:
among
a. Contact tracing
children aged 2 months to 3 years is caused by
b. Community survey
which microorganism?
c. Mass screening tests
a. Hemophilus influenzae
d. Interview of suspects
b. Morbillivirus
49. A 33-year old female client came for
278
consultation at the health center with the chief
c. Steptococcus pneumoniae
complaint of fever for a week. Accompanying
d. Neisseria meningitidis
symptoms were muscle pains and body malaise.
52. The student nurse is aware that the number of infants in the barangay would be:

pathognomonic sign of measles is Koplik’s spot a. 45 infants

and you may see Koplik’s spot by inspecting the: b. 50 infants

a. Nasal mucosa c. 55 infants

b. Buccal mucosa d. 65 infants

c. Skin on the abdomen 56. The community nurse is aware that the

d. Skin on neck biological used in Expanded Program on

53. Angel was diagnosed as having Dengue Immunization (EPI) should NOT be stored in the
fever.
freezer?
You will say that there is slow capillary refill
a. DPT
when the color of the nailbed that you pressed
b. Oral polio vaccine
does not return within how many seconds?
c. Measles vaccine
a. 3 seconds
d. MMR
b. 6 seconds
57. It is the most effective way of controlling
c. 9 seconds
schistosomiasis in an endemic area?
d. 10 seconds
a. Use of molluscicides
54. In Integrated Management of Childhood
b. Building of foot bridges
Illness,
c. Proper use of sanitary toilets
the nurse is aware that the severe conditions
d. Use of protective footwear, such as
generally require urgent referral to a hospital.
rubber boots
Which of the following severe conditions DOES
58. Several clients is newly admitted and
NOT always require urgent referral to a
diagnosed
hospital?
with leprosy. Which of the following clients
a. Mastoiditis
should be classified as a case of multibacillary
b. Severe dehydration
leprosy?
c. Severe pneumonia
a. 3 skin lesions, negative slit skin smear
d. Severe febrile disease
b. 3 skin lesions, positive slit skin smear
55. Myrna a public health nurse will conduct
c. 5 skin lesions, negative slit skin smear
outreach immunization in a barangay Masay
d. 5 skin lesions, positive slit skin smear
with a population of about 1500. The estimated
59. Nurses are aware that diagnosis of leprosy is you manage Jimmy?

highly dependent on recognition of symptoms. a. Refer the child urgently to a hospital for

Which of the following is an early sign of confinement.

leprosy? b. Coordinate with the social worker to

a. Macular lesions enroll the child in a feeding program.

b. Inability to close eyelids c. Make a teaching plan for the mother,

c. Thickened painful nerves focusing on menu planning for her child.

d. Sinking of the nosebridge d. Assess and treat the child for health

60. Marie brought her 10 month old infant for problems like infections and intestinal

consultation because of fever, started 4 days parasitism.

prior to consultation. In determining malaria 279

risk, what will you do? 63. Gina is using Oresol in the management of

a. Perform a tourniquet test. diarrhea of her 3-year old child. She asked you

b. Ask where the family resides. what to do if her child vomits. As a nurse you
will
c. Get a specimen for blood smear.
tell her to:
d. Ask if the fever is present every day.
a. Bring the child to the nearest hospital
61. Susie brought her 4 years old daughter to
the for further assessment.

RHU because of cough and colds. Following the b. Bring the child to the health center for

IMCI assessment guide, which of the following is intravenous fluid therapy.

a danger sign that indicates the need for urgent c. Bring the child to the health center for

referral to a hospital? assessment by the physician.

a. Inability to drink d. Let the child rest for 10 minutes then

b. High grade fever continue giving Oresol more slowly.

c. Signs of severe dehydration 64. Nikki a 5-month old infant was brought by
his
d. Cough for more than 30 days
mother to the health center because of diarrhea
62. Jimmy a 2-year old child revealed “baggy
pants”. for 4 to 5 times a day. Her skin goes back slowly

As a nurse, using the IMCI guidelines, how will after a skin pinch and her eyes are sunken.
Using
the IMCI guidelines, you will classify this infant b. 4 hours
in
c. 8 hours
which category?
d. At the end of the day
a. No signs of dehydration
68. The nurse explains to a breastfeeding
b. Some dehydration mother

c. Severe dehydration that breast milk is sufficient for all of the baby’s

d. The data is insufficient. nutrient needs only up to:

65. Chris a 4-month old infant was brought by a. 5 months

her
b. 6 months
mother to the health center because of cough.
c. 1 year
His respiratory rate is 42/minute. Using the
d. 2 years
Integrated Management of Child Illness (IMCI)
69. Nurse Ron is aware that the gestational age
guidelines of assessment, his breathing is of a

considered as: conceptus that is considered viable (able to live

a. Fast outside the womb) is:

b. Slow a. 8 weeks

c. Normal b. 12 weeks

d. Insignificant c. 24 weeks

66. Maylene had just received her 4th dose of d. 32 weeks

tetanus toxoid. She is aware that her baby will 70. When teaching parents of a neonate the
proper
have protection against tetanus for
position for the neonate’s sleep, the nurse
a. 1 year
Patricia stresses the importance of placing the
b. 3 years
neonate on his back to reduce the risk of which
c. 5 years
of the following?
d. Lifetime
a. Aspiration
67. Nurse Ron is aware that unused BCG should
be b. Sudden infant death syndrome (SIDS)

discarded after how many hours of c. Suffocation

reconstitution? d. Gastroesophageal reflux (GER)

a. 2 hours
71. Which finding might be seen in baby James would nurse Richard anticipate as a potential
a
problem in the neonate?
neonate suspected of having an infection?
a. Hypoglycemia
a. Flushed cheeks
b. Jitteriness
b. Increased temperature
c. Respiratory depression
c. Decreased temperature
d. Tachycardia
d. Increased activity level
75. Which symptom would indicate the Baby
72. Baby Jenny who is small-for-gestation is at
Alexandra was adapting appropriately to
increased risk during the transitional period for extrauterine

which complication? life without difficulty?

a. Anemia probably due to chronic fetal a. Nasal flaring

hyposia b. Light audible grunting

b. Hyperthermia due to decreased c. Respiratory rate 40 to 60

glycogen stores breaths/minute

c. Hyperglycemia due to decreased d. Respiratory rate 60 to 80

glycogen stores breaths/minute

d. Polycythemia probably due to chronic 76. When teaching umbilical cord care for
Jennifer a
fetal hypoxia
new mother, the nurse Jenny would include
73. Marjorie has just given birth at 42 weeks’
which information?
gestation. When the nurse assessing the
a. Apply peroxide to the cord with each
neonate, which physical finding is expected?
diaper change
a. A sleepy, lethargic baby
b. Cover the cord with petroleum jelly after
b. Lanugo covering the body
bathing
c. Desquamation of the epidermis
c. Keep the cord dry and open to air
d. Vernix caseosa covering the body
d. Wash the cord with soap and water each
280
day during a tub bath.
74. After reviewing the Myrna’s maternal history
of 77. Nurse John is performing an assessment on
a
magnesium sulfate during labor, which
condition neonate. Which of the following findings is
considered common in the healthy neonate? laceration. Which of the following would be

a. Simian crease contraindicated when caring for this client?

b. Conjunctival hemorrhage a. Applying cold to limit edema during the

c. Cystic hygroma first 12 to 24 hours.

d. Bulging fontanelle b. Instructing the client to use two or more

78. Dr. Esteves decides to artificially rupture the peripads to cushion the area.

membranes of a mother who is on labor. c. Instructing the client on the use of sitz

Following this procedure, the nurse Hazel baths if ordered.

checks
d. Instructing the client about the
the fetal heart tones for which the following
importance of perineal (kegel) exercises.
reasons?
81. A pregnant woman accompanied by her
a. To determine fetal well-being.
husband, seeks admission to the labor and
b. To assess for prolapsed cord
delivery area. She states that she's in labor and
c. To assess fetal position
says she attended the facility clinic for prenatal
d. To prepare for an imminent delivery.
care. Which question should the nurse Oliver
79. Which of the following would be least likely ask
to
her first?
indicate anticipated bonding behaviors by new
a. “Do you have any chronic illnesses?”
parents?
b. “Do you have any allergies?”
a. The parents’ willingness to touch and
c. “What is your expected due date?”
hold the new born.
d. “Who will be with you during labor?”
b. The parent’s expression of interest
82. A neonate begins to gag and turns a dusky
about the size of the new born. color.

c. The parents’ indication that they want to What should the nurse do first?

see the newborn. a. Calm the neonate.

d. The parents’ interactions with each b. Notify the physician.

other. c. Provide oxygen via face mask as ordered

80. Following a precipitous delivery, d. Aspirate the neonate’s nose and mouth
examination of
with a bulb syringe.
the client's vagina reveals a fourth-degree
83. When a client states that her "water broke," calorie intake?

which of the following actions would be a. 110 to 130 calories per kg.

inappropriate for the nurse to do? b. 30 to 40 calories per lb of body weight.

a. Observing the pooling of straw-colored c. At least 2 ml per feeding

fluid. d. 90 to 100 calories per kg

b. Checking vaginal discharge with nitrazine 86. Nurse John is knowledgeable that usually

paper. individual twins will grow appropriately and at

c. Conducting a bedside ultrasound for an the same rate as singletons until how many

amniotic fluid index. weeks?

d. Observing for flakes of vernix in the a. 16 to 18 weeks

vaginal discharge. b. 18 to 22 weeks

84. A baby girl is born 8 weeks premature. At c. 30 to 32 weeks

birth,
d. 38 to 40 weeks
she has no spontaneous respirations but is
87. Which of the following classifications applies
281 to

successfully resuscitated. Within several hours monozygotic twins for whom the cleavage of
the
she develops respiratory grunting, cyanosis,
fertilized ovum occurs more than 13 days after
tachypnea, nasal flaring, and retractions. She's
fertilization?
diagnosed with respiratory distress syndrome,
a. conjoined twins
intubated, and placed on a ventilator. Which
b. diamniotic dichorionic twins
nursing action should be included in the baby's
c. diamniotic monochorionic twin
plan of care to prevent retinopathy of
d. monoamniotic monochorionic twins
prematurity?
88. Tyra experienced painless vaginal bleeding
a. Cover his eyes while receiving oxygen.
has
b. Keep her body temperature low.
just been diagnosed as having a placenta previa.
c. Monitor partial pressure of oxygen
Which of the following procedures is usually
(Pao2) levels.
performed to diagnose placenta previa?
d. Humidify the oxygen.
a. Amniocentesis
85. Which of the following is normal newborn
b. Digital or speculum examination
c. External fetal monitoring a. Antihypertensive agents

d. Ultrasound b. Diuretic agents

89. Nurse Arnold knows that the following c. I.V. fluids

changes
d. Acetaminophen (Tylenol) for pain
in respiratory functioning during pregnancy is
93. Which of the following drugs is the antidote
considered normal: for

a. Increased tidal volume magnesium toxicity?

b. Increased expiratory volume a. Calcium gluconate (Kalcinate)

c. Decreased inspiratory capacity b. Hydralazine (Apresoline)

d. Decreased oxygen consumption c. Naloxone (Narcan)

90. Emily has gestational diabetes and it is d. Rho (D) immune globulin (RhoGAM)
usually
94. Marlyn is screened for tuberculosis during
managed by which of the following therapy? her

a. Diet first prenatal visit. An intradermal injection of

b. Long-acting insulin purified protein derivative (PPD) of the

c. Oral hypoglycemic tuberculin bacilli is given. She is considered to

d. Oral hypoglycemic drug and insulin have a positive test for which of the following

91. Magnesium sulfate is given to Jemma with results?

preeclampsia to prevent which of the following a. An indurated wheal under 10 mm in

condition? diameter appears in 6 to 12 hours.

a. Hemorrhage b. An indurated wheal over 10 mm in

b. Hypertension diameter appears in 48 to 72 hours.

c. Hypomagnesemia c. A flat circumcised area under 10 mm in

d. Seizure diameter appears in 6 to 12 hours.

92. Cammile with sickle cell anemia has an d. A flat circumcised area over 10 mm in
increased
diameter appears in 48 to 72 hours.
risk for having a sickle cell crisis during
95. Dianne, 24 year-old is 27 weeks’ pregnant
pregnancy. Aggressive management of a sickle
arrives at her physician’s office with complaints
cell crisis includes which of the following
of fever, nausea, vomiting, malaise, unilateral
measures?
282 98. Celeste who used heroin during her
pregnancy
flank pain, and costovertebral angle tenderness.
delivers a neonate. When assessing the
Which of the following diagnoses is most likely?
neonate,
a. Asymptomatic bacteriuria
the nurse Lhynnette expects to find:
b. Bacterial vaginosis
a. Lethargy 2 days after birth.
c. Pyelonephritis
b. Irritability and poor sucking.
d. Urinary tract infection (UTI)
c. A flattened nose, small eyes, and thin
96. Rh isoimmunization in a pregnant client
lips.
develops during which of the following
d. Congenital defects such as limb
conditions?
anomalies.
a. Rh-positive maternal blood crosses into
99. The uterus returns to the pelvic cavity in
fetal blood, stimulating fetal antibodies. which

b. Rh-positive fetal blood crosses into of the following time frames?

maternal blood, stimulating maternal a. 7th to 9th day postpartum.

antibodies. b. 2 weeks postpartum.

c. Rh-negative fetal blood crosses into c. End of 6th week postpartum.

maternal blood, stimulating maternal d. When the lochia changes to alba.

antibodies. 100. Maureen, a primigravida client, age 20, has

d. Rh-negative maternal blood crosses into just completed a difficult, forceps-assisted

fetal blood, stimulating fetal antibodies. delivery of twins. Her labor was unusually

97. To promote comfort during labor, the nurse long and required oxytocin (Pitocin)
John
augmentation. The nurse who's caring for her
advises a client to assume certain positions and
should stay alert for:
avoid others. Which position may cause
a. Uterine inversion
maternal hypotension and fetal hypoxia?
b. Uterine atony
a. Lateral position
c. Uterine involution
b. Squatting position
d. Uterine discomfort
c. Supine position
283
d. Standing position
Answers and Rationale – Community Health
Nursing and Care of the Mother and Child elevated levels of human chorionic

1. Answer: (A) Inevitable gonadotropin, vaginal bleeding, larger than

Rationale: An inevitable abortion is termination normal uterus for gestational age, failure to

of pregnancy that cannot be prevented. detect fetal heart activity even with sensitive

Moderate to severe bleeding with mild instruments, excessive nausea and vomiting,

cramping and cervical dilation would be noted and early development of pregnancy-induced

in this type of abortion. hypertension. Fetal activity would not be noted.

2. Answer: (B) History of syphilis 6. Answer: (B) Absent patellar reflexes

Rationale: Maternal infections such as syphilis, Rationale: Absence of patellar reflexes is an

toxoplasmosis, and rubella are causes of indicator of hypermagnesemia, which requires

spontaneous abortion. administration of calcium gluconate.

3. Answer: (C) Monitoring apical pulse 7. Answer: (C) Presenting part in 2 cm below the

Rationale: Nursing care for the client with a plane of the ischial spines.

possible ectopic pregnancy is focused on Rationale: Fetus at station plus two indicates

preventing or identifying hypovolemic shock that the presenting part is 2 cm below the

and controlling pain. An elevated pulse rate is plane of the ischial spines.

an indicator of shock. 8. Answer: (A) Contractions every 1 ½ minutes

4. Answer: (B) Increased caloric intake lasting 70-80 seconds.

Rationale: Glucose crosses the placenta, but Rationale: Contractions every 1 ½ minutes

insulin does not. High fetal demands for lasting 70-80 seconds, is indicative of

glucose, combined with the insulin resistance hyperstimulation of the uterus, which could

caused by hormonal changes in the last half of result in injury to the mother and the fetus if

pregnancy can result in elevation of maternal Pitocin is not discontinued.

blood glucose levels. This increases the 9. Answer: (C) EKG tracings

mother’s demand for insulin and is referred to Rationale: A potential side effect of calcium

as the diabetogenic effect of pregnancy. gluconate administration is cardiac arrest.

5. Answer: (A) Excessive fetal activity. Continuous monitoring of cardiac activity (EKG)

Rationale: The most common signs and throught administration of calcium gluconate is

symptoms of hydatidiform mole includes an essential part of care.

10. Answer: (D) First low transverse caesarean prevent infection, which could interfere with
was
healing and damage the cosmetic appearance
for breech position. Fetus in this pregnancy is in
of the repair.
a vertex presentation.
13. Answer: (B) Allow the infant to rest before
Rationale: This type of client has no obstetrical
feeding.
indication for a caesarean section as she did
Rationale: Because feeding requires so much
with her first caesarean delivery.
energy, an infant with heart failure should rest
11. Answer: (A) Talk to the mother first and then
before feeding.
to
14. Answer: (C) Iron-rich formula only.
the toddler.
Rationale: The infants at age 5 months should
Rationale: When dealing with a crying toddler,
receive iron-rich formula and that they
the best approach is to talk to the mother and
shouldn’t receive solid food, even baby food
ignore the toddler first. This approach helps the
until age 6 months.
toddler get used to the nurse before she
15. Answer: (D) 10 months
attempts any procedures. It also gives the
Rationale: A 10 month old infant can sit alone
toddler an opportunity to see that the mother
and understands object permanence, so he
trusts the nurse.
would look for the hidden toy. At age 4 to 6
12. Answer: (D) Place the infant’s arms in soft
months, infants can’t sit securely alone. At age
elbow restraints.
284
Rationale: Soft restraints from the upper arm to
8 months, infants can sit securely alone but
the wrist prevent the infant from touching her
cannot understand the permanence of objects.
lip but allow him to hold a favorite item such as
16. Answer: (D) Public health nursing focuses on
a blanket. Because they could damage the
preventive, not curative, services.
operative site, such as objects as pacifiers,
Rationale: The catchments area in PHN consists
suction catheters, and small spoons shouldn’t
of a residential community, many of whom are
be placed in a baby’s mouth after cleft repair. A
well individuals who have greater need for
baby in a prone position may rub her face on
preventive rather than curative services.
the sheets and traumatize the operative site.
17. Answer: (B) Efficiency
The suture line should be cleaned gently to
Rationale: Efficiency is determining whether the
goals were attained at the least possible cost. developmental service, with the goal of

18. Answer: (D) Rural Health Unit developing the people’s self-reliance in dealing

Rationale: R.A. 7160 devolved basic health with community health problems. A, B and C

services to local government units (LGU’s ). The are objectives of contributory objectives to this

public health nurse is an employee of the LGU. goal.

19. Answer: (A) Mayor 25. Answer: (D) Terminal

Rationale: The local executive serves as the Rationale: Tertiary prevention involves

chairman of the Municipal Health Board. rehabilitation, prevention of permanent

20. Answer: (A) 1 disability and disability limitations appropriate

Rationale: Each rural health midwife is given a for convalescents, the disabled, complicated

population assignment of about 5,000. cases and the terminally ill (those in the

21. Answer: (B) Health education and terminal stage of a disease).

community
26. Answer: (A) Intrauterine fetal death.
organizing are necessary in providing
Rationale: Intrauterine fetal death, abruptio
community health services. Rationale: The
placentae, septic shock, and amniotic fluid
community health nurse develops the health
embolism may trigger normal clotting
capability of people through health education
mechanisms; if clotting factors are depleted,
and community organizing activities.
DIC may occur. Placenta accreta, dysfunctional
22. Answer: (B) Measles
labor, and premature rupture of the
Rationale: Presidential Proclamation No. 4 is on
membranes aren't associated with DIC.
the Ligtas Tigdas Program.
27. Answer: (C) 120 to 160 beats/minute
23. Answer: (D) Core group formation
Rationale: A rate of 120 to 160 beats/minute in
Rationale: In core group formation, the nurse is
the fetal heart appropriate for filling the heart
able to transfer the technology of community
with blood and pumping it out to the system.
organizing to the potential or informal
28. Answer: (A) Change the diaper more often.
community leaders through a training program.
Rationale: Decreasing the amount of time the
24. Answer: (D) To maximize the community’s
skin comes contact with wet soiled diapers will
resources in dealing with health problems.
help heal the irritation.
Rationale: Community organizing is a
29. Answer: (D) Endocardial cushion defect
Rationale: Endocardial cushion defects are seen and drooling.

most in children with Down syndrome, Rationale: The infant with the airway

asplenia, or polysplenia. emergency should be treated first, because of

30. Answer: (B) Decreased urine output the risk of epiglottitis.

Rationale: Decreased urine output may occur in 35. Answer: (A) Placenta previa

clients receiving I.V. magnesium and should be Rationale: Placenta previa with painless vaginal

monitored closely to keep urine output at bleeding.

greater than 30 ml/hour, because magnesium is 36. Answer: (D) Early in the morning

excreted through the kidneys and can easily Rationale: Based on the nurse’s knowledge of

accumulate to toxic levels. microbiology, the specimen should be collected

31. Answer: (A) Menorrhagia early in the morning. The rationale for this

Rationale: Menorrhagia is an excessive 285

menstrual period. timing is that, because the female worm lays

32. Answer: (C) Blood typing eggs at night around the perineal area, the first

Rationale: Blood type would be a critical value bowel movement of the day will yield the best

to have because the risk of blood loss is always results. The specific type of stool specimen

a potential complication during the labor and used in the diagnosis of pinworms is called the

delivery process. Approximately 40% of a tape test.

woman’s cardiac output is delivered to the 37. Answer: (A) Irritability and seizures

uterus, therefore, blood loss can occur quite Rationale: Lead poisoning primarily affects the

rapidly in the event of uncontrolled bleeding. CNS, causing increased intracranial pressure.

33. Answer: (D) Physiologic anemia This condition results in irritability and changes

Rationale: Hemoglobin values and hematocrit in level of consciousness, as well as seizure

decrease during pregnancy as the increase in disorders, hyperactivity, and learning

plasma volume exceeds the increase in red disabilities.

blood cell production. 38. Answer: (D) “I really need to use the
diaphragm
34. Answer: (D) A 2 year old infant with
stridorous and jelly most during the middle of my

breath sounds, sitting up in his mother’s arms menstrual cycle”.

Rationale: The woman must understand that, production.

although the “fertile” period is approximately 43. Answer: (D) Voided

mid-cycle, hormonal variations do occur and Rationale: Before administering potassium I.V.

can result in early or late ovulation. To be to any client, the nurse must first check that the

effective, the diaphragm should be inserted client’s kidneys are functioning and that the

before every intercourse. client is voiding. If the client is not voiding, the

39. Answer: (C) Restlessness nurse should withhold the potassium and notify

Rationale: In a child, restlessness is the earliest the physician.

sign of hypoxia. Late signs of hypoxia in a child 44. Answer: (c) Laundry detergent

are associated with a change in color, such as Rationale: Eczema or dermatitis is an allergic

pallor or cyanosis. skin reaction caused by an offending allergen.

40. Answer: (B) Walk one step ahead, with the The topical allergen that is the most common

child’s hand on the nurse’s elbow. causative factor is laundry detergent.

Rationale: This procedure is generally 45. Answer: (A) 6 inches

recommended to follow in guiding a person Rationale: This distance allows for easy flow of

who is blind. the formula by gravity, but the flow will be slow

41. Answer: (A) Loud, machinery-like murmur. enough not to overload the stomach too

Rationale: A loud, machinery-like murmur is a rapidly.

characteristic finding associated with patent 46. Answer: (A) The older one gets, the more

ductus arteriosus. susceptible he becomes to the complications of

42. Answer: (C) More oxygen, and the chicken pox.

newborn’s
Rationale: Chicken pox is usually more severe in
metabolic rate increases.
adults than in children. Complications, such as
Rationale: When cold, the infant requires more
pneumonia, are higher in incidence in adults.
oxygen and there is an increase in metabolic
47. Answer: (D) Consult a physician who may
rate. Non-shievering thermogenesis is a give

complex process that increases the metabolic them rubella immunoglobulin.

rate and rate of oxygen consumption, Rationale: Rubella vaccine is made up of

therefore, the newborn increase heat attenuated German measles viruses. This is
contraindicated in pregnancy. Immune globulin, 52. Answer: (B) Buccal mucosa

a specific prophylactic against German measles, Rationale: Koplik’s spot may be seen on the

may be given to pregnant women. mucosa of the mouth or the throat.

48. Answer: (A) Contact tracing 53. Answer: (A) 3 seconds

Rationale: Contact tracing is the most practical 286

and reliable method of finding possible sources Rationale: Adequate blood supply to the area

of person-to-person transmitted infections, allows the return of the color of the nailbed

such as sexually transmitted diseases. within 3 seconds.

49. Answer: (D) Leptospirosis 54. Answer: (B) Severe dehydration

Rationale: Leptospirosis is transmitted through Rationale: The order of priority in the

contact with the skin or mucous membrane management of severe dehydration is as

with water or moist soil contaminated with follows: intravenous fluid therapy, referral to a

urine of infected animals, like rats. facility where IV fluids can be initiated within 30

50. Answer: (B) Cholera minutes, Oresol or nasogastric tube. When the

Rationale: Passage of profuse watery stools is foregoing measures are not possible or

the major symptom of cholera. Both amebic effective, then urgent referral to the hospital is

and bacillary dysentery are characterized by the done.

presence of blood and/or mucus in the stools. 55. Answer: (A) 45 infants

Giardiasis is characterized by fat malabsorption Rationale: To estimate the number of infants,

and, therefore, steatorrhea. multiply total population by 3%.

51. Answer: (A) Hemophilus influenzae 56. Answer: (A) DPT

Rationale: Hemophilus meningitis is unusual Rationale: DPT is sensitive to freezing. The

over the age of 5 years. In developing countries, appropriate storage temperature of DPT is 2 to

the peak incidence is in children less than 6 8° C only. OPV and measles vaccine are highly

months of age. Morbillivirus is the etiology of sensitive to heat and require freezing. MMR is

measles. Streptococcus pneumonia and not an immunization in the Expanded Program

Neisseria meningitidis may cause meningitis, on Immunization.

but age distribution is not specific in young 57. Answer: (C) Proper use of sanitary toilets

children. Rationale: The ova of the parasite get out of the

human body together with feces. Cutting the not able to feed or drink, vomits everything,

cycle at this stage is the most effective way of convulsions, abnormally sleepy or difficult to

preventing the spread of the disease to awaken.

susceptible hosts. 62. Answer: (A) Refer the child urgently to a

58. Answer: (D) 5 skin lesions, positive slit skin hospital for confinement.

smear Rationale: “Baggy pants” is a sign of severe

Rationale: A multibacillary leprosy case is one marasmus. The best management is urgent

who has a positive slit skin smear and at least 5 referral to a hospital.

skin lesions. 63. Answer: (D) Let the child rest for 10 minutes

59. Answer: (C) Thickened painful nerves then continue giving Oresol more slowly.

Rationale: The lesion of leprosy is not macular. Rationale: If the child vomits persistently, that

It is characterized by a change in skin color is, he vomits everything that he takes in, he has

(either reddish or whitish) and loss of sensation, to be referred urgently to a hospital. Otherwise,

sweating and hair growth over the lesion. vomiting is managed by letting the child rest for

Inability to close the eyelids (lagophthalmos) 10 minutes and then continuing with Oresol

and sinking of the nosebridge are late administration. Teach the mother to give Oresol

symptoms. more slowly.

60. Answer: (B) Ask where the family resides. 64. Answer: (B) Some dehydration

Rationale: Because malaria is endemic, the first Rationale: Using the assessment guidelines of

question to determine malaria risk is where the IMCI, a child (2 months to 5 years old) with

client’s family resides. If the area of residence is diarrhea is classified as having SOME

not a known endemic area, ask if the child had DEHYDRATION if he shows 2 or more of the

traveled within the past 6 months, where she following signs: restless or irritable, sunken

was brought and whether she stayed overnight eyes, the skin goes back slow after a skin pinch.

in that area. 65. Answer: (C) Normal

61. Answer: (A) Inability to drink Rationale: In IMCI, a respiratory rate of

Rationale: A sick child aged 2 months to 5 years 50/minute or more is fast breathing for an

must be referred urgently to a hospital if infant aged 2 to 12 months.

he/she has one or more of the following signs: 66. Answer: (A) 1 year
Rationale: The baby will have passive natural aspiration is slightly increased with the supine

immunity by placental transfer of antibodies. position. Suffocation would be less likely with

The mother will have active artificial immunity an infant supine than prone and the position

lasting for about 10 years. 5 doses will give the for GER requires the head of the bed to be

mother lifetime protection. elevated.

67. Answer: (B) 4 hours 71. Answer: (C) Decreased temperature

Rationale: While the unused portion of other Rationale: Temperature instability, especially

biologicals in EPI may be given until the end of when it results in a low temperature in the

the day, only BCG is discarded 4 hours after neonate, may be a sign of infection. The

reconstitution. This is why BCG immunization is neonate’s color often changes with an infection

scheduled only in the morning. process but generally becomes ashen or

68. Answer: (B) 6 months mottled. The neonate with an infection will

Rationale: After 6 months, the baby’s nutrient usually show a decrease in activity level or

needs, especially the baby’s iron requirement, lethargy.

can no longer be provided by mother’s milk 72. Answer: (D) Polycythemia probably due to

alone. chronic fetal hypoxia

69. Answer: (C) 24 weeks Rationale: The small-for-gestation neonate is at

Rationale: At approximately 23 to 24 weeks’ risk for developing polycythemia during the

gestation, the lungs are developed enough to transitional period in an attempt to decrease

sometimes maintain extrauterine life. The lungs hypoxia. The neonates are also at increased risk

are the most immature system during the for developing hypoglycemia and hypothermia

gestation period. Medical care for premature due to decreased glycogen stores.

labor begins much earlier (aggressively at 21 73. Answer: (C) Desquamation of the epidermis

weeks’ gestation) Rationale: Postdate fetuses lose the vernix

287 caseosa, and the epidermis may become

70. Answer: (B) Sudden infant death syndrome desquamated. These neonates are usually very

(SIDS) alert. Lanugo is missing in the postdate

Rationale: Supine positioning is recommended neonate.

to reduce the risk of SIDS in infancy. The risk of 74. Answer: (C) Respiratory depression
Rationale: Magnesium sulfate crosses the present in 40% of the neonates with trisomy 21.

placenta and adverse neonatal effects are Cystic hygroma is a neck mass that can affect

respiratory depression, hypotonia, and the airway.

bradycardia. The serum blood sugar isn’t 78. Answer: (B) To assess for prolapsed cord

affected by magnesium sulfate. The neonate Rationale: After a client has an amniotomy, the

would be floppy, not jittery. nurse should assure that the cord isn't

75. Answer: (C) Respiratory rate 40 to 60 prolapsed and that the baby tolerated the

breaths/minute procedure well. The most effective way to do

Rationale: A respiratory rate 40 to 60 this is to check the fetal heart rate. Fetal
wellbeing
breaths/minute is normal for a neonate during
is assessed via a nonstress test. Fetal
the transitional period. Nasal flaring,
position is determined by vaginal examination.
respiratory rate more than 60 breaths/minute,
Artificial rupture of membranes doesn't
and audible grunting are signs of respiratory
indicate an imminent delivery.
distress.
79. Answer: (D) The parents’ interactions with
76. Answer: (C) Keep the cord dry and open to
each
air
other.
Rationale: Keeping the cord dry and open to air
Rationale: Parental interaction will provide the
helps reduce infection and hastens drying.
nurse with a good assessment of the stability of
Infants aren’t given tub bath but are sponged
the family's home life but it has no indication
off until the cord falls off. Petroleum jelly
for parental bonding. Willingness to touch and
prevents the cord from drying and encourages
hold the newborn, expressing interest about
infection. Peroxide could be painful and isn’t
the newborn's size, and indicating a desire to
recommended.
see the newborn are behaviors indicating
77. Answer: (B) Conjunctival hemorrhage
parental bonding.
Rationale: Conjunctival hemorrhages are
80. Answer: (B) Instructing the client to use two
commonly seen in neonates secondary to the
or
cranial pressure applied during the birth
more peripads to cushion the area
process. Bulging fontanelles are a sign of
Rationale: Using two or more peripads would
intracranial pressure. Simian creases are
do little to reduce the pain or promote perineal
healing. Cold applications, sitz baths, and Kegel practice to perform and interpret a bedside

exercises are important measures when the ultrasound under these conditions and without

client has a fourth-degree laceration. specialized training. Observing for pooling of

81. Answer: (C) “What is your expected due straw-colored fluid, checking vaginal discharge
date?”
with nitrazine paper, and observing for flakes of
Rationale: When obtaining the history of a
vernix are appropriate assessments for
client who may be in labor, the nurse's highest
determining whether a client has ruptured
priority is to determine her current status,
membranes.
particularly her due date, gravidity, and parity.
84. Answer: (C) Monitor partial pressure of
Gravidity and parity affect the duration of labor oxygen

and the potential for labor complications. Later, (Pao2) levels.

the nurse should ask about chronic illnesses, Rationale: Monitoring PaO2 levels and reducing

allergies, and support persons. the oxygen concentration to keep PaO2 within

82. Answer: (D) Aspirate the neonate’s nose and normal limits reduces the risk of retinopathy of

mouth with a bulb syringe. prematurity in a premature infant receiving

Rationale: The nurse's first action should be to oxygen. Covering the infant's eyes and

clear the neonate's airway with a bulb syringe. humidifying the oxygen don't reduce the risk of

After the airway is clear and the neonate's color retinopathy of prematurity. Because cooling

improves, the nurse should comfort and calm increases the risk of acidosis, the infant should

288 be kept warm so that his respiratory distress

the neonate. If the problem recurs or the isn't aggravated.

neonate's color doesn't improve readily, the 85. Answer: (A) 110 to 130 calories per kg.

nurse should notify the physician. Rationale: Calories per kg is the accepted way

Administering oxygen when the airway isn't of determined appropriate nutritional intake

clear would be ineffective. for a newborn. The recommended calorie

83. Answer: (C) Conducting a bedside requirement is 110 to 130 calories per kg of
ultrasound
newborn body weight. This level will maintain a
for an amniotic fluid index.
consistent blood glucose level and provide
Rationale: It isn't within a nurse's scope of
enough calories for continued growth and
development. speculum examination shouldn’t be done as

86. Answer: (C) 30 to 32 weeks this may lead to severe bleeding or

Rationale: Individual twins usually grow at the hemorrhage. External fetal monitoring won’t

same rate as singletons until 30 to 32 weeks’ detect a placenta previa, although it will detect

gestation, then twins don’t’ gain weight as fetal distress, which may result from blood loss

rapidly as singletons of the same gestational or placenta separation.

age. The placenta can no longer keep pace with 89. Answer: (A) Increased tidal volume

the nutritional requirements of both fetuses Rationale: A pregnant client breathes deeper,

after 32 weeks, so there’s some growth which increases the tidal volume of gas moved

retardation in twins if they remain in utero at in and out of the respiratory tract with each

38 to 40 weeks. breath. The expiratory volume and residual

87. Answer: (A) conjoined twins volume decrease as the pregnancy progresses.

Rationale: The type of placenta that develops in The inspiratory capacity increases during

monozygotic twins depends on the time at pregnancy. The increased oxygen consumption

which cleavage of the ovum occurs. Cleavage in in the pregnant client is 15% to 20% greater

conjoined twins occurs more than 13 days after than in the nonpregnant state.

fertilization. Cleavage that occurs less than 3 90. Answer: (A) Diet

day after fertilization results in diamniotic Rationale: Clients with gestational diabetes are

dicchorionic twins. Cleavage that occurs usually managed by diet alone to control their

between days 3 and 8 results in diamniotic glucose intolerance. Oral hypoglycemic drugs

monochorionic twins. Cleavage that occurs are contraindicated in pregnancy. Long-acting

between days 8 to 13 result in monoamniotic insulin usually isn’t needed for blood glucose

monochorionic twins. control in the client with gestational diabetes.

88. Answer: (D) Ultrasound 91. Answer: (D) Seizure

Rationale: Once the mother and the fetus are Rationale: The anticonvulsant mechanism of

stabilized, ultrasound evaluation of the magnesium is believes to depress seizure foci in

placenta should be done to determine the the brain and peripheral neuromuscular

cause of the bleeding. Amniocentesis is blockade. Hypomagnesemia isn’t a

contraindicated in placenta previa. A digital or complication of preeclampsia. Antihypertensive

drug other than magnesium are preferred for raised wheal, not a flat circumcised area to be

sustained hypertension. Magnesium doesn’t considered positive.

help prevent hemorrhage in preeclamptic 95. Answer: (C) Pyelonephritis

clients. Rationale The symptoms indicate acute

92. Answer: (C) I.V. fluids pyelonephritis, a serious condition in a

Rationale: A sickle cell crisis during pregnancy is pregnant client. UTI symptoms include dysuria,

usually managed by exchange transfusion urgency, frequency, and suprapubic

oxygen, and L.V. Fluids. The client usually needs tenderness. Asymptomatic bacteriuria doesn’t

a stronger analgesic than acetaminophen to cause symptoms. Bacterial vaginosis causes

control the pain of a crisis. Antihypertensive milky white vaginal discharge but no systemic

drugs usually aren’t necessary. Diuretic symptoms.

wouldn’t be used unless fluid overload resulted. 96. Answer: (B) Rh-positive fetal blood crosses
into
289
maternal blood, stimulating maternal
93. Answer: (A) Calcium gluconate (Kalcinate)
antibodies.
Rationale: Calcium gluconate is the antidote for
Rationale: Rh isoimmunization occurs when
magnesium toxicity. Ten milliliters of 10%
Rhpositive
calcium gluconate is given L.V. push over 3 to 5
fetal blood cells cross into the maternal
minutes. Hydralazine is given for sustained
circulation and stimulate maternal antibody
elevated blood pressure in preeclamptic clients.
production. In subsequent pregnancies with
Rho (D) immune globulin is given to women Rhpositive

with Rh-negative blood to prevent antibody fetuses, maternal antibodies may cross

formation from RH-positive conceptions. back into the fetal circulation and destroy the

Naloxone is used to correct narcotic toxicity. fetal blood cells.

94. Answer: (B) An indurated wheal over 10 mm 97. Answer: (C) Supine position
in
Rationale: The supine position causes
diameter appears in 48 to 72 hours.
compression of the client's aorta and inferior
Rationale: A positive PPD result would be an
vena cava by the fetus. This, in turn, inhibits
indurated wheal over 10 mm in diameter that
maternal circulation, leading to maternal
appears in 48 to 72 hours. The area must be a
hypotension and, ultimately, fetal hypoxia. The
other positions promote comfort and aid labor 100. Answer: (B) Uterine atony

progress. For instance, the lateral, or side-lying, Rationale: Multiple fetuses, extended labor

position improves maternal and fetal stimulation with oxytocin, and traumatic

circulation, enhances comfort, increases delivery commonly are associated with uterine

maternal relaxation, reduces muscle tension, atony, which may lead to postpartum

and eliminates pressure points. The squatting hemorrhage. Uterine inversion may precede or

position promotes comfort by taking advantage follow delivery and commonly results from

of gravity. The standing position also takes apparent excessive traction on the umbilical

advantage of gravity and aligns the fetus with cord and attempts to deliver the placenta

the pelvic angle. manually. Uterine involution and some uterine

98. Answer: (B) Irritability and poor sucking. discomfort are normal after delivery.

Rationale: Neonates of heroin-addicted 290

mothers are physically dependent on the drug TEST III - Care of Clients with Physiologic and

and experience withdrawal when the drug is no Psychosocial Alterations

longer supplied. Signs of heroin withdrawal 1. Nurse Michelle should know that the
drainage is
include irritability, poor sucking, and
normal 4 days after a sigmoid colostomy when
restlessness. Lethargy isn't associated with
the stool is:
neonatal heroin addiction. A flattened nose,
a. Green liquid
small eyes, and thin lips are seen in infants with
b. Solid formed
fetal alcohol syndrome. Heroin use during
c. Loose, bloody
pregnancy hasn't been linked to specific
d. Semiformed
congenital anomalies.
2. Where would nurse Kristine place the call
99. Answer: (A) 7th to 9th day postpartum
light
Rationale: The normal involutional process
for a male client with a right-sided brain attack
returns the uterus to the pelvic cavity in 7 to 9
and left homonymous hemianopsia?
days. A significant involutional complication is
a. On the client’s right side
the failure of the uterus to return to the pelvic
b. On the client’s left side
cavity within the prescribed time period. This is
c. Directly in front of the client
known as subinvolution.
d. Where the client like c. Give two sharp thumps to the

3. A male client is admitted to the emergency precordium, and check the pulse.

department following an accident. What are the d. Administer two quick blows.

first nursing actions of the nurse? 6. Nurse Monett is caring for a client recovering

a. Check respiration, circulation, from gastro-intestinal bleeding. The nurse

neurological response. should:

b. Align the spine, check pupils, and check a. Plan care so the client can receive 8

for hemorrhage. hours of uninterrupted sleep each night.

c. Check respirations, stabilize spine, and b. Monitor vital signs every 2 hours.

check circulation. c. Make sure that the client takes food and

d. Assess level of consciousness and medications at prescribed intervals.

circulation. d. Provide milk every 2 to 3 hours.

4. In evaluating the effect of nitroglycerin, Nurse 7. A male client was on warfarin (Coumadin)
before
Arthur should know that it reduces preload and
admission, and has been receiving heparin I.V.
relieves angina by:
for 2 days. The partial thromboplastin time
a. Increasing contractility and slowing
(PTT)
heart rate.
is 68 seconds. What should Nurse Carla do?
b. Increasing AV conduction and heart rate.
a. Stop the I.V. infusion of heparin and
c. Decreasing contractility and oxygen
notify the physician.
consumption.
b. Continue treatment as ordered.
d. Decreasing venous return through
c. Expect the warfarin to increase the PTT.
vasodilation.
d. Increase the dosage, because the level is
5. Nurse Patricia finds a female client who is
lower than normal.
postmyocardial
8. A client undergone ileostomy, when should
infarction (MI) slumped on the side
the
rails of the bed and unresponsive to shaking or
drainage appliance be applied to the stoma?
shouting. Which is the nurse next action?
a. 24 hours later, when edema has
a. Call for help and note the time.
subsided.
b. Clear the airway
b. In the operating room.
c. After the ileostomy begin to function. may appear first?

d. When the client is able to begin self-care a. Altered mental status and dehydration

procedures. b. Fever and chills

9. A client undergone spinal anesthetic, it will be c. Hemoptysis and Dyspnea

important that the nurse immediately position d. Pleuritic chest pain and cough

the client in: 12. A male client has active tuberculosis (TB).
Which
a. On the side, to prevent obstruction of
of the following symptoms will be exhibit?
airway by tongue.
a. Chest and lower back pain
b. Flat on back.
b. Chills, fever, night sweats, and
c. On the back, with knees flexed 15
hemoptysis
degrees.
c. Fever of more than 104°F (40°C) and
d. Flat on the stomach, with the head
nausea
turned to the side.
d. Headache and photophobia
10. While monitoring a male client several hours
13. Mark, a 7-year-old client is brought to the
after a motor vehicle accident, which
emergency department. He’s tachypneic and
assessment data suggest increasing intracranial
afebrile and has a respiratory rate of 36
pressure?
breaths/minute and has a nonproductive cough.
a. Blood pressure is decreased from
He recently had a cold. Form this history; the
160/90 to 110/70.
client may have which of the following
b. Pulse is increased from 87 to 95, with an
conditions?
occasional skipped beat.
a. Acute asthma
c. The client is oriented when aroused
b. Bronchial pneumonia
from sleep, and goes back to sleep
c. Chronic obstructive pulmonary disease
immediately.
(COPD)
291
d. Emphysema
d. The client refuses dinner because of
14. Marichu was given morphine sulfate for
anorexia.
pain.
11. Mrs. Cruz, 80 years old is diagnosed with
She is sleeping and her respiratory rate is 4
pneumonia. Which of the following symptoms
breaths/minute. If action isn’t taken quickly, she 17. Nurse Ron is caring for a male client taking
an
might have which of the following reactions?
anticoagulant. The nurse should teach the client
a. Asthma attack
to:
b. Respiratory arrest
a. Report incidents of diarrhea.
c. Seizure
b. Avoid foods high in vitamin K
d. Wake up on his own
c. Use a straight razor when shaving.
15. A 77-year-old male client is admitted for
elective d. Take aspirin to pain relief.

knee surgery. Physical examination reveals 18. Nurse Lhynnette is preparing a site for the

shallow respirations but no sign of respiratory insertion of an I.V. catheter. The nurse should

distress. Which of the following is a normal treat excess hair at the site by:

physiologic change related to aging? a. Leaving the hair intact

a. Increased elastic recoil of the lungs b. Shaving the area

b. Increased number of functional c. Clipping the hair in the area

capillaries in the alveoli d. Removing the hair with a depilatory.

c. Decreased residual volume 19. Nurse Michelle is caring for an elderly

female
d. Decreased vital capacity
with osteoporosis. When teaching the client,
16. Nurse John is caring for a male client
the
receiving
nurse should include information about which
lidocaine I.V. Which factor is the most relevant
major complication:
to administration of this medication?
a. Bone fracture
a. Decrease in arterial oxygen saturation
b. Loss of estrogen
(SaO2) when measured with a pulse
c. Negative calcium balance
oximeter.
d. Dowager’s hump
b. Increase in systemic blood pressure.
20. Nurse Len is teaching a group of women to
c. Presence of premature ventricular
perform BSE. The nurse should explain that the
contractions (PVCs) on a cardiac
purpose of performing the examination is to
monitor.
discover:
d. Increase in intracranial pressure (ICP).
a. Cancerous lumps
b. Areas of thickness or fullness c. Hemorrhoidectomy

c. Changes from previous examinations. d. Cystectomy.

d. Fibrocystic masses 24. A 55-year old client underwent cataract

removal
21. When caring for a female client who is being
with intraocular lens implant. Nurse Oliver is
treated for hyperthyroidism, it is important to:
giving the client discharge instructions. These
a. Provide extra blankets and clothing to
instructions should include which of the
keep the client warm.
following?
b. Monitor the client for signs of
a. Avoid lifting objects weighing more than
restlessness, sweating, and excessive
5 lb (2.25 kg).
292
b. Lie on your abdomen when in bed
weight loss during thyroid replacement
c. Keep rooms brightly lit.
therapy.
d. Avoiding straining during bowel
c. Balance the client’s periods of activity
movement or bending at the waist.
and rest.
25. George should be taught about testicular
d. Encourage the client to be active to
examinations during:
prevent constipation.
a. when sexual activity starts
22. Nurse Kris is teaching a client with history of
b. After age 69
atherosclerosis. To decrease the risk of
c. After age 40
atherosclerosis, the nurse should encourage the
d. Before age 20.
client to:
26. A male client undergone a colon resection.
a. Avoid focusing on his weight.
While
b. Increase his activity level.
turning him, wound dehiscence with
c. Follow a regular diet.
evisceration occurs. Nurse Trish first response is
d. Continue leading a high-stress lifestyle.
to:
23. Nurse Greta is working on a surgical floor.
a. Call the physician
Nurse
b. Place a saline-soaked sterile dressing on
Greta must logroll a client following a:
the wound.
a. Laminectomy
c. Take a blood pressure and pulse.
b. Thoracotomy
d. Pull the dehiscence closed. b. The airways are so swollen that no air

27. Nurse Audrey is caring for a client who has cannot get through.

suffered a severe cerebrovascular accident. c. The swelling has decreased.

During routine assessment, the nurse notices d. Crackles have replaced wheezes.

Cheyne- Strokes respirations. Cheyne-strokes 30. Mike with epilepsy is having a seizure.
During
respirations are:
the active seizure phase, the nurse should:
a. A progressively deeper breaths followed
a. Place the client on his back remove
by shallower breaths with apneic
dangerous objects, and insert a bite
periods.
block.
b. Rapid, deep breathing with abrupt
b. Place the client on his side, remove
pauses between each breath.
dangerous objects, and insert a bite
c. Rapid, deep breathing and irregular
block.
breathing without pauses.
c. Place the client o his back, remove
d. Shallow breathing with an increased
dangerous objects, and hold down his
respiratory rate.
arms.
28. Nurse Bea is assessing a male client with
heart d. Place the client on his side, remove

failure. The breath sounds commonly dangerous objects, and protect his head.

auscultated in clients with heart failure are: 31. After insertion of a cheat tube for a

a. Tracheal pneumothorax, a client becomes hypotensive

b. Fine crackles with neck vein distention, tracheal shift, absent

c. Coarse crackles breath sounds, and diaphoresis. Nurse Amanda

d. Friction rubs suspects a tension pneumothorax has occurred.

29. The nurse is caring for Kenneth experiencing What cause of tension pneumothorax should
an the

acute asthma attack. The client stops wheezing nurse check for?

and breath sounds aren’t audible. The reason a. Infection of the lung.
for
293
this change is that:
b. Kinked or obstructed chest tube
a. The attack is over.
c. Excessive water in the water-seal b. Brush the teeth with client lying supine.

chamber c. Place the client in a side lying position,

d. Excessive chest tube drainage with the head of the bed lowered.

32. Nurse Maureen is talking to a male client; d. Clean the client’s mouth with hydrogen
the
peroxide.
client begins choking on his lunch. He’s
35. A 77-year-old male client is admitted with a
coughing
diagnosis of dehydration and change in mental
forcefully. The nurse should:
status. He’s being hydrated with L.V. fluids.
a. Stand him up and perform the
When the nurse takes his vital signs, she notes
abdominal thrust maneuver from
he has a fever of 103°F (39.4°C) a cough
behind.
producing yellow sputum and pleuritic chest
b. Lay him down, straddle him, and
pain. The nurse suspects this client may have
perform the abdominal thrust
which of the following conditions?
maneuver.
a. Adult respiratory distress syndrome
c. Leave him to get assistance
(ARDS)
d. Stay with him but not intervene at this
b. Myocardial infarction (MI)
time.
c. Pneumonia
33. Nurse Ron is taking a health history of an 84
year d. Tuberculosis
old client. Which information will be most useful 36. Nurse Oliver is working in an outpatient
clinic.
to the nurse for planning care?
He has been alerted that there is an outbreak of
a. General health for the last 10 years.
tuberculosis (TB). Which of the following clients
b. Current health promotion activities.
entering the clinic today most likely to have TB?
c. Family history of diseases.
a. A 16-year-old female high school
d. Marital status.
student
34. When performing oral care on a comatose
client, b. A 33-year-old day-care worker
Nurse Krina should: c. A 43-yesr-old homeless man with a
a. Apply lemon glycerin to the client’s lips history of alcoholism
at least every 2 hours. d. A 54-year-old businessman
37. Virgie with a positive Mantoux test result b. Asthma
will be
c. Chronic obstructive bronchitis
sent for a chest X-ray. The nurse is aware that
d. Emphysema
which of the following reasons this is done?
Situation: Francis, age 46 is admitted to the
a. To confirm the diagnosis hospital with

b. To determine if a repeat skin test is diagnosis of Chronic Lymphocytic Leukemia.

needed 40. The treatment for patients with leukemia is

bone
c. To determine the extent of lesions
marrow transplantation. Which statement
d. To determine if this is a primary or
about
secondary infection
bone marrow transplantation is not correct?
38. Kennedy with acute asthma showing
a. The patient is under local anesthesia
inspiratory
during the procedure
and expiratory wheezes and a decreased forced
b. The aspirated bone marrow is mixed
expiratory volume should be treated with which
with heparin.
of the following classes of medication right
c. The aspiration site is the posterior or
away?
anterior iliac crest.
a. Beta-adrenergic blockers
294
b. Bronchodilators
d. The recipient receives
c. Inhaled steroids
cyclophosphamide (Cytoxan) for 4
d. Oral steroids
consecutive days before the procedure.
39. Mr. Vasquez 56-year-old client with a 40-
year 41. After several days of admission, Francis
becomes
history of smoking one to two packs of
cigarettes disoriented and complains of frequent

per day has a chronic cough producing thick headaches. The nurse in-charge first action

sputum, peripheral edema and cyanotic nail would be:

beds. Based on this information, he most likely a. Call the physician

has which of the following conditions? b. Document the patient’s status in his

a. Adult respiratory distress syndrome charts.

(ARDS) c. Prepare oxygen treatment

d. Raise the side rails response by the nurse?

42. During routine care, Francis asks the nurse, a. Explain the risks of not having the

“How can I be anemic if this disease causes surgery

increased my white blood cell production?” The b. Notifying the physician immediately

nurse in-charge best response would be that the c. Notifying the nursing supervisor

increased number of white blood cells (WBC) is: d. Recording the client’s refusal in the

a. Crowd red blood cells nurses’ notes

b. Are not responsible for the anemia. 45. During the endorsement, which of the
following
c. Uses nutrients from other cells
clients should the on-duty nurse assess first?
d. Have an abnormally short life span of
a. The 58-year-old client who was admitted
cells.
2 days ago with heart failure, blood
43. Diagnostic assessment of Francis would
probably pressure of 126/76 mm Hg, and a

not reveal: respiratory rate of 22 breaths/ minute.

a. Predominance of lymhoblasts b. The 89-year-old client with end-stage

b. Leukocytosis right-sided heart failure, blood pressure

c. Abnormal blast cells in the bone marrow of 78/50 mm Hg, and a “do not

d. Elevated thrombocyte counts resuscitate” order

44. Robert, a 57-year-old client with acute c. The 62-year-old client who was admitted
arterial
1 day ago with thrombophlebitis and is
occlusion of the left leg undergoes an
receiving L.V. heparin
emergency embolectomy. Six hours later, the
d. The 75-year-old client who was admitted
nurse isn’t able to obtain pulses in his left foot
1 hour ago with new-onset atrial
using Doppler ultrasound. The nurse
fibrillation and is receiving L.V. dilitiazem
immediately notifies the physician, and asks her
(Cardizem)
to prepare the client for surgery. As the nurse
46. Honey, a 23-year old client complains of
enters the client’s room to prepare him, he
substernal chest pain and states that her heart
states that he won’t have any more surgery.
feels like “it’s racing out of the chest”. She
Which of the following is the best initial
reports no history of cardiac disorders. The
nurse attaches her to a cardiac monitor and b. Chemotherapy

notes sinus tachycardia with a rate of c. Radiation

136beats/minutes. Breath sounds are clear and d. Immunotherapy

the respiratory rate is 26 breaths/minutes. 49. Cristina undergoes a biopsy of a suspicious

Which of the following drugs should the nurse lesion. The biopsy report classifies the lesion

question the client about using? 295

a. Barbiturates according to the TNM staging system as follows:

b. Opioids TIS, N0, M0. What does this classification mean?

c. Cocaine a. No evidence of primary tumor, no

d. Benzodiazepines abnormal regional lymph nodes, and no

47. A 51-year-old female client tells the nurse evidence of distant metastasis
incharge
b. Carcinoma in situ, no abnormal regional
that she has found a painless lump in her
lymph nodes, and no evidence of distant
right breast during her monthly selfexamination.
metastasis
Which assessment finding would
c. Can't assess tumor or regional lymph
strongly suggest that this client's lump is
nodes and no evidence of metastasis
cancerous?
d. Carcinoma in situ, no demonstrable
a. Eversion of the right nipple and mobile
metastasis of the regional lymph nodes,
mass
and ascending degrees of distant
b. Nonmobile mass with irregular edges
metastasis
c. Mobile mass that is soft and easily
50. Lydia undergoes a laryngectomy to treat
delineated
laryngeal cancer. When teaching the client how
d. Nonpalpable right axillary lymph nodes
to care for the neck stoma, the nurse should
48. A 35-year-old client with vaginal cancer asks
include which instruction?
the
a. "Keep the stoma uncovered."
nurse, "What is the usual treatment for this type
b. "Keep the stoma dry."
of cancer?" Which treatment should the nurse
c. "Have a family member perform stoma
name?
care initially until you get used to the
a. Surgery
procedure."
d. "Keep the stoma moist." to screen for prostate cancer.

51. A 37-year-old client with uterine cancer asks b. protein serum antigen, which is used to
the
determine protein levels.
nurse, "Which is the most common type of
c. pneumococcal strep antigen, which is a
cancer in women?" The nurse replies that it's
bacteria that causes pneumonia.
breast cancer. Which type of cancer causes the
d. Papanicolaou-specific antigen, which is
most deaths in women?
used to screen for cervical cancer.
a. Breast cancer
54. What is the most important postoperative
b. Lung cancer
instruction that nurse Kate must give a client
c. Brain cancer
who has just returned from the operating room
d. Colon and rectal cancer
after receiving a subarachnoid block?
52. Antonio with lung cancer develops Horner's
a. "Avoid drinking liquids until the gag
syndrome when the tumor invades the ribs and
reflex returns."
affects the sympathetic nerve ganglia. When
b. "Avoid eating milk products for 24
assessing for signs and symptoms of this
hours."
syndrome, the nurse should note:
c. "Notify a nurse if you experience blood
a. miosis, partial eyelid ptosis, and
in your urine."
anhidrosis on the affected side of the
d. "Remain supine for the time specified by
face.
the physician."
b. chest pain, dyspnea, cough, weight loss,
55. A male client suspected of having colorectal
and fever.
cancer will require which diagnostic study to
c. arm and shoulder pain and atrophy of
confirm the diagnosis?
arm and hand muscles, both on the
a. Stool Hematest
affected side.
b. Carcinoembryonic antigen (CEA)
d. hoarseness and dysphagia.
c. Sigmoidoscopy
53. Vic asks the nurse what PSA is. The nurse
d. Abdominal computed tomography (CT)
should
scan
reply that it stands for:
56. During a breast examination, which finding
a. prostate-specific antigen, which is used
most
strongly suggests that the Luz has breast band.
cancer?
59. Nurse Cecile is teaching a female client
a. Slight asymmetry of the breasts. about

b. A fixed nodular mass with dimpling of preventing osteoporosis. Which of the following

the overlying skin teaching points is correct?

c. Bloody discharge from the nipple a. Obtaining an X-ray of the bones every 3

d. Multiple firm, round, freely movable years is recommended to detect bone

masses that change with the menstrual loss.

cycle b. To avoid fractures, the client should

57. A female client with cancer is being avoid strenuous exercise.

evaluated
c. The recommended daily allowance of
for possible metastasis. Which of the following
calcium may be found in a wide variety
is
of foods.
one of the most common metastasis sites for
d. Obtaining the recommended daily
cancer cells?
allowance of calcium requires taking a
a. Liver
calcium supplement.
b. Colon
60. Before Jacob undergoes arthroscopy, the
c. Reproductive tract
nurse
d. White blood cells (WBCs)
reviews the assessment findings for
58. Nurse Mandy is preparing a client for
contraindications for this procedure. Which
magnetic
finding is a contraindication?
resonance imaging (MRI) to confirm or rule out
a a. Joint pain
296 b. Joint deformity
spinal cord lesion. During the MRI scan, which c. Joint flexion of less than 50%
of
d. Joint stiffness
the following would pose a threat to the client?
61. Mr. Rodriguez is admitted with severe pain
a. The client lies still. in
b. The client asks questions. the knees. Which form of arthritis is
c. The client hears thumping sounds. characterized by urate deposits and joint pain,
d. The client wears a watch and wedding usually in the feet and legs, and occurs primarily
in men over age 30? osteoarthritis. Which of the following statement

a. Septic arthritis is correct about this deformity?

b. Traumatic arthritis a. It appears only in men

c. Intermittent arthritis b. It appears on the distal interphalangeal

d. Gouty arthritis joint

62. A heparin infusion at 1,500 unit/hour is c. It appears on the proximal

ordered
interphalangeal joint
for a 64-year-old client with stroke in evolution.
d. It appears on the dorsolateral aspect of
The infusion contains 25,000 units of heparin in
the interphalangeal joint.
500 ml of saline solution. How many milliliters
65. Which of the following statements explains
per hour should be given? the

a. 15 ml/hour main difference between rheumatoid arthritis

b. 30 ml/hour and osteoarthritis?

c. 45 ml/hour a. Osteoarthritis is gender-specific,

d. 50 ml/hour rheumatoid arthritis isn’t

63. A 76-year-old male client had a b. Osteoarthritis is a localized disease

thromboembolic
rheumatoid arthritis is systemic
right stroke; his left arm is swollen. Which of the
c. Osteoarthritis is a systemic disease,
following conditions may cause swelling after a
rheumatoid arthritis is localized
stroke?
d. Osteoarthritis has dislocations and
a. Elbow contracture secondary to
subluxations, rheumatoid arthritis
spasticity
doesn’t
b. Loss of muscle contraction decreasing
66. Mrs. Cruz uses a cane for assistance in
venous return walking.

c. Deep vein thrombosis (DVT) due to Which of the following statements is true about

immobility of the ipsilateral side a cane or other assistive devices?

d. Hypoalbuminemia due to protein a. A walker is a better choice than a cane.

escaping from an inflamed glomerulus b. The cane should be used on the affected

64. Heberden’s nodes are a common sign of side

c. The cane should be used on the b. Pancreas

unaffected side c. Adrenal medulla

d. A client with osteoarthritis should be d. Parathyroid

encouraged to ambulate without the 70. For a diabetic male client with a foot ulcer,
the
cane
doctor orders bed rest, a wet-to-dry dressing
67. A male client with type 1 diabetes is
scheduled change every shift, and blood glucose

to receive 30 U of 70/30 insulin. There is no monitoring before meals and bedtime. Why are

70/30 insulin available. As a substitution, the wet-to-dry dressings used for this client?

nurse may give the client: a. They contain exudate and provide a

297 moist wound environment.

a. 9 U regular insulin and 21 U neutral b. They protect the wound from

protamine Hagedorn (NPH). mechanical trauma and promote

b. 21 U regular insulin and 9 U NPH. healing.

c. 10 U regular insulin and 20 U NPH. c. They debride the wound and promote

d. 20 U regular insulin and 10 U NPH. healing by secondary intention.

68. Nurse Len should expect to administer d. They prevent the entrance of
which
microorganisms and minimize wound
medication to a client with gout?
discomfort.
a. aspirin
71. Nurse Zeny is caring for a client in acute
b. furosemide (Lasix)
addisonian crisis. Which laboratory data would
c. colchicines
the nurse expect to find?
d. calcium gluconate (Kalcinate)
a. Hyperkalemia
69. Mr. Domingo with a history of hypertension
b. Reduced blood urea nitrogen (BUN)
is
c. Hypernatremia
diagnosed with primary hyperaldosteronism.
d. Hyperglycemia
This diagnosis indicates that the client's
72. A client is admitted for treatment of the
hypertension is caused by excessive hormone
syndrome of inappropriate antidiuretic
secretion from which of the following glands?
hormone
a. Adrenal cortex
(SIADH). Which nursing intervention is a. Glucocorticoids and androgens

appropriate? b. Catecholamines and epinephrine

a. Infusing I.V. fluids rapidly as ordered c. Mineralocorticoids and catecholamines

b. Encouraging increased oral intake d. Norepinephrine and epinephrine

c. Restricting fluids 76. On the third day after a partial

thyroidectomy,
d. Administering glucose-containing I.V.
Proserfina exhibits muscle twitching and
fluids as ordered
hyperirritability of the nervous system. When
73. A female client tells nurse Nikki that she has
questioned, the client reports numbness and
been working hard for the last 3 months to
tingling of the mouth and fingertips. Suspecting
control her type 2 diabetes mellitus with diet
a life-threatening electrolyte disturbance, the
and exercise. To determine the effectiveness of
nurse notifies the surgeon immediately. Which
the client's efforts, the nurse should check:
electrolyte disturbance most commonly follows
a. urine glucose level.
thyroid surgery?
b. fasting blood glucose level.
a. Hypocalcemia
c. serum fructosamine level.
b. Hyponatremia
d. glycosylated hemoglobin level.
c. Hyperkalemia
74. Nurse Trinity administered neutral
protamine d. Hypermagnesemia

Hagedorn (NPH) insulin to a diabetic client at 7 77. Which laboratory test value is elevated in
clients
a.m. At what time would the nurse expect the
who smoke and can't be used as a general
client to be most at risk for a hypoglycemic
indicator of cancer?
reaction?
a. Acid phosphatase level
a. 10:00 am
b. Serum calcitonin level
b. Noon
c. Alkaline phosphatase level
c. 4:00 pm
d. Carcinoembryonic antigen level
d. 10:00 pm
298
75. The adrenal cortex is responsible for
producing 78. Francis with anemia has been admitted to
the
which substances?
medical-surgical unit. Which assessment d. "Avoid eating foods from serving dishes
findings
shared by other family members."
are characteristic of iron-deficiency anemia?
81. Nurse Marie is caring for a 32-year-old client
a. Nights sweats, weight loss, and diarrhea
admitted with pernicious anemia. Which set of
b. Dyspnea, tachycardia, and pallor
findings should the nurse expect when assessing
c. Nausea, vomiting, and anorexia
the client?
d. Itching, rash, and jaundice
a. Pallor, bradycardia, and reduced pulse
79. In teaching a female client who is HIV-
pressure
positive
b. Pallor, tachycardia, and a sore tongue
about pregnancy, the nurse would know more
c. Sore tongue, dyspnea, and weight gain
teaching is necessary when the client says:
d. Angina, double vision, and anorexia
a. The baby can get the virus from my
82. After receiving a dose of penicillin, a client
placenta."
develops dyspnea and hypotension. Nurse
b. "I'm planning on starting on birth control
Celestina suspects the client is experiencing
pills."
anaphylactic shock. What should the nurse do
c. "Not everyone who has the virus gives
first?
birth to a baby who has the virus."
a. Page an anesthesiologist immediately
d. "I'll need to have a C-section if I become
and prepare to intubate the client.
pregnant and have a baby."
b. Administer epinephrine, as prescribed,
80. When preparing Judy with acquired
and prepare to intubate the client if
immunodeficiency syndrome (AIDS) for
necessary.
discharge to the home, the nurse should be sure
c. Administer the antidote for penicillin, as
to include which instruction?
prescribed, and continue to monitor the
a. "Put on disposable gloves before
client's vital signs.
bathing."
d. Insert an indwelling urinary catheter and
b. "Sterilize all plates and utensils in boiling
begin to infuse I.V. fluids as ordered.
water."
83. Mr. Marquez with rheumatoid arthritis is
c. "Avoid sharing such articles as
about
toothbrushes and razors."
to begin aspirin therapy to reduce 86. During chemotherapy for lymphocytic
inflammation. leukemia,

When teaching the client about aspirin, the Mathew develops abdominal pain, fever, and

nurse discusses adverse reactions to prolonged "horse barn" smelling diarrhea. It would be
most
aspirin therapy. These include:
important for the nurse to advise the physician
a. weight gain.
to order:
b. fine motor tremors.
a. enzyme-linked immunosuppressant
c. respiratory acidosis.
assay (ELISA) test.
d. bilateral hearing loss.
b. electrolyte panel and hemogram.
84. A 23-year-old client is diagnosed with
human c. stool for Clostridium difficile test.

immunodeficiency virus (HIV). After recovering d. flat plate X-ray of the abdomen.

from the initial shock of the diagnosis, the client 87. A male client seeks medical evaluation for

expresses a desire to learn as much as possible fatigue, night sweats, and a 20-lb weight loss in
6
about HIV and acquired immunodeficiency
weeks. To confirm that the client has been
syndrome (AIDS). When teaching the client
infected with the human immunodeficiency
about the immune system, the nurse states that
virus
adaptive immunity is provided by which type of
(HIV), the nurse expects the physician to order:
white blood cell?
299
a. Neutrophil
a. E-rosette immunofluorescence.
b. Basophil
b. quantification of T-lymphocytes.
c. Monocyte
c. enzyme-linked immunosorbent assay
d. Lymphocyte
(ELISA).
85. In an individual with Sjögren's syndrome,
d. Western blot test with ELISA.
nursing
88. A complete blood count is commonly
care should focus on:
performed
a. moisture replacement.
before a Joe goes into surgery. What does this
b. electrolyte balance.
test seek to identify?
c. nutritional supplementation.
a. Potential hepatic dysfunction indicated
d. arrhythmia management.
by decreased blood urea nitrogen (BUN) 91. Nurse John is caring for clients in the
outpatient
and creatinine levels
clinic. Which of the following phone calls should
b. Low levels of urine constituents normally
the nurse return first?
excreted in the urine
a. A client with hepatitis A who states, “My
c. Abnormally low hematocrit (HCT) and
arms and legs are itching.”
hemoglobin (Hb) levels
b. A client with cast on the right leg who
d. Electrolyte imbalance that could affect
states, “I have a funny feeling in my right
the blood's ability to coagulate properly
leg.”
89. While monitoring a client for the
development c. A client with osteomyelitis of the spine

of disseminated intravascular coagulation (DIC), who states, “I am so nauseous that I

the nurse should take note of what assessment can’t eat.”

parameters? d. A client with rheumatoid arthritis who

a. Platelet count, prothrombin time, and states, “I am having trouble sleeping.”

partial thromboplastin time 92. Nurse Sarah is caring for clients on the
surgical
b. Platelet count, blood glucose levels, and
floor and has just received report from the
white blood cell (WBC) count
previous shift. Which of the following clients
c. Thrombin time, calcium levels, and
should the nurse see first?
potassium levels
a. A 35-year-old admitted three hours ago
d. Fibrinogen level, WBC, and platelet
with a gunshot wound; 1.5 cm area of
count
dark drainage noted on the dressing.
90. When taking a dietary history from a newly
b. A 43-year-old who had a mastectomy
admitted female client, Nurse Len should
two days ago; 23 ml of serosanguinous
remember that which of the following foods is a
fluid noted in the Jackson-Pratt drain.
common allergen?
c. A 59-year-old with a collapsed lung due
a. Bread
to an accident; no drainage noted in the
b. Carrots
previous eight hours.
c. Orange
d. A 62-year-old who had an abdominalperineal
d. Strawberries
resection three days ago; client dialysis. Which of the following actions should

complaints of chills. the nurse take first?

93. Nurse Eve is caring for a client who had a a. Assess for a bruit and a thrill.

thyroidectomy 12 hours ago for treatment of b. Warm the dialysate solution.

Grave’s disease. The nurse would be most c. Position the client on the left side.

concerned if which of the following was 300

observed? d. Insert a Foley catheter

a. Blood pressure 138/82, respirations 16, 96. Nurse Jannah teaches an elderly client with

oral temperature 99 degrees Fahrenheit. right-sided weakness how to use cane. Which of

b. The client supports his head and neck the following behaviors, if demonstrated by the

when turning his head to the right. client to the nurse, indicates that the teaching

c. The client spontaneously flexes his wrist was effective?

when the blood pressure is obtained. a. The client holds the cane with his right

d. The client is drowsy and complains of hand, moves the can forward followed

sore throat. by the right leg, and then moves the left

94. Julius is admitted with complaints of severe leg.

pain
b. The client holds the cane with his right
in the lower right quadrant of the abdomen. To
hand, moves the cane forward followed
assist with pain relief, the nurse should take
by his left leg, and then moves the right
which of the following actions?
leg.
a. Encourage the client to change positions
c. The client holds the cane with his left
frequently in bed.
hand, moves the cane forward followed
b. Administer Demerol 50 mg IM q 4 hours
by the right leg, and then moves the left
and PRN.
leg.
c. Apply warmth to the abdomen with a
d. The client holds the cane with his left
heating pad.
hand, moves the cane forward followed
d. Use comfort measures and pillows to
by his left leg, and then moves the right
position the client.
leg.
95. Nurse Tina prepares a client for peritoneal
97. An elderly client is admitted to the nursing walker while advancing it forward, then
home
takes small steps while balancing on the
setting. The client is occasionally confused and
walker.
her gait is often unsteady. Which of the
d. The client slides the walker 18 inches
following actions, if taken by the nurse, is most
forward, then takes small steps while
appropriate?
holding onto the walker for balance.
a. Ask the woman’s family to provide
99. Nurse Deric is supervising a group of elderly
personal items such as photos or
clients in a residential home setting. The nurse
mementos.
knows that the elderly are at greater risk of
b. Select a room with a bed by the door so
developing sensory deprivation for what
the woman can look down the hall. reason?

c. Suggest the woman eat her meals in the a. Increased sensitivity to the side effects

room with her roommate. of medications.

d. Encourage the woman to ambulate in b. Decreased visual, auditory, and

the halls twice a day. gustatory abilities.

98. Nurse Evangeline teaches an elderly client c. Isolation from their families and familiar
how
surroundings.
to use a standard aluminum walker. Which of
d. Decrease musculoskeletal function and
the following behaviors, if demonstrated by the
mobility.
client, indicates that the nurse’s teaching was
100. A male client with emphysema becomes
effective?
restless and confused. What step should
a. The client slowly pushes the walker
nurse Jasmine take next?
forward 12 inches, then takes small
a. Encourage the client to perform pursed
steps forward while leaning on the
lip breathing.
walker.
b. Check the client’s temperature.
b. The client lifts the walker, moves it
c. Assess the client’s potassium level.
forward 10 inches, and then takes
d. Increase the client’s oxygen flow rate.
several small steps forward.
301
c. The client supports his weight on the
Answers and Rationale – Care of Clients with
Physiologic and Psychosocial Alterations operator from the client’s phone and giving

1. Answer: (C) Loose, bloody the hospital code for cardiac arrest and the

Rationale: Normal bowel function and client’s room number to the operator, of if the
softformed
phone is not available, by pulling the
stool usually do not occur until around
emergency call button. Noting the time is
the seventh day following surgery. The stool
important baseline information for cardiac
consistency is related to how much water is
arrest procedure
being absorbed.
6. Answer: (C) Make sure that the client takes
2. Answer: (A) On the client’s right side
food and medications at prescribed intervals.
Rationale: The client has left visual field
Rationale: Food and drug therapy will prevent
blindness. The client will see only from the
the accumulation of hydrochloric acid, or will
right side.
neutralize and buffer the acid that does
3. Answer: (C) Check respirations, stabilize
accumulate.
spine,
7. Answer: (B) Continue treatment as ordered.
and check circulation
Rationale: The effects of heparin are
Rationale: Checking the airway would be
monitored by the PTT is normally 30 to 45
priority, and a neck injury should be
seconds; the therapeutic level is 1.5 to 2 times
suspected.
the normal level.
4. Answer: (D) Decreasing venous return
through 8. Answer: (B) In the operating room.
vasodilation. Rationale: The stoma drainage bag is applied
Rationale: The significant effect of in the operating room. Drainage from the
nitroglycerin is vasodilation and decreased ileostomy contains secretions that are rich in
venous return, so the heart does not have to digestive enzymes and highly irritating to the
work hard. skin. Protection of the skin from the effects of
5. Answer: (A) Call for help and note the time. these enzymes is begun at once. Skin exposed
Rationale: Having established, by stimulating to these enzymes even for a short time
the client, that the client is unconscious rather becomes reddened, painful, and excoriated.
than sleep, the nurse should immediately call 9. Answer: (B) Flat on back.
for help. This may be done by dialing the Rationale: To avoid the complication of a
painful spinal headache that can last for fevers, not higher than 102°F (38.9°C).

several days, the client is kept in flat in a Nausea, headache, and photophobia aren’t

supine position for approximately 4 to 12 usual TB symptoms.

hours postoperatively. Headaches are 13. Answer:(A) Acute asthma

believed to be causes by the seepage of Rationale: Based on the client’s history and

cerebral spinal fluid from the puncture site. By symptoms, acute asthma is the most likely

keeping the client flat, cerebral spinal fluid diagnosis. He’s unlikely to have bronchial

pressures are equalized, which avoids trauma pneumonia without a productive cough and

to the neurons. fever and he’s too young to have developed

10. Answer: (C) The client is oriented when (COPD) and emphysema.

aroused from sleep, and goes back to sleep 14. Answer: (B) Respiratory arrest

immediately. Rationale: Narcotics can cause respiratory

Rationale: This finding suggest that the level arrest if given in large quantities. It’s unlikely

of consciousness is decreasing. the client will have asthma attack or a seizure

11. Answer: (A) Altered mental status and or wake up on his own.

dehydration 15. Answer: (D) Decreased vital capacity

Rationale: Fever, chills, hemortysis, dyspnea, Rationale: Reduction in vital capacity is a

cough, and pleuritic chest pain are the normal physiologic change includes decreased

common symptoms of pneumonia, but elderly elastic recoil of the lungs, fewer functional

clients may first appear with only an altered 302

lentil status and dehydration due to a blunted capillaries in the alveoli, and an increased in

immune response. residual volume.

12. Answer: (B) Chills, fever, night sweats, and 16. Answer: (C) Presence of premature
ventricular
hemoptysis
contractions (PVCs) on a cardiac monitor.
Rationale: Typical signs and symptoms are
Rationale: Lidocaine drips are commonly used
chills, fever, night sweats, and hemoptysis.
to treat clients whose arrhythmias haven’t
Chest pain may be present from coughing, but
been controlled with oral medication and who
isn’t usual. Clients with TB typically have
lowgrade are having PVCs that are visible on the cardiac
monitor. SaO2, blood pressure, and ICP are when repeated vertebral fractures increase

important factors but aren’t as significant as spinal curvature.

PVCs in the situation. 20. Answer: (C) Changes from previous

17. Answer: (B) Avoid foods high in vitamin K examinations.

Rationale: The client should avoid consuming Rationale: Women are instructed to examine

large amounts of vitamin K because vitamin K themselves to discover changes that have

can interfere with anticoagulation. The client occurred in the breast. Only a physician can

may need to report diarrhea, but isn’t effect diagnose lumps that are cancerous, areas of

of taking an anticoagulant. An electric razornot thickness or fullness that signal the presence

a straight razor-should be used to prevent of a malignancy, or masses that are fibrocystic

cuts that cause bleeding. Aspirin may increase as opposed to malignant.

the risk of bleeding; acetaminophen should be 21. Answer: (C) Balance the client’s periods of

used to pain relief. activity and rest.

18. Answer: (C) Clipping the hair in the area Rationale: A client with hyperthyroidism

Rationale: Hair can be a source of infection needs to be encouraged to balance periods of

and should be removed by clipping. Shaving activity and rest. Many clients with

the area can cause skin abrasions and hyperthyroidism are hyperactive and complain

depilatories can irritate the skin. of feeling very warm.

19. Answer: (A) Bone fracture 22. Answer: (B) Increase his activity level.

Rationale: Bone fracture is a major Rationale: The client should be encouraged to

complication of osteoporosis that results increase his activity level. aintaining an ideal

when loss of calcium and phosphate increased weight; following a low-cholesterol, low

the fragility of bones. Estrogen deficiencies sodium diet; and avoiding stress are all

result from menopause-not osteoporosis. important factors in decreasing the risk of

Calcium and vitamin D supplements may be atherosclerosis.

used to support normal bone metabolism, But 23. Answer: (A) Laminectomy

a negative calcium balance isn’t a Rationale: The client who has had spinal

complication of osteoporosis. Dowager’s surgery, such as laminectomy, must be log

hump results from bone fractures. It develops rolled to keep the spinal column straight when
turning. Thoracotomy and cystectomy may prevent tissue drying and possible infection.

turn themselves or may be assisted into a Then the nurse should call the physician and

comfortable position. Under normal take the client’s vital signs. The dehiscence

circumstances, hemorrhoidectomy is an needs to be surgically closed, so the nurse

outpatient procedure, and the client may should never try to close it.

resume normal activities immediately after 27. Answer: (A) A progressively deeper breaths

surgery. followed by shallower breaths with apneic

24. Answer: (D) Avoiding straining during bowel periods.

movement or bending at the waist. Rationale: Cheyne-Strokes respirations are

Rationale: The client should avoid straining, breaths that become progressively deeper

lifting heavy objects, and coughing harshly fallowed by shallower respirations with

because these activities increase intraocular apneas periods. Biot’s respirations are rapid,

pressure. Typically, the client is instructed to 303

avoid lifting objects weighing more than 15 lb deep breathing with abrupt pauses between

(7kg) – not 5lb. instruct the client when lying each breath, and equal depth between each

in bed to lie on either the side or back. The breath. Kussmaul’s respirationa are rapid,

client should avoid bright light by wearing deep breathing without pauses. Tachypnea is

sunglasses. shallow breathing with increased respiratory

25. Answer: (D) Before age 20. rate.

Rationale: Testicular cancer commonly occurs 28. Answer: (B) Fine crackles

in men between ages 20 and 30. A male client Rationale: Fine crackles are caused by fluid in

should be taught how to perform testicular the alveoli and commonly occur in clients with

self- examination before age 20, preferably heart failure. Tracheal breath sounds are

when he enters his teens. auscultated over the trachea. Coarse crackles

26. Answer: (B) Place a saline-soaked sterile are caused by secretion accumulation in the

dressing on the wound. airways. Friction rubs occur with pleural

Rationale: The nurse should first place inflammation.

salinesoaked
29. Answer: (B) The airways are so swollen that
sterile dressings on the open wound to no
air cannot get through Rationale: If the client is coughing, he should

Rationale: During an acute attack, wheezing be able to dislodge the object or cause a

may stop and breath sounds become complete obstruction. If complete obstruction

inaudible because the airways are so swollen occurs, the nurse should perform the

that air can’t get through. If the attack is over abdominal thrust maneuver with the client

and swelling has decreased, there would be standing. If the client is unconscious, she

no more wheezing and less emergent concern. should lay him down. A nurse should never

Crackles do not replace wheezes during an leave a choking client alone.

acute asthma attack. 33. Answer: (B) Current health promotion

30. Answer: (D) Place the client on his side, activities

remove dangerous objects, and protect his Rationale: Recognizing an individual’s positive

head. health measures is very useful. General health

Rationale: During the active seizure phase, in the previous 10 years is important,

initiate precautions by placing the client on his however, the current activities of an 84 year

side, removing dangerous objects, and old client are most significant in planning care.

protecting his head from injury. A bite block Family history of disease for a client in later

should never be inserted during the active years is of minor significance. Marital status

seizure phase. Insertion can break the teeth information may be important for discharge

and lead to aspiration. planning but is not as significant for

31. Answer: (B) Kinked or obstructed chest tube addressing the immediate medical problem.

Rationales: Kinking and blockage of the chest 34. Answer: (C) Place the client in a side lying

tube is a common cause of a tension position, with the head of the bed lowered.

pneumothorax. Infection and excessive Rationale: The client should be positioned in a

drainage won’t cause a tension side-lying position with the head of the bed

pneumothorax. Excessive water won’t affect lowered to prevent aspiration. A small amount

the chest tube drainage. of toothpaste should be used and the mouth

32. Answer: (D) Stay with him but not intervene swabbed or suctioned to remove pooled
at
secretions. Lemon glycerin can be drying if
this time.
used for extended periods. Brushing the teeth
with the client lying supine may lead to chest X-ray will show their presence in the

aspiration. Hydrogen peroxide is caustic to lungs. Sputum culture confirms the diagnosis.

tissues and should not be used. There can be false-positive and false-negative

35. Answer: (C) Pneumonia skin test results. A chest X-ray can’t determine

Rationale: Fever productive cough and if this is a primary or secondary infection.

pleuritic chest pain are common signs and 38. Answer: (B) Bronchodilators

symptoms of pneumonia. The client with 304

ARDS has dyspnea and hypoxia with Rationale: Bronchodilators are the first line of

worsening hypoxia over time, if not treated treatment for asthma because
bronchoconstriction
aggressively. Pleuritic chest pain varies with
is the cause of reduced airflow.
respiration, unlike the constant chest pain
Beta- adrenergic blockers aren’t used to treat
during an MI; so this client most likely isn’t
asthma and can cause broncho- constriction.
having an MI. the client with TB typically has a
Inhaled oral steroids may be given to reduce
cough producing blood-tinged sputum. A
the inflammation but aren’t used for
sputum culture should be obtained to confirm
emergency relief.
the nurse’s suspicions.
39. Answer: (C) Chronic obstructive bronchitis
36. Answer: (C) A 43-yesr-old homeless man
with Rationale: Because of this extensive smoking

a history of alcoholism history and symptoms the client most likely

Rationale: Clients who are economically has chronic obstructive bronchitis. Client with

disadvantaged, malnourished, and have ARDS have acute symptoms of hypoxia and

reduced immunity, such as a client with a typically need large amounts of oxygen.

history of alcoholism, are at extremely high Clients with asthma and emphysema tend not

risk for developing TB. A high school student, to have chronic cough or peripheral edema.

day- care worker, and businessman probably 40. Answer: (A) The patient is under local

have a much low risk of contracting TB. anesthesia during the procedure Rationale:

37. Answer: (C ) To determine the extent of Before the procedure, the patient is

lesions administered with drugs that would help to

Rationale: If the lesions are large enough, the prevent infection and rejection of the
transplanted cells such as antibiotics, admitted 1 hour ago with new-onset atrial

cytotoxic, and corticosteroids. During the fibrillation and is receiving L.V. dilitiazem

transplant, the patient is placed under general (Cardizem)

anesthesia. Rationale: The client with atrial fibrillation has

41. Answer: (D) Raise the side rails the greatest potential to become unstable and

Rationale: A patient who is disoriented is at is on L.V. medication that requires close

risk of falling out of bed. The initial action of monitoring. After assessing this client, the

the nurse should be raising the side rails to nurse should assess the client with

ensure patients safety. thrombophlebitis who is receiving a heparin

42. Answer: (A) Crowd red blood cells infusion, and then the 58- year-old client

Rationale: The excessive production of white admitted 2 days ago with heart failure (his

blood cells crowd out red blood cells signs and symptoms are resolving and don’t

production which causes anemia to occur. require immediate attention). The lowest

43. Answer: (B) Leukocytosis priority is the 89-year-old with end-stage

Rationale: Chronic Lymphocytic leukemia (CLL) right-sided heart failure, who requires
timeconsuming
is characterized by increased production of
supportive measures.
leukocytes and lymphocytes resulting in
46. Answer: (C) Cocaine
leukocytosis, and proliferation of these cells
Rationale: Because of the client’s age and
within the bone marrow, spleen and liver.
negative medical history, the nurse should
44. Answer: (A) Explain the risks of not having
the question her about cocaine use. Cocaine

surgery increases myocardial oxygen consumption and

Rationale: The best initial response is to can cause coronary artery spasm, leading to

explain the risks of not having the surgery. If tachycardia, ventricular fibrillation, myocardial

the client understands the risks but still ischemia, and myocardial infarction.

refuses the nurse should notify the physician Barbiturate overdose may trigger respiratory

and the nurse supervisor and then record the depression and slow pulse. Opioids can cause

client’s refusal in the nurses’ notes. marked respiratory depression, while

45. Answer: (D) The 75-year-old client who was benzodiazepines can cause drowsiness and
confusion. the tumor and regional lymph nodes can't be

47. Answer: (B) Nonmobile mass with irregular assessed and no evidence of metastasis exists,

edges the lesion is classified as TX, NX, M0. A

Rationale: Breast cancer tumors are fixed, progressive increase in tumor size, no

hard, and poorly delineated with irregular demonstrable metastasis of the regional

edges. A mobile mass that is soft and easily lymph nodes, and ascending degrees of

delineated is most often a fluid-filled benign distant metastasis is classified as T1, T2, T3, or

cyst. Axillary lymph nodes may or may not be T4; N0; and M1, M2, or M3.

palpable on initial detection of a cancerous 50. Answer: (D) "Keep the stoma moist."

mass. Nipple retraction — not eversion — Rationale: The nurse should instruct the client

may be a sign of cancer. to keep the stoma moist, such as by applying a

48. Answer: (C) Radiation thin layer of petroleum jelly around the edges,

Rationale: The usual treatment for vaginal because a dry stoma may become irritated.

cancer is external or intravaginal radiation The nurse should recommend placing a stoma

therapy. Less often, surgery is performed. bib over the stoma to filter and warm air

Chemotherapy typically is prescribed only if before it enters the stoma. The client should

vaginal cancer is diagnosed in an early stage, begin performing stoma care without

which is rare. Immunotherapy isn't used to assistance as soon as possible to gain

treat vaginal cancer. independence in self-care activities.

49. Answer: (B) Carcinoma in situ, no abnormal 51. Answer: (B) Lung cancer

regional lymph nodes, and no evidence of Rationale: Lung cancer is the most deadly type

distant metastasis of cancer in both women and men. Breast

Rationale: TIS, N0, M0 denotes carcinoma in cancer ranks second in women, followed (in

situ, no abnormal regional lymph nodes, and descending order) by colon and rectal cancer,

no evidence of distant metastasis. No pancreatic cancer, ovarian cancer, uterine

evidence of primary tumor, no abnormal cancer, lymphoma, leukemia, liver cancer,

regional lymph nodes, and no evidence of brain cancer, stomach cancer, and multiple

distant metastasis is classified as T0, N0, M0. If myeloma.

305 52. Answer: (A) miosis, partial eyelid ptosis, and

anhidrosis on the affected side of the face. Local anesthetics don't cause hematuria.

Rationale: Horner's syndrome, which occurs 55. Answer: (C) Sigmoidoscopy

when a lung tumor invades the ribs and Rationale: Used to visualize the lower GI tract,

affects the sympathetic nerve ganglia, is sigmoidoscopy and proctoscopy aid in the

characterized by miosis, partial eyelid ptosis, detection of two-thirds of all colorectal

and anhidrosis on the affected side of the cancers. Stool Hematest detects blood, which

face. Chest pain, dyspnea, cough, weight loss, is a sign of colorectal cancer; however, the

and fever are associated with pleural tumors. test doesn't confirm the diagnosis. CEA may

Arm and shoulder pain and atrophy of the arm be elevated in colorectal cancer but isn't

and hand muscles on the affected side suggest considered a confirming test. An abdominal CT

Pancoast's tumor, a lung tumor involving the scan is used to stage the presence of

first thoracic and eighth cervical nerves within colorectal cancer.

the brachial plexus. Hoarseness in a client 56. Answer: (B) A fixed nodular mass with

with lung cancer suggests that the tumor has dimpling of the overlying skin

extended to the recurrent laryngeal nerve; Rationale: A fixed nodular mass with dimpling

dysphagia suggests that the lung tumor is of the overlying skin is common during late

compressing the esophagus. stages of breast cancer. Many women have

53. 53. Answer: (A) prostate-specific antigen, slightly asymmetrical breasts. Bloody nipple

which is used to screen for prostate cancer. discharge is a sign of intraductal papilloma, a

Rationale: PSA stands for prostate-specific benign condition. Multiple firm, round, freely

antigen, which is used to screen for prostate movable masses that change with the

cancer. The other answers are incorrect. menstrual cycle indicate fibrocystic breasts, a

54. Answer: (D) "Remain supine for the time benign condition.

specified by the physician." Rationale: The 57. Answer: (A) Liver

nurse should instruct the client to remain Rationale: The liver is one of the five most

supine for the time specified by the physician. common cancer metastasis sites. The others

Local anesthetics used in a subarachnoid block are the lymph nodes, lung, bone, and brain.

don't alter the gag reflex. No interactions The colon, reproductive tract, and WBCs are

between local anesthetics and food occur. occasional metastasis sites.

58. Answer: (D) The client wears a watch and exercise won't cause fractures.

wedding band. 60. Answer: (C) Joint flexion of less than 50%

Rationale: During an MRI, the client should Rationale: Arthroscopy is contraindicated in

wear no metal objects, such as jewelry, clients with joint flexion of less than 50%

because the strong magnetic field can pull on because of technical problems in inserting the

them, causing injury to the client and (if they instrument into the joint to see it clearly.

fly off) to others. The client must lie still Other contraindications for this procedure

during the MRI but can talk to those include skin and wound infections. Joint pain

performing the test by way of the microphone may be an indication, not a contraindication,

inside the scanner tunnel. The client should for arthroscopy. Joint deformity and joint

hear thumping sounds, which are caused by stiffness aren't contraindications for this

the sound waves thumping on the magnetic procedure.

field. 61. Answer: (D) Gouty arthritis

59. Answer: (C) The recommended daily Rationale: Gouty arthritis, a metabolic disease,

allowance of calcium may be found in a wide is characterized by urate deposits and pain in

variety of foods. the joints, especially those in the feet and

Rationale: Premenopausal women require legs. Urate deposits don't occur in septic or

1,000 mg of calcium per day. Postmenopausal traumatic arthritis. Septic arthritis results from

women require 1,500 mg per day. It's often, bacterial invasion of a joint and leads to

306 inflammation of the synovial lining. Traumatic

though not always, possible to get the arthritis results from blunt trauma to a joint or

recommended daily requirement in the foods ligament. Intermittent arthritis is a rare,

we eat. Supplements are available but not benign condition marked by regular, recurrent

always necessary. Osteoporosis doesn't show joint effusions, especially in the knees.

up on ordinary X-rays until 30% of the bone 62. Answer: (B) 30 ml/hou

loss has occurred. Bone densitometry can Rationale: An infusion prepared with 25,000

detect bone loss of 3% or less. This test is units of heparin in 500 ml of saline solution

sometimes recommended routinely for yields 50 units of heparin per milliliter of

women over 35 who are at risk. Strenuous solution. The equation is set up as 50 units
times X (the unknown quantity) equals 1,500 Rationale: A cane should be used on the

units/hour, X equals 30 ml/hour. unaffected side. A client with osteoarthritis

63. Answer: (B) Loss of muscle contraction should be encouraged to ambulate with a

decreasing venous return cane, walker, or other assistive device as

Rationale: In clients with hemiplegia or needed; their use takes weight and stress off

hemiparesis loss of muscle contraction joints.

decreases venous return and may cause 67. Answer: (A) a. 9 U regular insulin and 21 U

swelling of the affected extremity. neutral protamine Hagedorn (NPH).

Contractures, or bony calcifications may occur Rationale: A 70/30 insulin preparation is 70%

with a stroke, but don’t appear with swelling. NPH and 30% regular insulin. Therefore, a

DVT may develop in clients with a stroke but is correct substitution requires mixing 21 U of

more likely to occur in the lower extremities. NPH and 9 U of regular insulin. The other

A stroke isn’t linked to protein loss. choices are incorrect dosages for the

64. Answer: (B) It appears on the distal prescribed insulin.

interphalangeal joint 68. Answer: (C) colchicines

Rationale: Heberden’s nodes appear on the Rationale: A disease characterized by joint

distal interphalageal joint on both men and inflammation (especially in the great toe),

women. Bouchard’s node appears on the gout is caused by urate crystal deposits in the

dorsolateral aspect of the proximal joints. The physician prescribes colchicine to

interphalangeal joint. reduce these deposits and thus ease joint

65. Answer: (B) Osteoarthritis is a localized inflammation. Although aspirin is used to

disease rheumatoid arthritis is systemic reduce joint inflammation and pain in clients

Rationale: Osteoarthritis is a localized disease, with osteoarthritis and rheumatoid arthritis, it

rheumatoid arthritis is systemic. Osteoarthritis isn't indicated for gout because it has no

isn’t gender-specific, but rheumatoid arthritis effect on urate crystal formation. Furosemide,

is. Clients have dislocations and subluxations a diuretic, doesn't relieve gout. Calcium

in both disorders. gluconate is used to reverse a negative

66. Answer: (C) The cane should be used on the calcium balance and relieve muscle cramps,

unaffected side not to treat gout.

69. Answer: (A) Adrenal cortex secretion. BUN increases as the glomerular

Rationale: Excessive secretion of aldosterone filtration rate is reduced. Hyponatremia is

in the adrenal cortex is responsible for the caused by reduced aldosterone secretion.

client's hypertension. This hormone acts on Reduced cortisol secretion leads to impaired

the renal tubule, where it promotes glyconeogenesis and a reduction of glycogen

reabsorption of sodium and excretion of in the liver and muscle, causing hypoglycemia.

potassium and hydrogen ions. The pancreas 72. Answer: (C) Restricting fluids

mainly secretes hormones involved in fuel Rationale: To reduce water retention in a

metabolism. The adrenal medulla secretes the client with the SIADH, the nurse should

catecholamines — epinephrine and restrict fluids. Administering fluids by any

307 route would further increase the client's

norepinephrine. The parathyroids secrete already heightened fluid load.

parathyroid hormone. 73. Answer: (D) glycosylated hemoglobin level.

70. Answer: (C) They debride the wound and Rationale: Because some of the glucose in the

promote healing by secondary intention bloodstream attaches to some of the

Rationale: For this client, wet-to-dry dressings hemoglobin and stays attached during the

are most appropriate because they clean the 120-day life span of red blood cells,

foot ulcer by debriding exudate and necrotic glycosylated hemoglobin levels provide

tissue, thus promoting healing by secondary information about blood glucose levels during

intention. Moist, transparent dressings the previous 3 months. Fasting blood glucose

contain exudate and provide a moist wound and urine glucose levels only give information

environment. Hydrocolloid dressings prevent about glucose levels at the point in time when

the entrance of microorganisms and minimize they were obtained. Serum fructosamine

wound discomfort. Dry sterile dressings levels provide information about blood

protect the wound from mechanical trauma glucose control over the past 2 to 3 weeks.

and promote healing. 74. Answer: (C) 4:00 pm

71. Answer: (A) Hyperkalemia Rationale: NPH is an intermediate-acting

Rationale: In adrenal insufficiency, the client insulin that peaks 8 to 12 hours after

has hyperkalemia due to reduced aldosterone administration. Because the nurse

administered NPH insulin at 7 a.m., the client carcinoembryonic antigen is elevated.

is at greatest risk for hypoglycemia from 3 Therefore, it can't be used as a general

p.m. to 7 p.m. indicator of cancer. However, it is helpful in

75. Answer: (A) Glucocorticoids and androgens monitoring cancer treatment because the

Rationale: The adrenal glands have two level usually falls to normal within 1 month if

divisions, the cortex and medulla. The cortex treatment is successful. An elevated acid

produces three types of hormones: phosphatase level may indicate prostate

glucocorticoids, mineralocorticoids, and cancer. An elevated alkaline phosphatase level

androgens. The medulla produces may reflect bone metastasis. An elevated

catecholamines— epinephrine and serum calcitonin level usually signals thyroid

norepinephrine. cancer.

76. Answer: (A) Hypocalcemia 78. Answer: (B) Dyspnea, tachycardia, and pallor

Rationale: Hypocalcemia may follow thyroid Rationale: Signs of iron-deficiency anemia

surgery if the parathyroid glands were include dyspnea, tachycardia, and pallor as

removed accidentally. Signs and symptoms of well as fatigue, listlessness, irritability, and

hypocalcemia may be delayed for up to 7 days headache. Night sweats, weight loss, and

after surgery. Thyroid surgery doesn't directly diarrhea may signal acquired

cause serum sodium, potassium, or immunodeficiency syndrome (AIDS). Nausea,

magnesium abnormalities. Hyponatremia may vomiting, and anorexia may be signs of

occur if the client inadvertently received too hepatitis B. Itching, rash, and jaundice may

much fluid; however, this can happen to any result from an allergic or hemolytic reaction.

surgical client receiving I.V. fluid therapy, not 79. Answer: (D) "I'll need to have a C-section if I

just one recovering from thyroid surgery. become pregnant and have a baby."

Hyperkalemia and hypermagnesemia usually Rationale: The human immunodeficiency virus

are associated with reduced renal excretion of (HIV) is transmitted from mother to child via

potassium and magnesium, not thyroid the transplacental route, but a Cesarean

surgery. section delivery isn't necessary when the

77. Answer: (D) Carcinoembryonic antigen level mother is HIV-positive. The use of birth

Rationale: In clients who smoke, the level of control will prevent the conception of a child
who might have HIV. It's true that a mother if necessary.

308 Rationale: To reverse anaphylactic shock, the

who's HIV positive can give birth to a baby nurse first should administer epinephrine, a

who's HIV negative. potent bronchodilator as prescribed. The

80. Answer: (C) "Avoid sharing such articles as physician is likely to order additional

toothbrushes and razors." medications, such as antihistamines and

Rationale: The human immunodeficiency virus corticosteroids; if these medications don't

(HIV), which causes AIDS, is most relieve the respiratory compromise associated

concentrated in the blood. For this reason, the with anaphylaxis, the nurse should prepare to

client shouldn't share personal articles that intubate the client. No antidote for penicillin

may be blood-contaminated, such as exists; however, the nurse should continue to

toothbrushes and razors, with other family monitor the client's vital signs. A client who

members. HIV isn't transmitted by bathing or remains hypotensive may need fluid

by eating from plates, utensils, or serving resuscitation and fluid intake and output

dishes used by a person with AIDS. monitoring; however, administering

81. Answer: (B) Pallor, tachycardia, and a sore epinephrine is the first priority.

tongue 83. Answer: (D) bilateral hearing loss.

Rationale: Pallor, tachycardia, and a sore Rationale: Prolonged use of aspirin and other

tongue are all characteristic findings in salicylates sometimes causes bilateral hearing

pernicious anemia. Other clinical loss of 30 to 40 decibels. Usually, this adverse

manifestations include anorexia; weight loss; a effect resolves within 2 weeks after the

smooth, beefy red tongue; a wide pulse therapy is discontinued. Aspirin doesn't lead

pressure; palpitations; angina; weakness; to weight gain or fine motor tremors. Large or

fatigue; and paresthesia of the hands and feet. toxic salicylate doses may cause respiratory

Bradycardia, reduced pulse pressure, weight alkalosis, not respiratory acidosis.

gain, and double vision aren't characteristic 84. Answer: (D) Lymphocyte

findings in pernicious anemia. Rationale: The lymphocyte provides adaptive

82. Answer: (B) Administer epinephrine, as immunity — recognition of a foreign antigen

prescribed, and prepare to intubate the client and formation of memory cells against the
antigen. Adaptive immunity is mediated by B hemogram may be useful in the overall

and T lymphocytes and can be acquired evaluation of a client but aren't diagnostic for

actively or passively. The neutrophil is crucial specific causes of diarrhea. A flat plate of the

to phagocytosis. The basophil plays an abdomen may provide useful information

important role in the release of inflammatory about bowel function but isn't indicated in the

mediators. The monocyte functions in case of "horse barn" smelling diarrhea.

phagocytosis and monokine production. 87. Answer: (D) Western blot test with ELISA.

85. Answer: (A) moisture replacement. Rationale: HIV infection is detected by

Rationale: Sjogren's syndrome is an analyzing blood for antibodies to HIV, which

autoimmune disorder leading to progressive form approximately 2 to 12 weeks after

loss of lubrication of the skin, GI tract, ears, exposure to HIV and denote infection. The

nose, and vagina. Moisture replacement is the Western blot test — electrophoresis of

mainstay of therapy. Though malnutrition and antibody proteins — is more than 98%

electrolyte imbalance may occur as a result of accurate in detecting HIV antibodies when

Sjogren's syndrome's effect on the GI tract, it used in conjunction with the ELISA. It isn't

isn't the predominant problem. Arrhythmias specific when used alone. E-rosette

aren't a problem associated with Sjogren's immunofluorescence is used to detect viruses

syndrome. in general; it doesn't confirm HIV infection.

86. Answer: (C) stool for Clostridium difficile Quantification of T-lymphocytes is a useful
test.
monitoring test but isn't diagnostic for HIV.
Rationale: Immunosuppressed clients — for
The ELISA test detects HIV antibody particles
example, clients receiving chemotherapy, —
but may yield inaccurate results; a positive
are at risk for infection with C. difficile, which
309
causes "horse barn" smelling diarrhea.
ELISA result must be confirmed by the
Successful treatment begins with an accurate
Western blot test.
diagnosis, which includes a stool test. The
88. Answer: (C) Abnormally low hematocrit
ELISA test is diagnostic for human (HCT)

immunodeficiency virus (HIV) and isn't and hemoglobin (Hb) levels

indicated in this case. An electrolyte panel and Rationale: Low preoperative HCT and Hb
levels indicate the client may require a blood Rationale: It may indicate neurovascular

transfusion before surgery. If the HCT and Hb compromise, requires immediate assessment.

levels decrease during surgery because of 92. Answer: (D) A 62-year-old who had an

blood loss, the potential need for a abdominal-perineal resection three days ago;

transfusion increases. Possible renal failure is client complaints of chills.

indicated by elevated BUN or creatinine levels. Rationale: The client is at risk for peritonitis;

Urine constituents aren't found in the blood. should be assessed for further symptoms and

Coagulation is determined by the presence of infection.

appropriate clotting factors, not electrolytes. 93. Answer: (C) The client spontaneously flexes

89. Answer: (A) Platelet count, prothrombin his wrist when the blood pressure is obtained.
time,
Rationale: Carpal spasms indicate
and partial thromboplastin time
hypocalcemia.
Rationale: The diagnosis of DIC is based on the
94. Answer: (D) Use comfort measures and
results of laboratory studies of prothrombin
pillows to position the client.
time, platelet count, thrombin time, partial
Rationale: Using comfort measures and
thromboplastin time, and fibrinogen level as
pillows to position the client is a
well as client history and other assessment nonpharmacological

factors. Blood glucose levels, WBC count, methods of pain relief.

calcium levels, and potassium levels aren't 95. Answer: (B) Warm the dialysate solution.

used to confirm a diagnosis of DIC. Rationale: Cold dialysate increases discomfort.

90. Answer: (D) Strawberries The solution should be warmed to body

Rationale: Common food allergens include temperature in warmer or heating pad; don’t

berries, peanuts, Brazil nuts, cashews, use microwave oven.

shellfish, and eggs. Bread, carrots, and 96. Answer: (C) The client holds the cane with
his
oranges rarely cause allergic reactions.
left hand, moves the cane forward followed
91. Answer: (B) A client with cast on the right
leg by the right leg, and then moves the left leg.

who states, “I have a funny feeling in my right Rationale: The cane acts as a support and aids

leg.” in weight bearing for the weaker right leg.

97. Answer: (A) Ask the woman’s family to c. Hypertension

provide personal items such as photos or d. Shock

mementos. 2. The immediate objective of nursing care for

an
Rationale: Photos and mementos provide
overweight, mildly hypertensive male client
visual stimulation to reduce sensory
with
deprivation.
ureteral colic and hematuria is to decrease:
98. Answer: (B) The client lifts the walker, moves
a. Pain
it forward 10 inches, and then takes several
b. Weight
small steps forward.
c. Hematuria
Rationale: A walker needs to be picked up,
d. Hypertension
placed down on all legs.
3. Matilda, with hyperthyroidism is to receive
99. Answer: (C) Isolation from their families and
Lugol’s iodine solution before a subtotal
familiar surroundings.
thyroidectomy is performed. The nurse is aware
Rationale: Gradual loss of sight, hearing, and
that this medication is given to:
taste interferes with normal functioning.
a. Decrease the total basal metabolic rate.
100. Answer: (A) Encourage the client to
b. Maintain the function of the parathyroid
perform
glands.
pursed lip breathing.
c. Block the formation of thyroxine by the
Rationale: Purse lip breathing prevents the
thyroid gland.
collapse of lung unit and helps client control
d. Decrease the size and vascularity of the
rate and depth of breathing.
thyroid gland.
310
4. Ricardo, was diagnosed with type I diabetes.
TEST IV - Care of Clients with Physiologic and
The
Psychosocial Alterations
nurse is aware that acute hypoglycemia also can
1. Randy has undergone kidney transplant, what
develop in the client who is diagnosed with:
assessment would prompt Nurse Katrina to
a. Liver disease
suspect organ rejection?
b. Hypertension
a. Sudden weight loss
c. Type 2 diabetes
b. Polyuria
d. Hyperthyroidism
5. Tracy is receiving combination chemotherapy solution to stimulate evacuation of the
for
bowel.”
treatment of metastatic carcinoma. Nurse Ruby
d. Insert the irrigating catheter deeper into
should monitor the client for the systemic side
the stoma if cramping occurs during the
effect of:
procedure.”
a. Ascites
8. Patrick is in the oliguric phase of acute
b. Nystagmus tubular

c. Leukopenia necrosis and is experiencing fluid and

electrolyte
d. Polycythemia
imbalances. The client is somewhat confused
6. Norma, with recent colostomy expresses
and complains of nausea and muscle weakness.
concern about the inability to control the
As part of the prescribed therapy to correct this
passage of gas. Nurse Oliver should suggest that
electrolyte imbalance, the nurse would expect
the client plan to:
to:
a. Eliminate foods high in cellulose.
a. Administer Kayexalate
b. Decrease fluid intake at meal times.
b. Restrict foods high in protein
c. Avoid foods that in the past caused
c. Increase oral intake of cheese and milk.
flatus.
d. Administer large amounts of normal
d. Adhere to a bland diet prior to social
saline via I.V.
events.
9. Mario has burn injury. After Forty48 hours,
7. Nurse Ron begins to teach a male client how
the
to
physician orders for Mario 2 liters of IV fluid to
perform colostomy irrigations. The nurse would
be administered q12 h. The drop factor of the
evaluate that the instructions were understood
tubing is 10 gtt/ml. The nurse should set the
when the client states, “I should:
flow to provide:
a. Lie on my left side while instilling the
a. 18 gtt/min
irrigating solution.”
b. 28 gtt/min
b. Keep the irrigating container less than
c. 32 gtt/min
18 inches above the stoma.”
d. 36 gtt/min
c. Instill a minimum of 1200 ml of irrigating
10. Terence suffered from burn injury. Using the c. Have regular follow up care
rule
d. May engage in contact sports
of nines, which has the largest percent of
13. The nurse is ware that the most relevant
burns?
knowledge about oxygen administration to a
a. Face and neck
male client with COPD is
b. Right upper arm and penis
a. Oxygen at 1-2L/min is given to maintain
c. Right thigh and penis
the hypoxic stimulus for breathing.
d. Upper trunk
b. Hypoxia stimulates the central
11. Herbert, a 45 year old construction engineer
is chemoreceptors in the medulla that
brought to the hospital unconscious after falling makes the client breath.
311 c. Oxygen is administered best using a
nonrebreathing
from a 2-story building. When assessing the
mask
client, the nurse would be most concerned if
the d. Blood gases are monitored using a pulse
assessment revealed: oximeter.
a. Reactive pupils 14. Tonny has undergoes a left thoracotomy and
a
b. A depressed fontanel
partial pneumonectomy. Chest tubes are
c. Bleeding from ears
inserted, and one-bottle water-seal drainage is
d. An elevated temperature
instituted in the operating room. In the
12. Nurse Sherry is teaching male client
regarding postanesthesia care unit Tonny is placed in
his permanent artificial pacemaker. Which Fowler's position on either his right side or on
information given by the nurse shows her his back. The nurse is aware that this position:
knowledge deficit about the artificial cardiac a. Reduce incisional pain.
pacemaker? b. Facilitate ventilation of the left lung.
a. take the pulse rate once a day, in the c. Equalize pressure in the pleural space.
morning upon awakening d. Increase venous return
b. May be allowed to use electrical 15. Kristine is scheduled for a bronchoscopy.
When
appliances
teaching Kristine what to expect afterward, the
nurse's highest priority of information would be: c. The potential for transmission to her

a. Food and fluids will be withheld for at sexual partner will be eliminated if

least 2 hours. condoms are used every time they have

b. Warm saline gargles will be done q 2h. sexual intercourse.

c. Coughing and deep-breathing exercises d. The human papillomavirus (HPV), which

will be done q2h. causes condylomata acuminata, can't be

d. Only ice chips and cold liquids will be transmitted during oral sex.

allowed initially. 18. Maritess was recently diagnosed with a

16. Nurse Tristan is caring for a male client in genitourinary problem and is being examined in
acute
the emergency department. When palpating
renal failure. The nurse should expect her
hypertonic
kidneys, the nurse should keep which
glucose, insulin infusions, and sodium anatomical

bicarbonate to be used to treat: fact in mind?

a. hypernatremia. a. The left kidney usually is slightly higher

b. hypokalemia. than the right one.

c. hyperkalemia. b. The kidneys are situated just above the

d. hypercalcemia. adrenal glands.

17. Ms. X has just been diagnosed with c. The average kidney is approximately 5
condylomata
cm (2") long and 2 to 3 cm (¾" to 1-1/8")
acuminata (genital warts). What information is
wide.
appropriate to tell this client?
d. The kidneys lie between the 10th and
a. This condition puts her at a higher risk
12th thoracic vertebrae.
for cervical cancer; therefore, she should
19. Jestoni with chronic renal failure (CRF) is
have a Papanicolaou (Pap) smear
admitted to the urology unit. The nurse is aware
annually.
that the diagnostic test are consistent with CRF
b. The most common treatment is if

metronidazole (Flagyl), which should the result is:

eradicate the problem within 7 to 10 a. Increased pH with decreased hydrogen

days. ions.
312 symptoms of cancer. What is the most common

b. Increased serum levels of potassium, AIDS-related cancer?

magnesium, and calcium. a. Squamous cell carcinoma

c. Blood urea nitrogen (BUN) 100 mg/dl b. Multiple myeloma

and serum creatinine 6.5 mg/ dl. c. Leukemia

d. Uric acid analysis 3.5 mg/dl and d. Kaposi's sarcoma

phenolsulfonphthalein (PSP) excretion 22. Ricardo is scheduled for a prostatectomy,

and
75%.
the anesthesiologist plans to use a spinal
20. Katrina has an abnormal result on a
(subarachnoid) block during surgery. In the
Papanicolaou test. After admitting that she read
operating room, the nurse positions the client
her chart while the nurse was out of the room,
according to the anesthesiologist's instructions.
Katrina asks what dysplasia means. Which
Why does the client require special positioning
definition should the nurse provide?
for this type of anesthesia?
a. Presence of completely undifferentiated
a. To prevent confusion
tumor cells that don't resemble cells of
b. To prevent seizures
the tissues of their origin.
c. To prevent cerebrospinal fluid (CSF)
b. Increase in the number of normal cells in
leakage
a normal arrangement in a tissue or an
d. To prevent cardiac arrhythmias
organ.
23. A male client had a nephrectomy 2 days ago
c. Replacement of one type of fully
and
differentiated cell by another in tissues
is now complaining of abdominal pressure and
where the second type normally isn't
nausea. The first nursing action should be to:
found.
a. Auscultate bowel sounds.
d. Alteration in the size, shape, and
b. Palpate the abdomen.
organization of differentiated cells.
c. Change the client's position.
21. During a routine checkup, Nurse Mariane
d. Insert a rectal tube.
assesses a male client with acquired
24. Wilfredo with a recent history of rectal
immunodeficiency syndrome (AIDS) for signs bleeding
and
is being prepared for a colonoscopy. How should
the nurse Patricia position the client for this test potential problem?

initially? a. Partial pressure of arterial oxygen

a. Lying on the right side with legs straight (PaO2) value of 80 mm Hg.

b. Lying on the left side with knees bent b. Urine output of 20 ml/hour.

c. Prone with the torso elevated c. White pulmonary secretions.

d. Bent over with hands touching the floor d. Rectal temperature of 100.6° F (38° C).

25. A male client with inflammatory bowel 28. Mr. Mendoza who has suffered a
disease
cerebrovascular accident (CVA) is too weak to
undergoes an ileostomy. On the first day after
move on his own. To help the client avoid
surgery, Nurse Oliver notes that the client's
pressure ulcers, Nurse Celia should:
stoma appears dusky. How should the nurse
a. Turn him frequently.
interpret this finding?
b. Perform passive range-of-motion (ROM)
a. Blood supply to the stoma has been
exercises.
interrupted.
c. Reduce the client's fluid intake.
b. This is a normal finding 1 day after
d. Encourage the client to use a footboard.
surgery.
313
c. The ostomy bag should be adjusted.
29. Nurse Maria plans to administer
d. An intestinal obstruction has occurred. dexamethasone

26. Anthony suffers burns on the legs, which cream to a female client who has dermatitis
nursing over

intervention helps prevent contractures? the anterior chest. How should the nurse apply

a. Applying knee splints this topical agent?

b. Elevating the foot of the bed a. With a circular motion, to enhance

c. Hyperextending the client's palms absorption.

d. Performing shoulder range-of-motion b. With an upward motion, to increase

exercises blood supply to the affected area

27. Nurse Ron is assessing a client admitted with c. In long, even, outward, and downward

second- and third-degree burns on the face, strokes in the direction of hair growth

arms, and chest. Which finding indicates a d. In long, even, outward, and upward
strokes in the direction opposite hair lipoprotein (HDL) level and an elevated
lowdensity
growth
lipoprotein (LDL) level. Which of the
30. Nurse Kate is aware that one of the
following following dietary modifications is not

classes of medication protects the ischemic appropriate for this client?

myocardium by blocking catecholamines and a. Fiber intake of 25 to 30 g daily

sympathetic nerve stimulation is: b. Less than 30% of calories from fat

a. Beta -adrenergic blockers c. Cholesterol intake of less than 300 mg

b. Calcium channel blocker daily

c. Narcotics d. Less than 10% of calories from saturated

d. Nitrates fat

31. A male client has jugular distention. On 34. A 37-year-old male client was admitted to
what the

position should the nurse place the head of the coronary care unit (CCU) 2 days ago with an

bed to obtain the most accurate reading of acute myocardial infarction. Which of the

jugular vein distention? following actions would breach the client

a. High Fowler’s confidentiality?

b. Raised 10 degrees a. The CCU nurse gives a verbal report to

c. Raised 30 degrees the nurse on the telemetry unit before

d. Supine position transferring the client to that unit

32. The nurse is aware that one of the following b. The CCU nurse notifies the on-call

classes of medications maximizes cardiac physician about a change in the client’s

performance in clients with heart failure by condition

increasing ventricular contractility? c. The emergency department nurse calls

a. Beta-adrenergic blockers up the latest electrocardiogram results

b. Calcium channel blocker to check the client’s progress.

c. Diuretics d. At the client’s request, the CCU nurse

d. Inotropic agents updates the client’s wife on his condition

33. A male client has a reduced serum high- 35. A male client arriving in the emergency
density
department is receiving cardiopulmonary Oliver anticipate?

resuscitation from paramedics who are giving a. Cardiac monitor, oxygen, creatine kinase

ventilations through an endotracheal (ET) tube and lactate dehydrogenase levels

that they placed in the client’s home. During a b. Prothrombin time, partial

pause in compressions, the cardiac monitor thromboplastin time, fibrinogen and

shows narrow QRS complexes and a heart rate fibrin split product values.

of beats/minute with a palpable pulse. Which of 314

the following actions should the nurse take c. Electrocardiogram, complete blood
first?
count, testing for occult blood,
a. Start an L.V. line and administer
comprehensive serum metabolic panel.
amiodarone (Cardarone), 300 mg L.V.
d. Electroencephalogram, alkaline
over 10 minutes.
phosphatase and aspartate
b. Check endotracheal tube placement.
aminotransferase levels, basic serum
c. Obtain an arterial blood gas (ABG)
metabolic panel
sample.
38. Macario had coronary artery bypass graft
d. Administer atropine, 1 mg L.V. (CABG)

36. After cardiac surgery, a client’s blood surgery 3 days ago. Which of the following
pressure
conditions is suspected by the nurse when a
measures 126/80 mm Hg. Nurse Katrina
decrease in platelet count from 230,000 ul to
determines that mean arterial pressure (MAP) is
5,000 ul is noted?
which of the following?
a. Pancytopenia
a. 46 mm Hg
b. Idiopathic thrombocytopemic purpura
b. 80 mm Hg
(ITP)
c. 95 mm Hg
c. Disseminated intravascular coagulation
d. 90 mm Hg
(DIC)
37. A female client arrives at the emergency
d. Heparin-associated thrombosis and
department with chest and stomach pain and a
thrombocytopenia (HATT)
report of black tarry stool for several months.
39. Which of the following drugs would be
Which of the following order should the nurse ordered
by the physician to improve the platelet count in d. Von Willebrand’s disease

a male client with idiopathic thrombocytopenic 43. The nurse is aware that the following
symptom
purpura (ITP)?
is most commonly an early indication of stage 1
a. Acetylsalicylic acid (ASA)
Hodgkin’s disease?
b. Corticosteroids
a. Pericarditis
c. Methotrezate
b. Night sweat
d. Vitamin K
c. Splenomegaly
40. A female client is scheduled to receive a
heart d. Persistent hypothermia

valve replacement with a porcine valve. Which 44. Francis with leukemia has neutropenia.
Which of
of the following types of transplant is this?
the following functions must frequently
a. Allogeneic
assessed?
b. Autologous
a. Blood pressure
c. Syngeneic
b. Bowel sounds
d. Xenogeneic
c. Heart sounds
41. Marco falls off his bicycle and injuries his
ankle. d. Breath sounds

Which of the following actions shows the initial 45. The nurse knows that neurologic
complications
response to the injury in the extrinsic pathway?
of multiple myeloma (MM) usually involve
a. Release of Calcium
which
b. Release of tissue thromboplastin
of the following body system?
c. Conversion of factors XII to factor XIIa
a. Brain
d. Conversion of factor VIII to factor VIIIa
b. Muscle spasm
42. Instructions for a client with systemic lupus
c. Renal dysfunction
erythematosus (SLE) would include information
d. Myocardial irritability
about which of the following blood dyscrasias?
46. Nurse Patricia is aware that the average
a. Dressler’s syndrome length

b. Polycythemia of time from human immunodeficiency virus

c. Essential thrombocytopenia (HIV) infection to the development of acquired

immunodeficiency syndrome (AIDS)? AB negative. Which blood type would be the

a. Less than 5 years safest for him to receive?

b. 5 to 7 years a. AB Rh-positive

c. 10 years b. A Rh-positive

d. More than 10 years c. A Rh-negative

47. An 18-year-old male client admitted with d. O Rh-positive

heat
Situation: Stacy is diagnosed with acute
stroke begins to show signs of disseminated lymphoid

intravascular coagulation (DIC). Which of the leukemia (ALL) and beginning chemotherapy.

following laboratory findings is most consistent 50. Stacy is discharged from the hospital
following
with DIC?
her chemotherapy treatments. Which
a. Low platelet count
statement
b. Elevated fibrinogen levels
of Stacy’s mother indicated that she
c. Low levels of fibrin degradation products understands

d. Reduced prothrombin time when she will contact the physician?

48. Mario comes to the clinic complaining of a. “I should contact the physician if Stacy
fever,
has difficulty in sleeping”.
drenching night sweats, and unexplained weight
b. “I will call my doctor if Stacy has
loss over the past 3 months. Physical
persistent vomiting and diarrhea”.
examination reveals a single enlarged
c. “My physician should be called if Stacy is
supraclavicular lymph node. Which of the
irritable and unhappy”.
following is the most probable diagnosis?
d. “Should Stacy have continued hair loss, I
a. Influenza
need to call the doctor”.
b. Sickle cell anemia
51. Stacy’s mother states to the nurse that it is
c. Leukemia hard

d. Hodgkin’s disease to see Stacy with no hair. The best response for

315 the nurse is:

49. A male client with a gunshot wound requires a. “Stacy looks very nice wearing a hat”.
an
b. “You should not worry about her hair,
emergency blood transfusion. His blood type is
just be glad that she is alive”. which of the following conditions?

c. “Yes it is upsetting. But try to cover up a. Adult respiratory distress syndrome

your feelings when you are with her or (ARDS)

else she may be upset”. b. Asthma

d. “This is only temporary; Stacy will regrow c. Chronic obstructive bronchitis

new hair in 3-6 months, but may d. Emphysema

be different in texture”. 55. The term “pink puffer” refers to the female

52. Stacy has beginning stomatitis. To promote client with which of the following conditions?
oral
a. Adult respiratory distress syndrome
hygiene and comfort, the nurse in-charge
(ARDS)
should:
b. Asthma
a. Provide frequent mouthwash with
c. Chronic obstructive bronchitis
normal saline.
d. Emphysema
b. Apply viscous Lidocaine to oral ulcers as
56. Jose is in danger of respiratory arrest
needed. following

c. Use lemon glycerine swabs every 2 the administration of a narcotic analgesic. An

hours. arterial blood gas value is obtained. Nurse Oliver

d. Rinse mouth with Hydrogen Peroxide. would expect the paco2 to be which of the

53. During the administration of chemotherapy following values?

agents, Nurse Oliver observed that the IV site is a. 15 mm Hg

red and swollen, when the IV is touched Stacy b. 30 mm Hg

shouts in pain. The first nursing action to take is: c. 40 mm Hg

a. Notify the physician d. 80 mm Hg

b. Flush the IV line with saline solution 57. Timothy’s arterial blood gas (ABG) results
are as
c. Immediately discontinue the infusion
follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm
d. Apply an ice pack to the site, followed by
Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result
warm compress.
represents which of the following conditions?
54. The term “blue bloater” refers to a male
client a. Metabolic acidosis
b. Metabolic alkalosis because of:

c. Respiratory acidosis a. Impaired clotting mechanism

d. Respiratory alkalosis b. Varix formation

58. Norma has started a new drug for c. Inadequate nutrition

hypertension.
d. Trauma of invasive procedure
Thirty minutes after she takes the drug, she
61. Mr. Gonzales develops hepatic
develops chest tightness and becomes short of encephalopathy.

breath and tachypneic. She has a decreased Which clinical manifestation is most common
level
with this condition?
of consciousness. These signs indicate which of
a. Increased urine output
the following conditions?
b. Altered level of consciousness
a. Asthma attack
c. Decreased tendon reflex
b. Pulmonary embolism
d. Hypotension
c. Respiratory failure
62. When Mr. Gonzales regained consciousness,
d. Rheumatoid arthritis the

316 physician orders 50 ml of Lactose p.o. every 2

Situation: Mr. Gonzales was admitted to the hours. Mr. Gozales develops diarrhea. The nurse
hospital
best action would be:
with ascites and jaundice. To rule out cirrhosis
a. “I’ll see if your physician is in the
of the
hospital”.
liver:
b. “Maybe you’re reacting to the drug; I
59. Which laboratory test indicates liver
cirrhosis? will withhold the next dose”.
a. Decreased red blood cell count c. “I’ll lower the dosage as ordered so the
b. Decreased serum acid phosphate level drug causes only 2 to 4 stools a day”.
c. Elevated white blood cell count d. “Frequently, bowel movements are
d. Elevated serum aminotransferase needed to reduce sodium level”.
60. 60.The biopsy of Mr. Gonzales confirms the 63. Which of the following groups of symptoms
diagnosis of cirrhosis. Mr. Gonzales is at indicates a ruptured abdominal aortic
increased risk for excessive bleeding primarily aneurysm?
a. Lower back pain, increased blood c. Nitroglycerin

pressure, decreased red blood cell (RBC) d. Percutaneous transluminal coronary

count, increased white blood (WBC) angioplasty (PTCA)

count. 66. The nurse is aware that the following terms

used
b. Severe lower back pain, decreased blood
to describe reduced cardiac output and
pressure, decreased RBC count,
perfusion impairment due to ineffective
increased WBC count.
pumping of the heart is:
c. Severe lower back pain, decreased blood
a. Anaphylactic shock
pressure, decreased RBC count,
b. Cardiogenic shock
decreased RBC count, decreased WBC
c. Distributive shock
count.
d. Myocardial infarction (MI)
d. Intermitted lower back pain, decreased
67. A client with hypertension asks the nurse
blood pressure, decreased RBC count,
which
increased WBC count.
factors can cause blood pressure to drop to
64. After undergoing a cardiac catheterization,
normal levels?
Tracy
a. Kidneys’ excretion to sodium only.
has a large puddle of blood under his buttocks.
b. Kidneys’ retention of sodium and water
Which of the following steps should the nurse
c. Kidneys’ excretion of sodium and water
take first?
d. Kidneys’ retention of sodium and
a. Call for help.
excretion of water
b. Obtain vital signs
68. Nurse Rose is aware that the statement that
c. Ask the client to “lift up”
best explains why furosemide (Lasix) is
d. Apply gloves and assess the groin site
administered to treat hypertension is:
65. Which of the following treatment is a
suitable a. It dilates peripheral blood vessels.

surgical intervention for a client with unstable b. It decreases sympathetic

angina? cardioacceleration.

a. Cardiac catheterization c. It inhibits the angiotensin-coverting

b. Echocardiogram enzymes
d. It inhibits reabsorption of sodium and worsening condition.”

water in the loop of Henle. d. Stronger medications may lead to

317 vomiting, which increases the

69. Nurse Nikki knows that laboratory results intracarnial pressure (ICP).”

supports the diagnosis of systemic lupus 71. When evaluating an arterial blood gas from
a
erythematosus (SLE) is:
male client with a subdural hematoma, the
a. Elavated serum complement level
nurse notes the Paco2 is 30 mm Hg. Which of
b. Thrombocytosis, elevated sedimentation
the following responses best describes the
rate
result?
c. Pancytopenia, elevated antinuclear
a. Appropriate; lowering carbon dioxide
antibody (ANA) titer
(CO2) reduces intracranial pressure (ICP)
d. Leukocysis, elevated blood urea nitrogen
b. Emergent; the client is poorly
(BUN) and creatinine levels
oxygenated
70. Arnold, a 19-year-old client with a mild
c. Normal
concussion is discharged from the emergency
d. Significant; the client has alveolar
department. Before discharge, he complains of
a hypoventilation

headache. When offered acetaminophen, his 72. When prioritizing care, which of the
following
mother tells the nurse the headache is severe
clients should the nurse Olivia assess first?
and she would like her son to have something
a. A 17-year-old client’s 24-hours
stronger. Which of the following responses by
postappendectomy
the nurse is appropriate?
b. A 33-year-old client with a recent
a. “Your son had a mild concussion,
diagnosis of Guillain-Barre syndrome
acetaminophen is strong enough.”
c. A 50-year-old client 3 days
b. “Aspirin is avoided because of the
postmyocardial infarction
danger of Reye’s syndrome in children or
d. A 50-year-old client with diverticulitis
young adults.”
73. JP has been diagnosed with gout and wants
c. “Narcotics are avoided after a head
to
injury because they may hide a
know why colchicine is used in the treatment of
gout. Which of the following actions of report to the physician immediately?

colchicines explains why it’s effective for gout? a. Pitting edema of the legs

a. Replaces estrogen b. An irregular apical pulse

b. Decreases infection c. Dry mucous membranes

c. Decreases inflammation d. Frequent urination

d. Decreases bone demineralization 77. Cyrill with severe head trauma sustained in a
car
74. Norma asks for information about
osteoarthritis. accident is admitted to the intensive care unit.

Which of the following statements about Thirty-six hours later, the client's urine output

osteoarthritis is correct? suddenly rises above 200 ml/hour, leading the

a. Osteoarthritis is rarely debilitating nurse to suspect diabetes insipidus. Which

b. Osteoarthritis is a rare form of arthritis laboratory findings support the nurse's

suspicion
c. Osteoarthritis is the most common form
of diabetes insipidus?
of arthritis
a. Above-normal urine and serum
d. Osteoarthritis afflicts people over 60
osmolality levels
75. Ruby is receiving thyroid replacement
therapy b. Below-normal urine and serum

develops the flu and forgets to take her thyroid osmolality levels

replacement medicine. The nurse understands c. Above-normal urine osmolality level,

that skipping this medication will put the client below-normal serum osmolality level

at risk for developing which of the following d. Below-normal urine osmolality level,
lifethreatening
above-normal serum osmolality level
complications?
318
a. Exophthalmos
78. Jomari is diagnosed with hyperosmolar
b. Thyroid storm
hyperglycemic nonketotic syndrome (HHNS) is
c. Myxedema coma
stabilized and prepared for discharge. When
d. Tibial myxedema
preparing the client for discharge and home
76. Nurse Sugar is assessing a client with
management, which of the following statements
Cushing's
indicates that the client understands her
syndrome. Which observation should the nurse
condition and how to control it? a. "I'll take my hydrocortisone in the late

a. "I can avoid getting sick by not becoming afternoon, before dinner."

dehydrated and by paying attention to b. "I'll take all of my hydrocortisone in the

my need to urinate, drink, or eat more morning, right after I wake up."

than usual." c. "I'll take two-thirds of the dose when I

b. "If I experience trembling, weakness, wake up and one-third in the late

and headache, I should drink a glass of afternoon."

soda that contains sugar." d. "I'll take the entire dose at bedtime."

c. "I will have to monitor my blood glucose 81. Which of the following laboratory test
results
level closely and notify the physician if
would suggest to the nurse Len that a client has
it's constantly elevated."
a corticotropin-secreting pituitary adenoma?
d. "If I begin to feel especially hungry and
a. High corticotropin and low cortisol levels
thirsty, I'll eat a snack high in
b. Low corticotropin and high cortisol levels
carbohydrates."
c. High corticotropin and high cortisol
79. A 66-year-old client has been complaining of
levels
sleeping more, increased urination, anorexia,
d. Low corticotropin and low cortisol levels
weakness, irritability, depression, and bone pain
82. A male client is scheduled for a
that interferes with her going outdoors. Based
transsphenoidal
on these assessment findings, the nurse would
hypophysectomy to remove a pituitary tumor.
suspect which of the following disorders?
Preoperatively, the nurse should assess for
a. Diabetes mellitus
potential complications by doing which of the
b. Diabetes insipidus
following?
c. Hypoparathyroidism
a. Testing for ketones in the urine
d. Hyperparathyroidism
b. Testing urine specific gravity
80. Nurse Lourdes is teaching a client recovering
c. Checking temperature every 4 hours
from addisonian crisis about the need to take
d. Performing capillary glucose testing
fludrocortisone acetate and hydrocortisone at
every 4 hours
home. Which statement by the client indicates
83. Capillary glucose monitoring is being
an understanding of the instructions? performed
every 4 hours for a client diagnosed with radioimmunoassay

diabetic ketoacidosis. Insulin is administered 85. Rico with diabetes mellitus must learn how
to
using a scale of regular insulin according to
self-administer insulin. The physician has
glucose results. At 2 p.m., the client has a
prescribed 10 U of U-100 regular insulin and 35
capillary glucose level of 250 mg/dl for which he
U of U-100 isophane insulin suspension (NPH) to
receives 8 U of regular insulin. Nurse Mariner
be taken before breakfast. When teaching the
should expect the dose's:
client how to select and rotate insulin injection
a. onset to be at 2 p.m. and its peak to be
sites, the nurse should provide which
at 3 p.m.
instruction?
b. onset to be at 2:15 p.m. and its peak to
319
be at 3 p.m.
a. "Inject insulin into healthy tissue with
c. onset to be at 2:30 p.m. and its peak to
large blood vessels and nerves."
be at 4 p.m.
b. "Rotate injection sites within the same
d. onset to be at 4 p.m. and its peak to be
anatomic region, not among different
at 6 p.m.
regions."
84. The physician orders laboratory tests to
confirm c. "Administer insulin into areas of scar

hyperthyroidism in a female client with classic tissue or hypotrophy whenever

signs and symptoms of this disorder. Which test possible."

result would confirm the diagnosis? d. "Administer insulin into sites above

a. No increase in the thyroid-stimulating muscles that you plan to exercise heavily

hormone (TSH) level after 30 minutes later that day."

during the TSH stimulation test 86. Nurse Sarah expects to note an elevated
serum
b. A decreased TSH level
glucose level in a client with hyperosmolar
c. An increase in the TSH level after 30
hyperglycemic nonketotic syndrome (HHNS).
minutes during the TSH stimulation test
Which other laboratory finding should the nurse
d. Below-normal levels of serum
anticipate?
triiodothyronine (T3) and serum
a. Elevated serum acetone level
thyroxine (T4) as detected by
b. Serum ketone bodies smoke inhalation. He develops severe hypoxia

c. Serum alkalosis 48 hours after the incident, requiring intubation

d. Below-normal serum potassium level and mechanical ventilation. He most likely has

87. For a client with Graves' disease, which developed which of the following conditions?
nursing
a. Adult respiratory distress syndrome
intervention promotes comfort?
(ARDS)
a. Restricting intake of oral fluids
b. Atelectasis
b. Placing extra blankets on the client's bed
c. Bronchitis
c. Limiting intake of high-carbohydrate
d. Pneumonia
foods
91. A 67-year-old client develops acute
d. Maintaining room temperature in the shortness of

low-normal range breath and progressive hypoxia requiring right

88. Patrick is treated in the emergency femur. The hypoxia was probably caused by
department
which of the following conditions?
for a Colles' fracture sustained during a fall.
a. Asthma attack
What is a Colles' fracture?
b. Atelectasis
a. Fracture of the distal radius
c. Bronchitis
b. Fracture of the olecranon
d. Fat embolism
c. Fracture of the humerus
92. A client with shortness of breath has
d. Fracture of the carpal scaphoid decreased

89. Cleo is diagnosed with osteoporosis. Which to absent breath sounds on the right side, from

electrolytes are involved in the development of the apex to the base. Which of the following

this disorder? conditions would best explain this?

a. Calcium and sodium a. Acute asthma

b. Calcium and phosphorous b. Chronic bronchitis

c. Phosphorous and potassium c. Pneumonia

d. Potassium and sodium d. Spontaneous pneumothorax

90. Johnny a firefighter was involved in 93. A 62-year-old male client was in a motor
vehicle
extinguishing a house fire and is being treated
to accident as an unrestrained driver. He’s now in
the emergency department complaining of have an arterial blood gas analysis performed to

difficulty of breathing and chest pain. On determine the extent of hypoxia. The acid-base

auscultation of his lung field, no breath sounds disorder that may be present is?

are present in the upper lobe. This client may a. Metabolic acidosis

have which of the following conditions? b. Metabolic alkalosis

a. Bronchitis c. Respiratory acidosis

b. Pneumonia d. Respiratory alkalosis

c. Pneumothorax 97. After a motor vehicle accident, Armand an

22-
d. Tuberculosis (TB)
year-old client is admitted with a
94. If a client requires a pneumonectomy, what
pneumothorax.
fills
The surgeon inserts a chest tube and attaches it
the area of the thoracic cavity?
to a chest drainage system. Bubbling soon
a. The space remains filled with air only
appears in the water seal chamber. Which of the
b. The surgeon fills the space with a gel
following is the most likely cause of the
c. Serous fluids fills the space and
bubbling?
consolidates the region
a. Air leak
d. The tissue from the other lung grows
b. Adequate suction
over to the other side
c. Inadequate suction
95. Hemoptysis may be present in the client
with a d. Kinked chest tube

pulmonary embolism because of which of the 98. Nurse Michelle calculates the IV flow rate for
a
following reasons?
postoperative client. The client receives 3,000
a. Alveolar damage in the infracted area
ml
b. Involvement of major blood vessels in
of Ringer’s lactate solution IV to run over 24
the occluded area
hours. The IV infusion set has a drop factor of 10
c. Loss of lung parenchyma
drops per milliliter. The nurse should regulate
d. Loss of lung tissue
the client’s IV to deliver how many drops per
320
minute?
96. Aldo with a massive pulmonary embolism
a. 18
will
b. 21 1. Answer: (C) Hypertension

c. 35 Rationale: Hypertension, along with fever,

d. 40 and tenderness over the grafted kidney,

99. Mickey, a 6-year-old child with a congenital reflects acute rejection.

heart disorder is admitted with congestive heart 2. Answer: (A) Pain

failure. Digoxin (lanoxin) 0.12 mg is ordered for Rationale: Sharp, severe pain (renal colic)

the child. The bottle of Lanoxin contains .05 mg radiating toward the genitalia and thigh is

of Lanoxin in 1 ml of solution. What amount caused by uretheral distention and

should the nurse administer to the child? smooth muscle spasm; relief form pain is

a. 1.2 ml the priority.

b. 2.4 ml 3. Answer: (D) Decrease the size and

c. 3.5 ml vascularity of the thyroid gland.

d. 4.2 ml Rationale: Lugol’s solution provides

100. Nurse Alexandra teaches a client about iodine, which aids in decreasing the
elastic
vascularity of the thyroid gland, which
stockings. Which of the following statements,
limits the risk of hemorrhage when
if made by the client, indicates to the nurse
surgery is performed.
that the teaching was successful?
4. Answer: (A) Liver Disease
a. “I will wear the stockings until the
Rationale: The client with liver disease has
physician tells me to remove them.”
a decreased ability to metabolize
b. “I should wear the stockings even when I
carbohydrates because of a decreased
am sleep.”
ability to form glycogen (glycogenesis) and
c. “Every four hours I should remove the
to form glucose from glycogen.
stockings for a half hour.”
5. Answer: (C) Leukopenia
d. “I should put on the stockings before
Rationale: Leukopenia, a reduction in
getting out of bed in the morning.”
WBCs, is a systemic effect of
321
chemotherapy as a result of
Answers and Rationale – Care of Clients with
myelosuppression.
Physiologic and Psychosocial Alterations
6. Answer: (C) Avoid foods that in the past
caused flatus. 11. Answer: (C) Bleeding from ears

Rationale: Foods that bothered a person Rationale: The nurse needs to perform a

preoperatively will continue to do so after thorough assessment that could indicate

a colostomy. alterations in cerebral function, increased

7. Answer: (B) Keep the irrigating container intracranial pressures, fractures and

less than 18 inches above the stoma.” bleeding. Bleeding from the ears occurs

Rationale: This height permits the solution only with basal skull fractures that can

to flow slowly with little force so that easily contribute to increased intracranial

excessive peristalsis is not immediately pressure and brain herniation.

precipitated. 12. Answer: (D) may engage in contact sports

8. Answer: (A) Administer Kayexalate Rationale: The client should be advised by

Rationale: Kayexalate,a potassium the nurse to avoid contact sports. This will

exchange resin, permits sodium to be prevent trauma to the area of the

exchanged for potassium in the intestine, pacemaker generator.

reducing the serum potassium level. 13. Answer: (A) Oxygen at 1-2L/min is given to

9. Answer:(B) 28 gtt/min maintain the hypoxic stimulus for

Rationale: This is the correct flow rate; breathing.

multiply the amount to be infused (2000 Rationale: COPD causes a chronic CO2

ml) by the drop factor (10) and divide the retention that renders the medulla

result by the amount of time in minutes insensitive to the CO2 stimulation for

(12 hours x 60 minutes) breathing. The hypoxic state of the client

10. Answer: (D) Upper trunk then becomes the stimulus for breathing.

Rationale: The percentage designated for Giving the client oxygen in low

each burned part of the body using the concentrations will maintain the client’s

rule of nines: Head and neck 9%; Right hypoxic drive.

upper extremity 9%; Left upper extremity 14. Answer: (B) Facilitate ventilation of the

9%; Anterior trunk 18%; Posterior trunk left lung.

18%; Right lower extremity 18%; Left Rationale: Since only a partial

lower extremity 18%; Perineum 1%. pneumonectomy is done, there is a need

to promote expansion of this remaining 17. Answer: (A) This condition puts her at a

Left lung by positioning the client on the higher risk for cervical cancer; therefore,

opposite unoperated side. she should have a Papanicolaou (Pap)

15. Answer: (A) Food and fluids will be smear annually.

withheld for at least 2 hours. Rationale: Women with condylomata

Rationale: Prior to bronchoscopy, the acuminata are at risk for cancer of the

doctors sprays the back of the throat with cervix and vulva. Yearly Pap smears are

anesthetic to minimize the gag reflex and very important for early detection.

thus facilitate the insertion of the Because condylomata acuminata is a

bronchoscope. Giving the client food and virus, there is no permanent cure.

drink after the procedure without Because condylomata acuminata can

checking on the return of the gag reflex occur on the vulva, a condom won't

can cause the client to aspirate. The gag protect sexual partners. HPV can be

reflex usually returns after two hours. transmitted to other parts of the body,

16. Answer: (C) hyperkalemia. such as the mouth, oropharynx, and

322 larynx.

Rationale: Hyperkalemia is a common 18. Answer: (A) The left kidney usually is

complication of acute renal failure. It's slightly higher than the right one.

life-threatening if immediate action isn't Rationale: The left kidney usually is

taken to reverse it. The administration of slightly higher than the right one. An

glucose and regular insulin, with sodium adrenal gland lies atop each kidney. The

bicarbonate if necessary, can temporarily average kidney measures approximately

prevent cardiac arrest by moving 11 cm (4-3/8") long, 5 to 5.8 cm (2" to

potassium into the cells and temporarily 2¼") wide, and 2.5 cm (1") thick. The

reducing serum potassium levels. kidneys are located retroperitoneally, in

Hypernatremia, hypokalemia, and the posterior aspect of the abdomen, on

hypercalcemia don't usually occur with either side of the vertebral column. They

acute renal failure and aren't treated with lie between the 12th thoracic and 3rd

glucose, insulin, or sodium bicarbonate. lumbar vertebrae.

19. Answer: (C) Blood urea nitrogen (BUN) type of fully differentiated cell by another

100 mg/dl and serum creatinine 6.5mg/dl. in tissues where the second type normally

Rationale: The normal BUN level ranges 8 isn't found is called metaplasia.

to 23 mg/dl; the normal serum creatinine 21. Answer: (D) Kaposi's sarcoma

level ranges from 0.7 to 1.5 mg/dl. The Rationale: Kaposi's sarcoma is the most

test results in option C are abnormally common cancer associated with AIDS.

elevated, reflecting CRF and the kidneys' Squamous cell carcinoma, multiple

decreased ability to remove nonprotein myeloma, and leukemia may occur in

nitrogen waste from the blood. CRF anyone and aren't associated specifically

causes decreased pH and increased with AIDS.

hydrogen ions — not vice versa. CRF also 22. Answer: (C) To prevent cerebrospinal fluid

increases serum levels of potassium, (CSF) leakage

magnesium, and phosphorous, and Rationale: The client receiving a

decreases serum levels of calcium. A uric subarachnoid block requires special

acid analysis of 3.5 mg/dl falls within the positioning to prevent CSF leakage and

normal range of 2.7 to 7.7 mg/dl; PSP headache and to ensure proper anesthetic

excretion of 75% also falls with the normal distribution. Proper positioning doesn't

range of 60% to 75%. help prevent confusion, seizures, or

20. Answer: (D) Alteration in the size, shape, cardiac arrhythmias.

and organization of differentiated cells 23. Answer: (A) Auscultate bowel sounds.

Rationale: Dysplasia refers to an alteration Rationale: If abdominal distention is

in the size, shape, and organization of accompanied by nausea, the nurse must

differentiated cells. The presence of first auscultate bowel sounds. If bowel

completely undifferentiated tumor cells sounds are absent, the nurse should

that don't resemble cells of the tissues of suspect gastric or small intestine dilation

their origin is called anaplasia. An increase and these findings must be reported to

in the number of normal cells in a normal the physician. Palpation should be

arrangement in a tissue or an organ is avoided postoperatively with abdominal

called hyperplasia. Replacement of one distention. If peristalsis is absent,

changing positions and inserting a rectal intestinal obstruction also wouldn't

tube won't relieve the client's discomfort. change stoma color.

24. Answer: (B) Lying on the left side with 26. Answer: (A) Applying knee splints

knees bent Rationale: Applying knee splints prevents

Rationale: For a colonoscopy, the nurse leg contractures by holding the joints in a

initially should position the client on the position of function. Elevating the foot of

323 the bed can't prevent contractures

left side with knees bent. Placing the because this action doesn't hold the joints

client on the right side with legs straight, in a position of function. Hyperextending a

prone with the torso elevated, or bent body part for an extended time is

over with hands touching the floor inappropriate because it can cause

wouldn't allow proper visualization of the contractures. Performing shoulder rangeof-

large intestine. motion exercises can prevent

25. Answer: (A) Blood supply to the stoma has contractures in the shoulders, but not in

been interrupted the legs.

Rationale: An ileostomy stoma forms as 27. Answer: (B) Urine output of 20 ml/hour.

the ileum is brought through the Rationale: A urine output of less than 40

abdominal wall to the surface skin, ml/hour in a client with burns indicates a

creating an artificial opening for waste fluid volume deficit. This client's PaO2

elimination. The stoma should appear value falls within the normal range (80 to

cherry red, indicating adequate arterial 100 mm Hg). White pulmonary secretions

perfusion. A dusky stoma suggests also are normal. The client's rectal

decreased perfusion, which may result temperature isn't significantly elevated

from interruption of the stoma's blood and probably results from the fluid

supply and may lead to tissue damage or volume deficit.

necrosis. A dusky stoma isn't a normal 28. Answer: (A) Turn him frequently.

finding. Adjusting the ostomy bag Rationale: The most important

wouldn't affect stoma color, which intervention to prevent pressure ulcers is

depends on blood supply to the area. An frequent position changes, which relieve
pressure on the skin and underlying stimulation. They protect the

tissues. If pressure isn't relieved, myocardium, helping to reduce the risk of

capillaries become occluded, reducing another infraction by decreasing

circulation and oxygenation of the tissues myocardial oxygen demand. Calcium

and resulting in cell death and ulcer channel blockers reduce the workload of

formation. During passive ROM exercises, the heart by decreasing the heart rate.

the nurse moves each joint through its Narcotics reduce myocardial oxygen

range of movement, which improves joint demand, promote vasodilation, and

mobility and circulation to the affected decrease anxiety. Nitrates reduce

area but doesn't prevent pressure ulcers. myocardial oxygen consumption bt

Adequate hydration is necessary to decreasing left ventricular end diastolic

maintain healthy skin and ensure tissue pressure (preload) and systemic vascular

repair. A footboard prevents plantar resistance (afterload).

flexion and footdrop by maintaining the 31. Answer: (C) Raised 30 degrees

foot in a dorsiflexed position. Rationale: Jugular venous pressure is

29. Answer: (C) In long, even, outward, and measured with a centimeter ruler to

downward strokes in the direction of hair obtain the vertical distance between the

growth sternal angle and the point of highest

Rationale: When applying a topical agent, pulsation with the head of the bed

the nurse should begin at the midline and inclined between 15 to 30 degrees.

use long, even, outward, and downward Increased pressure can’t be seen when

strokes in the direction of hair growth. the client is supine or when the head of

This application pattern reduces the risk the bed is raised 10 degrees because the

of follicle irritation and skin inflammation. point that marks the pressure level is

30. Answer: (A) Beta -adrenergic blockers above the jaw (therefore, not visible). In

Rationale: Beta-adrenergic blockers work 324

by blocking beta receptors in the high Fowler’s position, the veins would be

myocardium, reducing the response to barely discernible above the clavicle.

catecholamines and sympathetic nerve 32. Answer: (D) Inotropic agents

Rationale: Inotropic agents are the client requested that the nurse update

administered to increase the force of the his wife on his condition, doing so doesn’t

heart’s contractions, thereby increasing breach confidentiality.

ventricular contractility and ultimately 35. Answer: (B) Check endotracheal tube

increasing cardiac output. Beta-adrenergic placement.

blockers and calcium channel blockers Rationale: ET tube placement should be

decrease the heart rate and ultimately confirmed as soon as the client arrives in

decreased the workload of the heart. the emergency department. Once the

Diuretics are administered to decrease the airways is secured, oxygenation and

overall vascular volume, also decreasing ventilation should be confirmed using an

the workload of the heart. end-tidal carbon dioxide monitor and

33. Answer: (B) Less than 30% of calories from pulse oximetry. Next, the nurse should

fat make sure L.V. access is established. If the

Rationale: A client with low serum HDL client experiences symptomatic

and high serum LDL levels should get less bradycardia, atropine is administered as

than 30% of daily calories from fat. The ordered 0.5 to 1 mg every 3 to 5 minutes

other modifications are appropriate for to a total of 3 mg. Then the nurse should

this client. try to find the cause of the client’s arrest

34. Answer: (C) The emergency department by obtaining an ABG sample. Amiodarone

nurse calls up the latest electrocardiogram is indicated for ventricular tachycardia,

results to check the client’s progress ventricular fibrillation and atrial flutter –

Rationale: The emergency department not symptomatic bradycardia.

nurse is no longer directly involved with 36. Answer: (C) 95 mm Hg

the client’s care and thus has no legal Rationale: Use the following formula to

right to information about his present calculate MAP

condition. Anyone directly involved in his MAP = systolic + 2 (diastolic)

care (such as the telemetry nurse and the 3

on-call physician) has the right to MAP=126 mm Hg + 2 (80 mm Hg)

information about his condition. Because 3

MAP=286 mm HG surgery. Pancytopenia is a reduction in all

3 blood cells.

MAP=95 mm Hg 39. Answer: (B) Corticosteroids

37. Answer: (C) Electrocardiogram, complete Rationale: Corticosteroid therapy can

blood count, testing for occult blood, decrease antibody production and

comprehensive serum metabolic panel. phagocytosis of the antibody-coated

Rationale: An electrocardiogram evaluates platelets, retaining more functioning

the complaints of chest pain, laboratory platelets. Methotrexate can cause

tests determines anemia, and the stool thrombocytopenia. Vitamin K is used to

test for occult blood determines blood in treat an excessive anticoagulate state

the stool. Cardiac monitoring, oxygen, and from warfarin overload, and ASA

creatine kinase and lactate decreases platelet aggregation.

dehydrogenase levels are appropriate for 40. Answer: (D) Xenogeneic

a cardiac primary problem. A basic Rationale: An xenogeneic transplant is

metabolic panel and alkaline phosphatase between is between human and another

and aspartate aminotransferase levels 325

assess liver function. Prothrombin time, species. A syngeneic transplant is between

partial thromboplastin time, fibrinogen identical twins, allogeneic transplant is

and fibrin split products are measured to between two humans, and autologous is a

verify bleeding dyscrasias; an transplant from the same individual.

electroencephalogram evaluates brain 41. Answer: (B)

electrical activity. Rationale: Tissue thromboplastin is

38. Answer: (D) Heparin-associated released when damaged tissue comes in

thrombosis and thrombocytopenia (HATT) contact with clotting factors. Calcium is

Rationale: HATT may occur after CABG released to assist the conversion of

surgery due to heparin use during surgery. factors X to Xa. Conversion of factors XII to

Although DIC and ITP cause platelet XIIa and VIII to IIIa are part of the intrinsic

aggregation and bleeding, neither is pathway.

common in a client after revascularization 42. Answer: (C) Essential thrombocytopenia

Rationale: Essential thrombocytopenia is sounds is required. Although assessing

linked to immunologic disorders, such as blood pressure, bowel sounds, and heart

SLE and human immunodeficiency virus. sounds is important, it won’t help detect

The disorder known as von Willebrand’s pneumonia.

disease is a type of hemophilia and isn’t 45. Answer: (B) Muscle spasm

linked to SLE. Moderate to severe anemia Rationale: Back pain or paresthesia in the

is associated with SLE, not polycythemia. lower extremities may indicate impending

Dressler’s syndrome is pericarditis that spinal cord compression from a spinal

occurs after a myocardial infarction and tumor. This should be recognized and

isn’t linked to SLE. treated promptly as progression of the

43. Answer: (B) Night sweat tumor may result in paraplegia. The other

Rationale: In stage 1, symptoms include a options, which reflect parts of the nervous

single enlarged lymph node (usually), system, aren’t usually affected by MM.

unexplained fever, night sweats, malaise, 46. Answer: (C) 10 years

and generalized pruritis. Although Rationale: Epidermiologic studies show

splenomegaly may be present in some the average time from initial contact with

clients, night sweats are generally more HIV to the development of AIDS is 10

prevalent. Pericarditis isn’t associated years.

with Hodgkin’s disease, nor is 47. Answer: (A) Low platelet count

hypothermia. Moreover, splenomegaly Rationale: In DIC, platelets and clotting

and pericarditis aren’t symptoms. factors are consumed, resulting in

Persistent hypothermia is associated with microthrombi and excessive bleeding. As

Hodgkin’s but isn’t an early sign of the clots form, fibrinogen levels decrease and

disease. the prothrombin time increases. Fibrin

44. Answer: (D) Breath sounds degeneration products increase as

Rationale: Pneumonia, both viral and fibrinolysis takes places.

fungal, is a common cause of death in 48. Answer: (D) Hodgkin’s disease

clients with neutropenia, so frequent Rationale: Hodgkin’s disease typically

assessment of respiratory rate and breath causes fever night sweats, weight loss,
and lymph mode enlargement. Influenza medication and notify the health care

doesn’t last for months. Clients with sickle provider. The other manifestations are

cell anemia manifest signs and symptoms expected side effects of chemotherapy.

of chronic anemia with pallor of the 51. Answer: (D) “This is only temporary; Stacy

mucous membrane, fatigue, and will re-grow new hair in 3-6 months, but

decreased tolerance for exercise; they may be different in texture”.

don’t show fever, night sweats, weight 326

loss or lymph node enlargement. Rationale: This is the appropriate

Leukemia doesn’t cause lymph node response. The nurse should help the

enlargement. mother how to cope with her own feelings

49. Answer: (C) A Rh-negative regarding the child’s disease so as not to

Rationale: Human blood can sometimes affect the child negatively. When the hair

contain an inherited D antigen. Persons grows back, it is still of the same color and

with the D antigen have Rh-positive blood texture.

type; those lacking the antigen have Rhnegative 52. Answer: (B) Apply viscous Lidocaine to

blood. It’s important that a oral ulcers as needed.

person with Rh- negative blood receives Rationale: Stomatitis can cause pain and

Rh-negative blood. If Rh-positive blood is this can be relieved by applying topical

administered to an Rh-negative person, anesthetics such as lidocaine before

the recipient develops anti-Rh agglutinins, mouth care. When the patient is already

and sub sequent transfusions with Rhpositive comfortable, the nurse can proceed with

blood may cause serious providing the patient with oral rinses of

reactions with clumping and hemolysis of saline solution mixed with equal part of

red blood cells. water or hydrogen peroxide mixed water

50. Answer: (B) “I will call my doctor if Stacy in 1:3 concentrations to promote oral

has persistent vomiting and diarrhea”. hygiene. Every 2-4 hours.

Rationale: Persistent (more than 24 hours) 53. Answer: (C) Immediately discontinue the

vomiting, anorexia, and diarrhea are signs infusion

of toxicity and the patient should stop the Rationale: Edema or swelling at the IV site
is a sign that the needle has been particular characteristics, and clients with

dislodged and the IV solution is leaking chronic obstructive bronchitis are bloated

into the tissues causing the edema. The and cyanotic in appearance.

patient feels pain as the nerves are 56. Answer: D 80 mm Hg

irritated by pressure and the IV solution. Rationale: A client about to go into

The first action of the nurse would be to respiratory arrest will have inefficient

discontinue the infusion right away to ventilation and will be retaining carbon

prevent further edema and other dioxide. The value expected would be

complication. around 80 mm Hg. All other values are

54. Answer: (C) Chronic obstructive bronchitis lower than expected.

Rationale: Clients with chronic obstructive 57. Answer: (C) Respiratory acidosis

bronchitis appear bloated; they have large Rationale: Because Paco2 is high at 80 mm

barrel chest and peripheral edema, Hg and the metabolic measure, HCO3- is

cyanotic nail beds, and at times, normal, the client has respiratory acidosis.

circumoral cyanosis. Clients with ARDS are The pH is less than 7.35, academic, which

acutely short of breath and frequently eliminates metabolic and respiratory

need intubation for mechanical ventilation alkalosis as possibilities. If the HCO3- was

and large amount of oxygen. Clients with below 22 mEq/L the client would have

asthma don’t exhibit characteristics of metabolic acidosis.

chronic disease, and clients with 58. Answer: (C) Respiratory failure

emphysema appear pink and cachectic. Rationale: The client was reacting to the

55. Answer: (D) Emphysema drug with respiratory signs of impending

Rationale: Because of the large amount of anaphylaxis, which could lead to

energy it takes to breathe, clients with eventually respiratory failure. Although

emphysema are usually cachectic. They’re the signs are also related to an asthma

pink and usually breathe through pursed attack or a pulmonary embolism, consider

lips, hence the term “puffer.” Clients with the new drug first. Rheumatoid arthritis

ARDS are usually acutely short of breath. doesn’t manifest these signs.

Clients with asthma don’t have any 59. Answer: (D) Elevated serum
aminotransferase Rationale: Lactulose is given to a patients

Rationale: Hepatic cell death causes with hepatic encephalopathy to reduce

release of liver enzymes alanine absorption of ammonia in the intestines

aminotransferase (ALT), aspartate by binding with ammonia and promoting

aminotransferase (AST) and lactate more frequent bowel movements. If the

dehydrogenase (LDH) into the circulation. patient experience diarrhea, it indicates

Liver cirrhosis is a chronic and irreversible over dosage and the nurse must reduce

disease of the liver characterized by the amount of medication given to the

generalized inflammation and fibrosis of patient. The stool will be mashy or soft.

the liver tissues. Lactulose is also very sweet and may

60. Answer: (A) Impaired clotting mechanism cause cramping and bloating.

Rationale: Cirrhosis of the liver results in 63. Answer: (B) Severe lower back pain,

decreased Vitamin K absorption and decreased blood pressure, decreased RBC

formation of clotting factors resulting in count, increased WBC count.

impaired clotting mechanism. Rationale: Severe lower back pain

61. Answer: (B) Altered level of consciousness indicates an aneurysm rupture, secondary

Rationale: Changes in behavior and level to pressure being applied within the

of consciousness are the first sins of abdominal cavity. When ruptured occurs,

hepatic encephalopathy. Hepatic the pain is constant because it can’t be

encephalopathy is caused by liver failure alleviated until the aneurysm is repaired.

and develops when the liver is unable to Blood pressure decreases due to the loss

convert protein metabolic product of blood. After the aneurysm ruptures, the

ammonia to urea. This results in vasculature is interrupted and blood

accumulation of ammonia and other toxic volume is lost, so blood pressure wouldn’t

in the blood that damages the cells. increase. For the same reason, the RBC

327 count is decreased – not increased. The

62. Answer: (C) “I’ll lower the dosage as WBC count increases as cell migrate to the

ordered so the drug causes only 2 to 4 site of injury.

stools a day”. 64. Answer: (D) Apply gloves and assess the
groin site allergic reaction. Distributive shock results

Rationale: Observing standard precautions from changes in the intravascular volume

is the first priority when dealing with any distribution and is usually associated with

blood fluid. Assessment of the groin site is increased cardiac output. MI isn’t a shock

the second priority. This establishes where state, though a severe MI can lead to

the blood is coming from and determines shock.

how much blood has been lost. The goal in 67. Answer: (C) Kidneys’ excretion of sodium

this situation is to stop the bleeding. The and water

nurse would call for help if it were Rationale: The kidneys respond to rise in

warranted after the assessment of the blood pressure by excreting sodium and

situation. After determining the extent of excess water. This response ultimately

the bleeding, vital signs assessment is affects sysmolic blood pressure by

important. The nurse should never move regulating blood volume. Sodium or water

the client, in case a clot has formed. retention would only further increase

Moving can disturb the clot and cause blood pressure. Sodium and water travel

rebleeding. together across the membrane in the

65. Answer: (D) Percutaneous transluminal kidneys; one can’t travel without the

coronary angioplasty (PTCA) other.

Rationale: PTCA can alleviate the blockage 68. Answer: (D) It inhibits reabsorption of

and restore blood flow and oxygenation. sodium and water in the loop of Henle.

An echocardiogram is a noninvasive Rationale: Furosemide is a loop diuretic

diagnosis test. Nitroglycerin is an oral that inhibits sodium and water

sublingual medication. Cardiac reabsorption in the loop Henle, thereby

catheterization is a diagnostic tool – not a causing a decrease in blood pressure.

treatment. Vasodilators cause dilation of peripheral

66. Answer: (B) Cardiogenic shock blood vessels, directly relaxing vascular

Rationale: Cardiogenic shock is shock smooth muscle and decreasing blood

related to ineffective pumping of the pressure. Adrenergic blockers decrease

heart. Anaphylactic shock results from an sympathetic cardioacceleration and

decrease blood pressure. Angiotensinconverting thereby masking changes in his level of

enzyme inhibitors decrease consciousness.

blood pressure due to their action on 71. Answer: (A) Appropriate; lowering carbon

angiotensin. dioxide (CO2) reduces intracranial

69. Answer: (C) Pancytopenia, elevated pressure (ICP)

antinuclear antibody (ANA) titer Rationale: A normal Paco2 value is 35 to

Rationale: Laboratory findings for clients 45 mm Hg CO2 has vasodilating

with SLE usually show pancytopenia, properties; therefore, lowering Paco2

elevated ANA titer, and decreased serum through hyperventilation will lower ICP

complement levels. Clients may have caused by dilated cerebral vessels.

elevated BUN and creatinine levels from Oxygenation is evaluated through Pao2

nephritis, but the increase does not and oxygen saturation. Alveolar

indicate SLE. hypoventilation would be reflected in an

70. Answer: (C) Narcotics are avoided after a increased Paco2.

head injury because they may hide a 72. Answer: (B) A 33-year-old client with a

worsening condition. recent diagnosis of Guillain-Barre

328 syndrome

Rationale: Narcotics may mask changes in Rationale: Guillain-Barre syndrome is

the level of consciousness that indicate characterized by ascending paralysis and

increased ICP and shouldn’t potential respiratory failure. The order of

acetaminophen is strong enough ignores client assessment should follow client

the mother’s question and therefore isn’t priorities, with disorder of airways,

appropriate. Aspirin is contraindicated in breathing, and then circulation. There’s no

conditions that may have bleeding, such information to suggest the postmyocardial

as trauma, and for children or young infarction client has an arrhythmia or

adults with viral illnesses due to the other complication. There’s no evidence

danger of Reye’s syndrome. Stronger to suggest hemorrhage or perforation for

medications may not necessarily lead to the remaining clients as a priority of care.

vomiting but will sedate the client, 73. Answer: (C) Decreases inflammation
Rationale: Then action of colchicines is to Therefore, the nurse should immediately

decrease inflammation by reducing the report signs and symptoms of

migration of leukocytes to synovial fluid. hypokalemia, such as an irregular apical

Colchicine doesn’t replace estrogen, pulse, to the physician. Edema is an

decrease infection, or decrease bone expected finding because aldosterone

demineralization. overproduction causes sodium and fluid

74. Answer: (C) Osteoarthritis is the most retention. Dry mucous membranes and

common form of arthritis frequent urination signal dehydration,

Rationale: Osteoarthritis is the most which isn't associated with Cushing's

common form of arthritis and can be syndrome.

extremely debilitating. It can afflict people 77. Answer: (D) Below-normal urine

of any age, although most are elderly. osmolality level, above-normal serum

75. Answer: (C) Myxedema coma osmolality level

Rationale: Myxedema coma, severe Rationale: In diabetes insipidus, excessive

hypothyroidism, is a life-threatening polyuria causes dilute urine, resulting in a

condition that may develop if thyroid below-normal urine osmolality level. At

replacement medication isn't taken. the same time, polyuria depletes the body

Exophthalmos, protrusion of the eyeballs, of water, causing dehydration that leads

is seen with hyperthyroidism. Thyroid to an above-normal serum osmolality

storm is life-threatening but is caused by level. For the same reasons, diabetes

severe hyperthyroidism. Tibial myxedema, insipidus doesn't cause above-normal

peripheral mucinous edema involving the urine osmolality or below-normal serum

lower leg, is associated with osmolality levels.

hypothyroidism but isn't life-threatening. 78. Answer: (A) "I can avoid getting sick by not

76. Answer: (B) An irregular apical pulse becoming dehydrated and by paying

Rationale: Because Cushing's syndrome attention to my need to urinate, drink, or

causes aldosterone overproduction, which eat more than usual."

increases urinary potassium loss, the Rationale: Inadequate fluid intake during

disorder may lead to hypokalemia. hyperglycemic episodes often leads to

HHNS. By recognizing the signs of Rationale: Hydrocortisone, a

hyperglycemia (polyuria, polydipsia, and glucocorticoid, should be administered

polyphagia) and increasing fluid intake, according to a schedule that closely

the client may prevent HHNS. Drinking a reflects the bodies own secretion of this

glass of nondiet soda would be hormone; therefore, two-thirds of the

appropriate for hypoglycemia. A client dose of hydrocortisone should be taken in

whose diabetes is controlled with oral the morning and one-third in the late

329 afternoon. This dosage schedule reduces

antidiabetic agents usually doesn't need adverse effects.

to monitor blood glucose levels. A 81. Answer: (C) High corticotropin and high
highcarbohydrate
cortisol levels
diet would exacerbate the
Rationale: A corticotropin-secreting
client's condition, particularly if fluid
pituitary tumor would cause high
intake is low.
corticotropin and high cortisol levels. A
79. Answer: (D) Hyperparathyroidism
high corticotropin level with a low cortisol
Rationale: Hyperparathyroidism is most
level and a low corticotropin level with a
common in older women and is
low cortisol level would be associated
characterized by bone pain and weakness
with hypocortisolism. Low corticotropin
from excess parathyroid hormone (PTH).
and high cortisol levels would be seen if
Clients also exhibit hypercaliuria-causing
there was a primary defect in the adrenal
polyuria. While clients with diabetes
glands.
mellitus and diabetes insipidus also have
82. Answer: (D) Performing capillary glucose
polyuria, they don't have bone pain and
testing every 4 hours
increased sleeping. Hypoparathyroidism is
Rationale: The nurse should perform
characterized by urinary frequency rather
capillary glucose testing every 4 hours
than polyuria.
because excess cortisol may cause insulin
80. Answer: (C) "I'll take two-thirds of the
resistance, placing the client at risk for
dose when I wake up and one-third in the
hyperglycemia. Urine ketone testing isn't
late afternoon."
indicated because the client does secrete
insulin and, therefore, isn't at risk for disease and may result from

ketosis. Urine specific gravity isn't administration of phenytoin and certain

indicated because although fluid balance other drugs.

can be compromised, it usually isn't 85. Answer: (B) "Rotate injection sites within

dangerously imbalanced. Temperature the same anatomic region, not among

regulation may be affected by excess different regions."

cortisol and isn't an accurate indicator of Rationale: The nurse should instruct the

infection. client to rotate injection sites within the

83. Answer: (C) onset to be at 2:30 p.m. and same anatomic region. Rotating sites

its peak to be at 4 p.m. among different regions may cause

Rationale: Regular insulin, which is a excessive day-to-day variations in the

short-acting insulin, has an onset of 15 to blood glucose level; also, insulin

30 minutes and a peak of 2 to 4 hours. absorption differs from one region to the

Because the nurse gave the insulin at 2 next. Insulin should be injected only into

p.m., the expected onset would be from healthy tissue lacking large blood vessels,

2:15 p.m. to 2:30 p.m. and the peak from nerves, or scar tissue or other deviations.

4 p.m. to 6 p.m. Injecting insulin into areas of hypertrophy

84. Answer: (A) No increase in the may delay absorption. The client shouldn't
thyroidstimulating
inject insulin into areas of lipodystrophy
hormone (TSH) level after 30
(such as hypertrophy or atrophy); to
minutes during the TSH stimulation test
prevent lipodystrophy, the client should
Rationale: In the TSH test, failure of the
rotate injection sites systematically.
TSH level to rise after 30 minutes confirms
Exercise speeds drug absorption, so the
hyperthyroidism. A decreased TSH level
client shouldn't inject insulin into sites
indicates a pituitary deficiency of this
above muscles that will be exercised
hormone. Below-normal levels of T3 and
heavily.
T4, as detected by radioimmunoassay,
86. Answer: (D) Below-normal serum
signal hypothyroidism. A below-normal T4
potassium level
level also occurs in malnutrition and liver
330
Rationale: A client with HHNS has an outstretched hand. It's most common in

overall body deficit of potassium resulting women. Colles' fracture doesn't refer to a

from diuresis, which occurs secondary to fracture of the olecranon, humerus, or

the hyperosmolar, hyperglycemic state carpal scaphoid.

caused by the relative insulin deficiency. 89. Answer: (B) Calcium and phosphorous

An elevated serum acetone level and Rationale: In osteoporosis, bones lose

serum ketone bodies are characteristic of calcium and phosphate salts, becoming

diabetic ketoacidosis. Metabolic acidosis, porous, brittle, and abnormally vulnerable

not serum alkalosis, may occur in HHNS. to fracture. Sodium and potassium aren't

87. Answer: (D) Maintaining room involved in the development of

temperature in the low-normal range steoporosis.

Rationale: Graves' disease causes signs 90. Answer: (A) Adult respiratory distress

and symptoms of hypermetabolism, such syndrome (ARDS)

as heat intolerance, diaphoresis, excessive Rationale: Severe hypoxia after smoke

thirst and appetite, and weight loss. To inhalation is typically related to ARDS. The

reduce heat intolerance and diaphoresis, other conditions listed aren’t typically

the nurse should keep the client's room associated with smoke inhalation and

temperature in the low-normal range. To severe hypoxia.

replace fluids lost via diaphoresis, the 91. Answer: (D) Fat embolism

nurse should encourage, not restrict, Rationale: Long bone fractures are

intake of oral fluids. Placing extra blankets correlated with fat emboli, which cause

on the bed of a client with heat shortness of breath and hypoxia. It’s

intolerance would cause discomfort. To unlikely the client has developed asthma

provide needed energy and calories, the or bronchitis without a previous history.

nurse should encourage the client to eat He could develop atelectasis but it

high-carbohydrate foods. typically doesn’t produce progressive

88. Answer: (A) Fracture of the distal radius hypoxia.

Rationale: Colles' fracture is a fracture of 92. Answer: (D) Spontaneous pneumothorax

the distal radius, such as from a fall on an Rationale: A spontaneous pneumothorax

occurs when the client’s lung collapses, Rationale: The infracted area produces

causing an acute decreased in the amount alveolar damage that can lead to the

of functional lung used in oxygenation. production of bloody sputum, sometimes

The sudden collapse was the cause of his in massive amounts. Clot formation

chest pain and shortness of breath. An usually occurs in the legs. There’s a loss of

asthma attack would show wheezing lung parenchyma and subsequent scar

breath sounds, and bronchitis would have tissue formation.

rhonchi. Pneumonia would have bronchial 96. Answer: (D) Respiratory alkalosis

breath sounds over the area of Rationale: A client with massive

consolidation. pulmonary embolism will have a large

93. Answer: (C) Pneumothorax region and blow off large amount of

Rationale: From the trauma the client carbon dioxide, which crosses the

experienced, it’s unlikely he has unaffected alveolar-capillary membrane

bronchitis, pneumonia, or TB; rhonchi more readily than does oxygen and results

with bronchitis, bronchial breath sounds in respiratory alkalosis.

with TB would be heard. 97. Answer: (A) Air leak

94. Answer: (C) Serous fluids fills the space Rationale: Bubbling in the water seal

and consolidates the region chamber of a chest drainage system stems

Rationale: Serous fluid fills the space and from an air leak. In pneumothorax an air

eventually consolidates, preventing 331

extensive mediastinal shift of the heart leak can occur as air is pulled from the

and remaining lung. Air can’t be left in the pleural space. Bubbling doesn’t normally

space. There’s no gel that can be placed in occur with either adequate or inadequate

the pleural space. The tissue from the suction or any preexisting bubbling in the

other lung can’t cross the mediastinum, water seal chamber.

although a temporary mediastinal shift 98. Answer: (B) 21

exits until the space is filled. Rationale: 3000 x 10 divided by 24 x 60.

95. Answer: (A) Alveolar damage in the 99. Answer: (B) 2.4 ml

infracted area Rationale: .05 mg/ 1 ml = .12mg/ x ml,

.05x = .12, x = 2.4 ml. c. Call the attending physician and report

100. Answer: (D) “I should put on the stockings the behavior.

before getting out of bed in the morning. d. Remove all other clients from the

Rationale: Promote venous return by dayroom.

applying external pressure on veins. 3. Tina who is manic, but not yet on medication,

332 comes to the drug treatment center. The nurse

TEST V - Care of Clients with Physiologic and would not let this client join the group session

Psychosocial Alterations because:

1. Mr. Marquez reports of losing his job, not a. The client is disruptive.
being
b. The client is harmful to self.
able to sleep at night, and feeling upset with his
c. The client is harmful to others.
wife. Nurse John responds to the client, “You
d. The client needs to be on medication
may want to talk about your employment
first.
situation in group today.” The Nurse is using
4. Dervid, an adolescent boy was admitted for
which therapeutic technique?
substance abuse and hallucinations. The client’s
a. Observations
mother asks Nurse Armando to talk with his
b. Restating
husband when he arrives at the hospital. The
c. Exploring
mother says that she is afraid of what the father
d. Focusing
might say to the boy. The most appropriate
2. Tony refuses his evening dose of Haloperidol
nursing intervention would be to:
(Haldol), then becomes extremely agitated in
a. Inform the mother that she and the
the
father can work through this problem
dayroom while other clients are watching
themselves.
television. He begins cursing and throwing
b. Refer the mother to the hospital social
furniture. Nurse Oliver first action is to:
worker.
a. Check the client’s medical record for an
c. Agree to talk with the mother and the
order for an as-needed I.M. dose of
father together.
medication for agitation.
d. Suggest that the father and son work
b. Place the client in full leather restraints.
things out.
5. What is Nurse John likely to note in a male c. Superego
client
d. Oedipal complex
being admitted for alcohol withdrawal?
8. In preparing a female client for
a. Perceptual disorders. electroconvulsive

b. Impending coma. therapy (ECT), Nurse Michelle knows that

c. Recent alcohol intake. succinylcoline (Anectine) will be administered

d. Depression with mutism. for which therapeutic effect?

6. Aira has taken amitriptyline HCL (Elavil) for 3 a. Short-acting anesthesia

days, but now complains that it “doesn’t help” b. Decreased oral and respiratory

and refuses to take it. What should the nurse secretions.

say
c. Skeletal muscle paralysis.
or do?
d. Analgesia.
a. Withhold the drug.
9. Nurse Gina is aware that the dietary
b. Record the client’s response. implications

c. Encourage the client to tell the doctor. for a client in manic phase of bipolar disorder is:

d. Suggest that it takes a while before a. Serve the client a bowl of soup, buttered

seeing the results. French bread, and apple slices.

7. Dervid, an adolescent has a history of truancy b. Increase calories, decrease fat, and

from school, running away from home and decrease protein.

“barrowing” other people’s things without their c. Give the client pieces of cut-up steak,

permission. The adolescent denies stealing, carrots, and an apple.

rationalizing instead that as long as no one was 333

using the items, it was all right to borrow them. d. Increase calories, carbohydrates, and

It is important for the nurse to understand the protein.

psychodynamically, this behavior may be largely 10. What parental behavior toward a child
during an
attributed to a developmental defect related to
admission procedure should cause Nurse Ron to
the:
suspect child abuse?
a. Id
a. Flat affect
b. Ego
b. Expressing guilt
c. Acting overly solicitous toward the child. d. Exploring the meaning of the traumatic

d. Ignoring the child. event with the client.

11. Nurse Lynnette notices that a female client 13. Meryl, age 19, is highly dependent on her
with
parents and fears leaving home to go away to
obsessive-compulsive disorder washes her
college. Shortly before the semester starts, she
hands
complains that her legs are paralyzed and is
for long periods each day. How should the nurse
rushed to the emergency department. When
respond to this compulsive behavior?
physical examination rules out a physical cause
a. By designating times during which the
for her paralysis, the physician admits her to the
client can focus on the behavior.
psychiatric unit where she is diagnosed with
b. By urging the client to reduce the
conversion disorder. Meryl asks the nurse, "Why
frequency of the behavior as rapidly as
has this happened to me?" What is the nurse's
possible.
best response?
c. By calling attention to or attempting to
a. "You've developed this paralysis so you
prevent the behavior.
can stay with your parents. You must
d. By discouraging the client from
deal with this conflict if you want to walk
verbalizing anxieties.
again."
12. After seeking help at an outpatient mental
b. "It must be awful not to be able to move
health clinic, Ruby who was raped while walking
your legs. You may feel better if you
her dog is diagnosed with posttraumatic stress
realize the problem is psychological, not
disorder (PTSD). Three months later, Ruby
physical."
returns to the clinic, complaining of fear, loss of
c. "Your problem is real but there is no
control, and helpless feelings. Which nursing
physical basis for it. We'll work on what
intervention is most appropriate for Ruby?
is going on in your life to find out why
a. Recommending a high-protein, low-fat
it's happened."
diet.
d. "It isn't uncommon for someone with
b. Giving sleep medication, as prescribed,
your personality to develop a conversion
to restore a normal sleep- wake cycle.
disorder during times of stress."
c. Allowing the client time to heal.
14. Nurse Krina knows that the following drugs for 4 months. Classic signs and symptoms of
have
phobias include:
been known to be effective in treating
a. Insomnia and an inability to concentrate.
obsessive-compulsive disorder (OCD):
b. Severe anxiety and fear.
a. benztropine (Cogentin) and
c. Depression and weight loss.
diphenhydramine (Benadryl).
d. Withdrawal and failure to distinguish
b. chlordiazepoxide (Librium) and
reality from fantasy.
diazepam (Valium)
17. Which medications have been found to help
c. fluvoxamine (Luvox) and clomipramine
reduce or eliminate panic attacks?
(Anafranil)
334
d. divalproex (Depakote) and lithium
a. Antidepressants
(Lithobid)
b. Anticholinergics
15. Alfred was newly diagnosed with anxiety
c. Antipsychotics
disorder. The physician prescribed buspirone
d. Mood stabilizers
(BuSpar). The nurse is aware that the teaching
18. A client seeks care because she feels
instructions for newly prescribed buspirone depressed

should include which of the following? and has gained weight. To treat her atypical

a. A warning about the drugs delayed depression, the physician prescribes

therapeutic effect, which is from 14 to tranylcypromine sulfate (Parnate), 10 mg by

30 days. mouth twice per day. When this drug is used to

b. A warning about the incidence of treat atypical depression, what is its onset of

neuroleptic malignant syndrome (NMS). action?

c. A reminder of the need to schedule a. 1 to 2 days

blood work in 1 week to check blood b. 3 to 5 days

levels of the drug. c. 6 to 8 days

d. A warning that immediate sedation can d. 10 to 14 days

occur with a resultant drop in pulse. 19. A 65 years old client is in the first stage of

16. Richard with agoraphobia has been Alzheimer's disease. Nurse Patricia should plan
symptomfree
to focus this client's care on:
a. Offering nourishing finger foods to help b. Frequent expression of guilt regarding

maintain the client's nutritional status. antisocial behavior

b. Providing emotional support and c. Demonstrated ability to maintain close,

individual counseling. stable relationships

c. Monitoring the client to prevent minor d. A low tolerance for frustration

illnesses from turning into major 22. Nurse Amy is providing care for a male client

problems. undergoing opiate withdrawal. Opiate

d. Suggesting new activities for the client withdrawal causes severe physical discomfort

and family to do together. and can be life-threatening. To minimize these

20. The nurse is assessing a client who has just effects, opiate users are commonly detoxified
been
with:
admitted to the emergency department. Which
a. Barbiturates
signs would suggest an overdose of an
b. Amphetamines
antianxiety agent?
c. Methadone
a. Combativeness, sweating, and confusion
d. Benzodiazepines
b. Agitation, hyperactivity, and grandiose
23. Nurse Cristina is caring for a client who
ideation
experiences false sensory perceptions with no
c. Emotional lability, euphoria, and
basis in reality. These perceptions are known as:
impaired memory
a. Delusions
d. Suspiciousness, dilated pupils, and
b. Hallucinations
increased blood pressure
c. Loose associations
21. The nurse is caring for a client diagnosed
d. Neologisms
with
24. Nurse Marco is developing a plan of care for
antisocial personality disorder. The client has a
a
history of fighting, cruelty to animals, and
client with anorexia nervosa. Which action
stealing. Which of the following traits would the
should the nurse include in the plan?
nurse be most likely to uncover during
a. Restricts visits with the family and
assessment?
friends until the client begins to eat.
a. History of gainful employment
b. Provide privacy during meals.
c. Set up a strict eating plan for the client. cocaine overdose. The client tells the nurse that

d. Encourage the client to exercise, which he frequently uses cocaine but that he can

will reduce her anxiety. control his use if he chooses. Which coping

25. Tim is admitted with a diagnosis of delusions mechanism is he using?

of
a. Withdrawal
grandeur. The nurse is aware that this diagnosis
b. Logical thinking
reflects a belief that one is:
c. Repression
a. Highly important or famous.
d. Denial
b. Being persecuted
28. Richard is admitted with a diagnosis of
c. Connected to events unrelated to
schizotypal personality disorder. hich signs
oneself
would this client exhibit during social situations?
d. Responsible for the evil in the world.
a. Aggressive behavior
26. Nurse Jen is caring for a male client with
b. Paranoid thoughts
manic
c. Emotional affect
depression. The plan of care for a client in a
d. Independence needs
manic state would include:
29. Nurse Mickey is caring for a client diagnosed
a. Offering a high-calorie meals and
with bulimia. The most appropriate initial goal
strongly encouraging the client to finish
for a client diagnosed with bulimia is to:
all food.
a. Avoid shopping for large amounts of
b. Insisting that the client remain active
food.
through the day so that he’ll sleep at
b. Control eating impulses.
night.
c. Identify anxiety-causing situations
c. Allowing the client to exhibit
d. Eat only three meals per day.
hyperactive, demanding, manipulative
30. Rudolf is admitted for an overdose of
behavior without setting limits.
amphetamines. When assessing the client, the
335
nurse should expect to see:
d. Listening attentively with a neutral
a. Tension and irritability
attitude and avoiding power struggles.
b. Slow pulse
27. Ramon is admitted for detoxification after a
c. Hypotension
d. Constipation b. Denial stage

31. Nicolas is experiencing hallucinations tells c. Bargaining stage

the
d. Acceptance stage
nurse, “The voices are telling me I’m no good.”
34. The outcome that is unrelated to a crisis
The client asks if the nurse hears the voices. The state is:

most appropriate response by the nurse would a. Learning more constructive coping skills

be: b. Decompensation to a lower level of

a. “It is the voice of your conscience, which functioning.

only you can control.” c. Adaptation and a return to a prior level

b. “No, I do not hear your voices, but I of functioning.

believe you can hear them”. d. A higher level of anxiety continuing for

c. “The voices are coming from within you more than 3 months.

and only you can hear them.” 35. Miranda a psychiatric client is to be
discharged
d. “Oh, the voices are a symptom of your
with orders for haloperidol (haldol) therapy.
illness; don’t pay any attention to them.”
When developing a teaching plan for discharge,
32. The nurse is aware that the side effect of
the nurse should include cautioning the client
electroconvulsive therapy that a client may
against:
experience:
a. Driving at night
a. Loss of appetite
b. Staying in the sun
b. Postural hypotension
c. Ingesting wines and cheeses
c. Confusion for a time after treatment
d. Taking medications containing aspirin
d. Complete loss of memory for a time
36. Jen a nursing student is anxious about the
33. A dying male client gradually moves toward
upcoming board examination but is able to
resolution of feelings regarding impending
study
death. Basing care on the theory of Kubler-Ross,
intently and does not become distracted by a
Nurse Trish plans to use nonverbal interventions
roommate’s talking and loud music. The
when assessment reveals that the client is in
student’s ability to ignore distractions and to
the:
focus on studying demonstrates:
a. Anger stage
a. Mild-level anxiety
b. Panic-level anxiety 40. Josefina is to be discharged on a regimen of

c. Severe-level anxiety lithium carbonate. In the teaching plan for

d. Moderate-level anxiety discharge the nurse should include:

37. When assessing a premorbid personality a. Advising the client to watch the diet

characteristic of a client with a major carefully

depression, it would be unusual for the nurse to b. Suggesting that the client take the pills

find that this client demonstrated: with milk

a. Rigidity c. Reminding the client that a CBC must be

b. Stubbornness done once a month.

336 d. Encouraging the client to have blood

c. Diverse interest levels checked as ordered.

d. Over meticulousness 41. The psychiatrist orders lithium carbonate

600
38. Nurse Krina recognizes that the suicidal risk
for mg p.o t.i.d for a female client. Nurse Katrina

depressed client is greatest: would be aware that the teachings about the

a. As their depression begins to improve side effects of this drug were understood when

b. When their depression is most severe the client state, “I will call my doctor

c. Before any type of treatment is started immediately if I notice any:

d. As they lose interest in the environment a. Sensitivity to bright light or sun

39. Nurse Kate would expect that a client with b. Fine hand tremors or slurred speech

vascular dementis would experience: c. Sexual dysfunction or breast

a. Loss of remote memory related to enlargement

anoxia d. Inability to urinate or difficulty when

b. Loss of abstract thinking related to urinating

emotional state 42. Nurse Mylene recognizes that the most

c. Inability to concentrate related to important factor necessary for the

establishment
decreased stimuli
of trust in a critical care area is:
d. Disturbance in recalling recent events
a. Privacy
related to cerebral hypoxia.
b. Respect 45. Nurse John is a aware that most crisis
situations
c. Empathy
should resolve in about:
d. Presence
a. 1 to 2 weeks
43. When establishing an initial nurse-client
b. 4 to 6 weeks
relationship, Nurse Hazel should explore with
c. 4 to 6 months
the client the:
d. 6 to 12 months
a. Client’s perception of the presenting
46. Nurse Judy knows that statistics show that in
problem.
adolescent suicide behavior:
b. Occurrence of fantasies the client may
a. Females use more dramatic methods
experience.
than males
c. Details of any ritualistic acts carried out
b. Males account for more attempts than
by the client
do females
d. Client’s feelings when external; controls
c. Females talk more about suicide before
are instituted.
attempting it
44. Tranylcypromine sulfate (Parnate) is
prescribed d. Males are more likely to use lethal

for a depressed client who has not responded to methods than are females

the tricyclic antidepressants. After teaching the 47. Dervid with paranoid schizophrenia
repeatedly
client about the medication, Nurse Marian
uses profanity during an activity therapy
evaluates that learning has occurred when the
session.
client states, “I will avoid:
Which response by the nurse would be most
a. Citrus fruit, tuna, and yellow
appropriate?
vegetables.”
a. "Your behavior won't be tolerated. Go to
b. Chocolate milk, aged cheese, and
your room immediately."
yogurt’”
337
c. Green leafy vegetables, chicken, and
b. "You're just doing this to get back at me
milk.”
for making you come to therapy."
d. Whole grains, red meats, and
c. "Your cursing is interrupting the activity.
carbonated soda.”
Take time out in your room for 10
minutes." b. Dystonia.

d. "I'm disappointed in you. You can't c. Neuroleptic malignant syndrome.

control yourself even for a few minutes." d. Akathisia.

48. Nurse Maureen knows that the 51. Which nursing intervention would be most
nonantipsychotic
appropriate if a male client develop orthostatic
medication used to treat some clients with
hypotension while taking amitriptyline (Elavil)?
schizoaffective disorder is:
a. Consulting with the physician about
a. phenelzine (Nardil)
substituting a different type of
b. chlordiazepoxide (Librium)
antidepressant.
c. lithium carbonate (Lithane)
b. Advising the client to sit up for 1 minute
d. imipramine (Tofranil)
before getting out of bed.
49. Which information is most important for the
c. Instructing the client to double the
nurse Trinity to include in a teaching plan for a
dosage until the problem resolves.
male schizophrenic client taking clozapine
d. Informing the client that this adverse
(Clozaril)?
reaction should disappear within 1
a. Monthly blood tests will be necessary.
week.
b. Report a sore throat or fever to the
52. Mr. Cruz visits the physician's office to seek
physician immediately.
treatment for depression, feelings of
c. Blood pressure must be monitored for
hopelessness, poor appetite, insomnia, fatigue,
hypertension.
low self- esteem, poor concentration, and
d. Stop the medication when symptoms
difficulty making decisions. The client states that
subside.
these symptoms began at least 2 years ago.
50. Ricky with chronic schizophrenia takes
Based on this report, the nurse Tyfany suspects:
neuroleptic medication is admitted to the
a. Cyclothymic disorder.
psychiatric unit. Nursing assessment reveals
b. Atypical affective disorder.
rigidity, fever, hypertension, and diaphoresis.
c. Major depression.
These findings suggest which life- threatening
d. Dysthymic disorder.
reaction:
53. After taking an overdose of phenobarbital
a. Tardive dyskinesia.
(Barbita), Mario is admitted to the emergency
department. Dr. Trinidad prescribes activated a. It's characterized by an acute onset and

charcoal (Charcocaps) to be administered by lasts about 1 month.

mouth immediately. Before administering the b. It's characterized by a slowly evolving

dose, the nurse verifies the dosage ordered. onset and lasts about 1 week.

What is the usual minimum dose of activated c. It's characterized by a slowly evolving

charcoal? onset and lasts about 1 month.

a. 5 g mixed in 250 ml of water d. It's characterized by an acute onset and

b. 15 g mixed in 500 ml of water lasts hours to a number of days.

c. 30 g mixed in 250 ml of water 338

d. 60 g mixed in 500 ml of water 57. Edward, a 66 year old client with slight
memory
54. What herbal medication for depression,
widely impairment and poor concentration is
diagnosed
used in Europe, is now being prescribed in the
with primary degenerative dementia of the
United States?
Alzheimer's type. Early signs of this dementia
a. Ginkgo biloba
include subtle personality changes and
b. Echinacea
withdrawal from social interactions. To assess
c. St. John's wort
for progression to the middle stage of
d. Ephedra
Alzheimer's disease, the nurse should observe
55. Cely with manic episodes is taking lithium.
the client for:
Which electrolyte level should the nurse check
a. Occasional irritable outbursts.
before administering this medication?
b. Impaired communication.
a. Clcium
c. Lack of spontaneity.
b. Sodium
d. Inability to perform self-care activities.
c. Chloride
58. Isabel with a diagnosis of depression is
d. Potassium
started
56. Nurse Josefina is caring for a client who has
on imipramine (Tofranil), 75 mg by mouth at
been
bedtime. The nurse should tell the client that:
diagnosed with delirium. Which statement
about a. This medication may be habit forming

delirium is true? and will be discontinued as soon as the

client feels better. suspects that the client is going through which
of
b. This medication has no serious adverse
the following withdrawals?
effects.
a. Alcohol withdrawal
c. The client should avoid eating such
b. Cannibis withdrawal
foods as aged cheeses, yogurt, and
c. Cocaine withdrawal
chicken livers while taking the
d. Opioid withdrawal
medication.
61. Mr. Garcia, an attorney who throws books
d. This medication may initially cause
and
tiredness, which should become less
furniture around the office after losing a case is
bothersome over time.
referred to the psychiatric nurse in the law
59. Kathleen is admitted to the psychiatric clinic firm's
for
employee assistance program. Nurse Beatriz
treatment of anorexia nervosa. To promote the
knows that the client's behavior most likely
client's physical health, the nurse should plan
represents the use of which defense
to:
mechanism?
a. Severely restrict the client's physical
a. Regression
activities.
b. Projection
b. Weigh the client daily, after the evening
c. Reaction-formation
meal.
d. Intellectualization
c. Monitor vital signs, serum electrolyte
62. Nurse Anne is caring for a client who has
levels, and acid-base balance.
been
d. Instruct the client to keep an accurate
treated long term with antipsychotic
record of food and fluid intake. medication.

60. Celia with a history of polysubstance abuse During the assessment, Nurse Anne checks the
is
client for tardive dyskinesia. If tardive dyskinesia
admitted to the facility. She complains of nausea
is present, Nurse Anne would most likely
and vomiting 24 hours after admission. The
observe:
nurse assesses the client and notes piloerection,
a. Abnormal movements and involuntary
pupillary dilation, and lacrimation. The nurse
movements of the mouth, tongue, and
face. 339

b. Abnormal breathing through the nostrils 65. Nurse Irish is aware that Ritalin is the drug
of
accompanied by a “thrill.”
choice for a child with ADHD. The side effects of
c. Severe headache, flushing, tremors, and
the following may be noted by the nurse:
ataxia.
a. Increased attention span and
d. Severe hypertension, migraine
concentration
headache,
b. Increase in appetite
63. Dennis has a lithium level of 2.4 mEq/L. The
c. Sleepiness and lethargy
nurse immediately would assess the client for
d. Bradycardia and diarrhea
which of the following signs or symptoms?
66. Kitty, a 9 year old child has very limited
a. Weakness
vocabulary and interaction skills. She has an I.Q.
b. Diarrhea
of 45. She is diagnosed to have Mental
c. Blurred vision
retardation of this classification:
d. Fecal incontinence
a. Profound
64. Nurse Jannah is monitoring a male client
who b. Mild

has been placed inrestraints because of violent c. Moderate

behavior. Nurse determines that it will be safe d. Severe

to
67. The therapeutic approach in the care of
remove the restraints when: Armand

a. The client verbalizes the reasons for the an autistic child include the following EXCEPT:

violent behavior. a. Engage in diversionary activities when

b. The client apologizes and tells the nurse acting -out

that it will never happen again. b. Provide an atmosphere of acceptance

c. No acts of aggression have been c. Provide safety measures

observed within 1 hour after the release d. Rearrange the environment to activate

of two of the extremity restraints. the child

d. The administered medication has taken 68. Jeremy is brought to the emergency room
by
effect.
friends who state that he took something an
hour ago. He is actively hallucinating, agitated, d. The client feels angry towards the nurse

with irritated nasal septum. who resembles his mother.

a. Heroin 72. Tristan is on Lithium has suffered from

diarrhea
b. Cocaine
and vomiting. What should the nurse in-charge
c. LSD
do first:
d. Marijuana
a. Recognize this as a drug interaction
69. Nurse Pauline is aware that Dementia unlike
b. Give the client Cogentin
delirium is characterized by:
c. Reassure the client that these are
a. Slurred speech
common side effects of lithium therapy
b. Insidious onset
d. Hold the next dose and obtain an order
c. Clouding of consciousness
for a stat serum lithium level
d. Sensory perceptual change
73. Nurse Sarah ensures a therapeutic
70. A 35 year old female has intense fear of
environment
riding an
for all the client. Which of the following best
elevator. She claims “ As if I will die inside.” The
describes a therapeutic milieu?
client is suffering from:
a. A therapy that rewards adaptive
a. Agoraphobia
behavior
b. Social phobia
b. A cognitive approach to change behavior
c. Claustrophobia
c. A living, learning or working
d. Xenophobia
environment.
71. Nurse Myrna develops a counter-
transference d. A permissive and congenial environment

reaction. This is evidenced by: 74. Anthony is very hostile toward one of the
staff
a. Revealing personal information to the
for no apparent reason. He is manifesting:
client
a. Splitting
b. Focusing on the feelings of the client.
b. Transference
c. Confronting the client about
c. Countertransference
discrepancies in verbal or non-verbal
d. Resistance
behavior
75. Marielle, 17 years old was sexually attacked
while on her way home from school. She is facility is anxious most of the time and

brought to the hospital by her mother. Rape is frequently complains of a number of vague

an example of which type of crisis: symptoms that interfere with his ability to eat.

a. Situational These symptoms indicate which of the following

b. Adventitious disorders?

c. Developmental a. Conversion disorder

d. Internal b. Hypochondriasis

76. Nurse Greta is aware that the following is c. Severe anxiety

classified as an Axis I disorder by the Diagnosis d. Sublimation

and Statistical Manual of Mental Disorders, Text 79. Charina, a college student who frequently
visited
Revision (DSM-IV-TR) is:
the health center during the past year with
a. Obesity
multiple vague complaints of GI symptoms
b. Borderline personality disorder
before course examinations. Although physical
c. Major depression
causes have been eliminated, the student
d. Hypertension
continues to express her belief that she has a
340
serious illness. These symptoms are typically of
77. Katrina, a newly admitted is extremely
hostile which of the following disorders?

toward a staff member she has just met, a. Conversion disorder

without
b. Depersonalization
apparent reason. According to Freudian theory,
c. Hypochondriasis
the nurse should suspect that the client is
d. Somatization disorder
experiencing which of the following
80. Nurse Daisy is aware that the following
phenomena?
pharmacologic agents are sedative- hypnotic
a. Intellectualization
medication is used to induce sleep for a client
b. Transference
experiencing a sleep disorder is:
c. Triangulation
a. Triazolam (Halcion)
d. Splitting
b. Paroxetine (Paxil)\
78. An 83year-old male client is in extended
c. Fluoxetine (Prozac)
care
d. Risperidone (Risperdal) self –reports?

81. Aldo, with a somatoform pain disorder may a. “I’m sleeping better and don’t have

obtain secondary gain. Which of the following nightmares”

statement refers to a secondary gain? b. “I’m not losing my temper as much”

a. It brings some stability to the family c. “I’ve lost my craving for alcohol”

b. It decreases the preoccupation with the d. I’ve lost my phobia for water”

physical illness 84. Mark, with a diagnosis of generalized

anxiety
c. It enables the client to avoid some
disorder wants to stop taking his lorazepam
unpleasant activity
(Ativan). Which of the following important facts
d. It promotes emotional support or
should nurse Betty discuss with the client about
attention for the client
discontinuing the medication?
82. Dervid is diagnosed with panic disorder with
a. Stopping the drug may cause depression
agoraphobia is talking with the nurse in-charge
b. Stopping the drug increases cognitive
about the progress made in treatment. Which of
abilities
the following statements indicates a positive
c. Stopping the drug decreases sleeping
client response?
difficulties
a. “I went to the mall with my friends last
d. Stopping the drug can cause withdrawal
Saturday”
symptoms
b. “I’m hyperventilating only when I have a
85. Jennifer, an adolescent who is depressed
panic attack”
and
c. “Today I decided that I can stop taking
reported by his parents as having difficulty in
my medication”
school is brought to the community mental
d. “Last night I decided to eat more than a
health center to be evaluated. Which of the
bowl of cereal”
following other health problems would the
83. The effectiveness of monoamine oxidase nurse
(MAO)
suspect?
inhibitor drug therapy in a client with
a. Anxiety disorder
posttraumatic stress disorder can be
b. Behavioral difficulties
demonstrated by which of the following client
c. Cognitive impairment
d. Labile moods with delirium and has history of hypertension

341 and anxiety. She had been taking digoxin,

86. Ricardo, an outpatient in psychiatric facility furosemide (Lasix), and diazepam (Valium) for
is
anxiety. This client’s impairment may be related
diagnosed with dysthymic disorder. Which of
to which of the following conditions?
the
a. Infection
following statement about dysthymic disorder is
b. Metabolic acidosis
true?
c. Drug intoxication
a. It involves a mood range from moderate
d. Hepatic encephalopathy
depression to hypomania
89. Nurse Ron enters a client’s room, the client
b. It involves a single manic depression
says,
c. It’s a form of depression that occurs in
“They’re crawling on my sheets! Get them off
the fall and winter
my bed!” Which of the following assessment is
d. It’s a mood disorder similar to major
the most accurate?
depression but of mild to moderate
a. The client is experiencing aphasia
severity
b. The client is experiencing dysarthria
87. The nurse is aware that the following ways
c. The client is experiencing a flight of ideas
in
d. The client is experiencing visual
vascular dementia different from Alzheimer’s
hallucination
disease is:
90. Which of the following descriptions of a
a. Vascular dementia has more abrupt
client’s
onset
experience and behavior can be assessed as an
b. The duration of vascular dementia is
illusion?
usually brief
a. The client tries to hit the nurse when
c. Personality change is common in
vital signs must be taken
vascular dementia
b. The client says, “I keep hearing a voice
d. The inability to perform motor activities
telling me to run away”
occurs in vascular dementia
c. The client becomes anxious whenever
88. Loretta, a newly admitted client was
the nurse leaves the bedside
diagnosed
d. The client looks at the shadow on a wall extrapyramidal adverse reaction

and tells the nurse she sees frightening c. Explain that the drug is less affective if

faces on the wall. the client smokes

91. During conversation of Nurse John with a d. Discuss the need to report paradoxical
client,
effects such as euphoria
he observes that the client shift from one topic
94. Nurse Alexandra notices other clients on the
to the next on a regular basis. Which of the unit

following terms describes this disorder? avoiding a client diagnosed with antisocial

a. Flight of ideas personality disorder. When discussing

b. Concrete thinking appropriate behavior in group therapy, which of

c. Ideas of reference the following comments is expected about this

d. Loose association client by his peers?

92. Francis tells the nurse that her coworkers a. Lack of honesty
are
b. Belief in superstition
sabotaging the computer. When the nurse asks
c. Show of temper tantrums
questions, the client becomes argumentative.
d. Constant need for attention
This behavior shows personality traits
95. Tommy, with dependent personality
associated
disorder is
with which of the following personality
working to increase his self- esteem. Which of
disorder?
the following statements by the Tommy shows
a. Antisocial
teaching was successful?
b. Histrionic
342
c. Paranoid
a. “I’m not going to look just at the
d. Schizotypal
negative things about myself”
93. Which of the following interventions is
b. “I’m most concerned about my level of
important for a Cely experiencing with paranoid
competence and progress”
personality disorder taking olanzapine
c. “I’m not as envious of the things other
(Zyprexa)?
people have as I used to be”
a. Explain effects of serotonin syndrome
d. “I find I can’t stop myself from taking
b. Teach the client to watch for
over things other should be doing” client’s perception?

96. Norma, a 42-year-old client with a diagnosis a. Delusion

of
b. Disorganized speech
chronic undifferentiated schizophrenia lives in a
c. Hallucination
rooming house that has a weekly nursing clinic.
d. Idea of reference
She scratches while she tells the nurse she feels
99. Mike is admitted to a psychiatric unit with a
creatures eating away at her skin. Which of the
diagnosis of undifferentiated schizophrenia.
following interventions should be done first?
Which of the following defense mechanisms is
a. Talk about his hallucinations and fears
probably used by mike?
b. Refer him for anticholinergic adverse
a. Projection
reactions
b. Rationalization
c. Assess for possible physical problems
c. Regression
such as rash
d. Repression
d. Call his physician to get his medication
100. Rocky has started taking haloperidol
increased to control his psychosis (Haldol).

97. Ivy, who is on the psychiatric unit is copying Which of the following instructions is most
and
appropriate for Ricky before taking
imitating the movements of her primary nurse.
haloperidol?
During recovery, she says, “I thought the nurse
a. Should report feelings of restlessness or
was my mirror. I felt connected only when I saw
agitation at once
my nurse.” This behavior is known by which of
b. Use a sunscreen outdoors on a yearround
the following terms?
basis
a. Modeling
c. Be aware you’ll feel increased energy
b. Echopraxia
taking this drug
c. Ego-syntonicity
d. This drug will indirectly control essential
d. Ritualism
hypertension
98. Jun approaches the nurse and tells that he
343
hears
Answers and Rationale – Care of Clients with
a voice telling him that he’s evil and deserves to
Physiologic and Psychosocial Alterations
die. Which of the following terms describes the
1. Answer: (D) Focusing seeing the results.

Rationale: The nurse is using focusing by Rationale: The client needs a specific response;

suggesting that the client discuss a specific that it takes 2 to 3 weeks (a delayed effect) until
issue.
the therapeutic blood level is reached.
The nurse didn’t restate the question, make
7. Answer: (C) Superego
observation, or ask further question (exploring).
Rationale: This behavior shows a weak sense of
2. Answer: (D) Remove all other clients from the
moral consciousness. According to Freudian
dayroom.
theory, personality disorders stem from a weak
Rationale: The nurse’s first priority is to consider
superego.
the safety of the clients in the therapeutic
8. Answer: (C) Skeletal muscle paralysis.
setting. The other actions are appropriate
Rationale: Anectine is a depolarizing muscle
responses after ensuring the safety of other
relaxant causing paralysis. It is used to reduce
clients.
the intensity of muscle contractions during the
3. Answer: (A) The client is disruptive.
convulsive stage, thereby reducing the risk of
Rationale: Group activity provides too much
bone fractures or dislocation.
stimulation, which the client will not be able to
9. Answer: (D) Increase calories, carbohydrates,
handle (harmful to self) and as a result will be
and protein.
disruptive to others.
Rationale: This client increased protein for
4. Answer: (C) Agree to talk with the mother tissue
and
building and increased calories to replace what
the father together. is

Rationale: By agreeing to talk with both parents, burned up (usually via carbohydrates).

the nurse can provide emotional support and 10. Answer: (C) Acting overly solicitous toward
the
further assess and validate the family’s needs.
child.
5. Answer: (A) Perceptual disorders.
Rationale: This behavior is an example of
Rationale: Frightening visual hallucinations are
reaction formation, a coping mechanism.
especially common in clients experiencing
11. Answer: (A) By designating times during
alcohol withdrawal.
which
6. Answer: (D) Suggest that it takes a while
the client can focus on the behavior.
before
Rationale: The nurse should designate times diet isn't indicated unless the client also has an

during which the client can focus on the eating disorder or a nutritional problem.

compulsive behavior or obsessive thoughts. The 13. Answer: (C) "Your problem is real but there
is no
nurse should urge the client to reduce the
physical basis for it. We'll work on what is going
frequency of the compulsive behavior gradually,
on in your life to find out why it's happened."
not rapidly. She shouldn't call attention to or try
Rationale: The nurse must be honest with the
to prevent the behavior. Trying to prevent the
client by telling her that the paralysis has no
behavior may cause pain and terror in the client.
physiologic cause while also conveying empathy
The nurse should encourage the client to
and acknowledging that her symptoms are real.
verbalize anxieties to help distract attention
The client will benefit from psychiatric
from the compulsive behavior.
treatment, which will help her understand the
12. Answer: (D) Exploring the meaning of the
underlying cause of her symptoms. After the
traumatic event with the client.
psychological conflict is resolved, her symptoms
Rationale: The client with PTSD needs
will disappear. Saying that it must be awful not
encouragement to examine and understand the
to be able to move her legs wouldn't answer the
meaning of the traumatic event and consequent
client's question; knowing that the cause is
losses. Otherwise, symptoms may worsen and
psychological wouldn't necessarily make her feel
the client may become depressed or engage in
better. Telling her that she has developed
self-destructive behavior such as substance
paralysis to avoid leaving her parents or that her
abuse. The client must explore the meaning of
personality caused her disorder wouldn't help
the event and won't heal without this, no
matter her understand and resolve the underlying

how much time passes. Behavioral techniques, conflict.

such as relaxation therapy, may help decrease 344

the client's anxiety and induce sleep. The 14. Answer: (C) fluvoxamine (Luvox) and

physician may prescribe antianxiety agents or clomipramine (Anafranil)

antidepressants cautiously to avoid Rationale: The antidepressants fluvoxamine and

dependence;
clomipramine have been effective in the
sleep medication is rarely appropriate. A special
treatment of OCD. Librium and Valium may be
helpful in treating anxiety related to OCD but panic attacks. Why these drugs help control

aren't drugs of choice to treat the illness. The panic attacks isn't clearly understood.

other medications mentioned aren't effective in Anticholinergic agents, which are smoothmuscle

the treatment of OCD. relaxants, relieve physical symptoms of

15. Answer: (A) A warning about the drugs anxiety but don't relieve the anxiety itself.
delayed
Antipsychotic drugs are inappropriate because
therapeutic effect, which is from 14 to 30 days.
clients who experience panic attacks aren't
Rationale: The client should be informed that
psychotic. Mood stabilizers aren't indicated
the drug's therapeutic effect might not be
because panic attacks are rarely associated with
reached for 14 to 30 days. The client must be
mood changes.
instructed to continue taking the drug as
18. Answer: (B) 3 to 5 days
directed. Blood level checks aren't necessary.
Rationale: Monoamine oxidase inhibitors, such
NMS hasn't been reported with this drug, but
as tranylcypromine, have an onset of action of
tachycardia is frequently reported.
approximately 3 to 5 days. A full clinical
16. Answer: (B) Severe anxiety and fear.
response may be delayed for 3 to 4 weeks. The
Rationale: Phobias cause severe anxiety (such as
therapeutic effects may continue for 1 to 2
a panic attack) that is out of proportion to the
weeks after discontinuation.
threat of the feared object or situation. Physical
19. Answer: (B) Providing emotional support
signs and symptoms of phobias include profuse and

sweating, poor motor control, tachycardia, and individual counseling.

elevated blood pressure. Insomnia, an inability Rationale: Clients in the first stage of
Alzheimer's
to concentrate, and weight loss are common in
disease are aware that something is happening
depression. Withdrawal and failure to
to them and may become overwhelmed and
distinguish reality from fantasy occur in
frightened. Therefore, nursing care typically
schizophrenia.
focuses on providing emotional support and
17. Answer: (A) Antidepressants
individual counseling. The other options are
Rationale: Tricyclic and monoamine oxidase
appropriate during the second stage of
(MAO) inhibitor antidepressants have been
Alzheimer's disease, when the client needs
found to be effective in treating clients with
continuous monitoring to prevent minor trust in others, clients with antisocial
personality
illnesses from progressing into major problems
disorder commonly have difficulty developing
and when maintaining adequate nutrition may
stable, close relationships.
become a challenge. During this stage, offering
22. Answer: (C) Methadone
nourishing finger foods helps clients to feed
Rationale: Methadone is used to detoxify opiate
themselves and maintain adequate nutrition.
users because it binds with opioid receptors at
20. Answer: (C) Emotional lability, euphoria, and
many sites in the central nervous system but
impaired memory
doesn’t have the same deterious effects as
Rationale: Signs of antianxiety agent overdose
other
include emotional lability, euphoria, and
opiates, such as cocaine, heroin, and morphine.
impaired memory. Phencyclidine overdose can
Barbiturates, amphetamines, and
cause combativeness, sweating, and confusion.
benzodiazepines are highly addictive and would
Amphetamine overdose can result in agitation,
require detoxification treatment.
hyperactivity, and grandiose ideation.
23. Answer: (B) Hallucinations
Hallucinogen overdose can produce
Rationale: Hallucinations are visual, auditory,
suspiciousness, dilated pupils, and increased
gustatory, tactile, or olfactory perceptions that
blood pressure.
have no basis in reality. Delusions are false
21. Answer: (D) A low tolerance for frustration
beliefs, rather than perceptions, that the client
Rationale: Clients with an antisocial personality
345
disorder exhibit a low tolerance for frustration,
accepts as real. Loose associations are rapid
emotional immaturity, and a lack of impulse
shifts among unrelated ideas. Neologisms are
control. They commonly have a history of
bizarre words that have meaning only to the
unemployment, miss work repeatedly, and quit
client.
work without other plans for employment. They
24. Answer: (C) Set up a strict eating plan for the
don't feel guilt about their behavior and
client.
commonly perceive themselves as victims. They
Rationale: Establishing a consistent eating plan
also display a lack of responsibility for the
and monitoring the client’s weight are very
outcome of their actions. Because of a lack of
important in this disorder. The family and
friends
should be included in the client’s care. The finid=sh a meal. The nurse should set limits in a
client
calm, clear, and self-confident tone of voice.
should be monitored during meals-not given
27. Answer: (D) Denial
privacy. Exercise must be limited and
Rationale: Denial is unconscious defense
supervised.
mechanism in which emotional conflict and
25. Answer: (A) Highly important or famous.
anxiety is avoided by refusing to acknowledge
Rationale: A delusion of grandeur is a false
belief feelings, desires, impulses, or external facts that
that one is highly important or famous. A are consciously intolerable. Withdrawal is a
delusion of persecution is a false belief that one common response to stress, characterized by
is being persecuted. A delusion of reference is a apathy. Logical thinking is the ability to think
false belief that one is connected to events rationally and make responsible decisions,
which
unrelated to oneself or a belief that one is
would lead the client admitting the problem and
responsible for the evil in the world.
seeking help. Repression is suppressing past
26. Answer: (D) Listening attentively with a
neutral events from the consciousness because of guilty
attitude and avoiding power struggles. association.
Rationale: The nurse should listen to the client’s 28. Answer: (B) Paranoid thoughts
requests, express willingness to seriously Rationale: Clients with schizotypal personality
consider the request, and respond later. The disorder experience excessive social anxiety that
nurse should encourage the client to take short can lead to paranoid thoughts. Aggressive
daytime naps because he expends so much behavior is uncommon, although these clients
energy. The nurse shouldn’t try to restrain the may experience agitation with anxiety. Their
client when he feels the need to move around behavior is emotionally cold with a flattened
as
affect, regardless of the situation. These clients
long as his activity isn’t harmful. High calorie
demonstrate a reduced capacity for close or
finger foods should be offered to supplement
dependent relationships.
the client’s diet, if he can’t remain seated long
29. Answer: (C) Identify anxiety-causing
enough to eat a complete meal. The nurse situations
shouldn’t be forced to stay seated at the table Rationale: Bulimic behavior is generally a
to
maladaptive coping response to stress and the client gestures to hold the nurse’s hand.

underlying issues. The client must identify 34. Answer: (D) A higher level of anxiety
continuing
anxiety-causing situations that stimulate the
for more than 3 months.
bulimic behavior and then learn new ways of
Rationale: This is not an expected outcome of a
coping with the anxiety.
crisis because by definition a crisis would be
30. Answer: (A) Tension and irritability
resolved in 6 weeks.
Rationale: An amphetamine is a nervous system
35. Answer: (B) Staying in the sun
stimulant that is subject to abuse because of its
Rationale: Haldol causes photosensitivity.
ability to produce wakefulness and euphoria. An
Severe
overdose increases tension and irritability.
sunburn can occur on exposure to the sun.
Options B and C are incorrect because
36. Answer: (D) Moderate-level anxiety
amphetamines stimulate norepinephrine, which
Rationale: A moderately anxious person can
increase the heart rate and blood flow. Diarrhea
ignore peripheral events and focuses on central
is a common adverse effect so option D is
concerns.
incorrect.
37. Answer: (C) Diverse interest
31. Answer: (B) “No, I do not hear your voices,
Rationale: Before onset of depression, these
but I
clients usually have very narrow, limited
believe you can hear them”.
interest.
Rationale: The nurse, demonstrating knowledge
346
and understanding, accepts the client’s
38. Answer: (A) As their depression begins to
perceptions even though they are hallucinatory.
improve
32. Answer: (C) Confusion for a time after
treatment Rationale: At this point the client may have

Rationale: The electrical energy passing through enough energy to plan and execute an attempt.

the cerebral cortex during ECT results in a 39. Answer: (D) Disturbance in recalling recent

temporary state of confusion after treatment. events related to cerebral hypoxia.

33. Answer: (D) Acceptance stage Rationale: Cell damage seems to interfere with

Rationale: Communication and intervention registering input stimuli, which affects the
ability
during this stage are mainly nonverbal, as when
to register and recall recent events; vascular
dementia is related to multiple vascular lesions ingested in the presence of an MAO inhibitor,

of the cerebral cortex and subcortical structure. cause a severe hypertensive response.

40. Answer: (D) Encouraging the client to have 45. Answer: (B) 4 to 6 weeks
blood
Rationale: Crisis is self-limiting and lasts from 4
levels checked as ordered.
to 6 weeks.
Rationale: Blood levels must be checked
46. Answer: (D) Males are more likely to use
monthly
lethal
or bimonthly when the client is on maintenance
methods than are females
therapy because there is only a small range
Rationale: This finding is supported by research;
between therapeutic and toxic levels.
females account for 90% of suicide attempts but
41. Answer: (B) Fine hand tremors or slurred
males are three times more successful because
speech
of methods used.
Rationale: These are common side effects of
47. Answer: (C) "Your cursing is interrupting the
lithium carbonate.
activity. Take time out in your room for 10
42. Answer: (D) Presence
minutes."
Rationale: The constant presence of a nurse
Rationale: The nurse should set limits on client
provides emotional support because the client
behavior to ensure a comfortable environment
knows that someone is attentive and available
in for all clients. The nurse should accept hostile or
case of an emergency. quarrelsome client outbursts within limits
43. Answer: (A) Client’s perception of the without becoming personally offended, as in
presenting
option A. Option B is incorrect because it
problem. implies
Rationale: The nurse can be most therapeutic by that the client’s actions reflect feelings toward
starting where the client is, because it is the the staff instead of the client's own misery.
client’s concept of the problem that serves as Judgmental remarks, such as option D, may
the starting point of the relationship. decrease the client's self-esteem.
44. Answer: (B) Chocolate milk, aged cheese, 48. Answer: (C) lithium carbonate (Lithane)
and
Rationale: Lithium carbonate, an antimania
yogurt’” drug,
Rationale: These high-tyramine foods, when is used to treat clients with cyclical
schizoaffective disorder, a psychotic disorder be continued, even when symptoms have been

once classified under schizophrenia that causes controlled. If the medication must be stopped, it

affective symptoms, including maniclike activity. should be slowly tapered over 1 to 2 weeks and

Lithium helps control the affective component only under the supervision of a physician.
of
50. Answer: (C) Neuroleptic malignant
this disorder. Phenelzine is a monoamine syndrome.

oxidase inhibitor prescribed for clients who Rationale: The client's signs and symptoms
don't
suggest neuroleptic malignant syndrome, a
respond to other antidepressant drugs such as lifethreatening

imipramine. Chlordiazepoxide, an antianxiety reaction to neuroleptic medication

agent, generally is contraindicated in psychotic that requires immediate treatment. Tardive

clients. Imipramine, primarily considered an dyskinesia causes involuntary movements of the

antidepressant agent, is also used to treat tongue, mouth, facial muscles, and arm and leg
clients
muscles. Dystonia is characterized by cramps
with agoraphobia and that undergoing cocaine
and rigidity of the tongue, face, neck, and back
detoxification.
muscles. Akathisia causes restlessness, anxiety,
49. Answer: (B) Report a sore throat or fever to
and jitteriness.
the
51. Answer: (B) Advising the client to sit up for 1
physician immediately.
minute before getting out of bed.
Rationale: A sore throat and fever are
Rationale: To minimize the effects of
indications of an infection caused by
amitriptyline-induced orthostatic hypotension,
agranulocytosis, a potentially life-threatening
347
complication of clozapine. Because of the risk of
the nurse should advise the client to sit up for 1
agranulocytosis, white blood cell (WBC) counts
minute before getting out of bed. Orthostatic
are necessary weekly, not monthly. If the WBC
hypotension commonly occurs with tricyclic
count drops below 3,000/μl, the medication
antidepressant therapy. In these cases, the
must be stopped. Hypotension may occur in
dosage may be reduced or the physician may
clients taking this medication. Warn the client to
prescribe nortriptyline, another tricyclic
stand up slowly to avoid dizziness from
antidepressant. Orthostatic hypotension
orthostatic hypotension. The medication should
disappears only when the drug is discontinued. reactions, although toxicity doesn't occur with

52. Answer: (D) Dysthymic disorder. activated charcoal, even at the maximum dose.

Rationale: Dysthymic disorder is marked by 54. Answer: (C) St. John's wort

feelings of depression lasting at least 2 years, Rationale: St. John's wort has been found to

accompanied by at least two of the following have serotonin-elevating properties, similar to

symptoms: sleep disturbance, appetite prescription antidepressants. Ginkgo biloba is

disturbance, low energy or fatigue, low prescribed to enhance mental acuity. Echinacea
selfesteem,
has immune-stimulating properties. Ephedra is a
poor concentration, difficulty making
naturally occurring stimulant that is similar to
decisions, and hopelessness. These symptoms
ephedrine.
may be relatively continuous or separated by
55. Answer: (B) Sodium
intervening periods of normal mood that last a
Rationale: Lithium is chemically similar to
few days to a few weeks. Cyclothymic disorder is
sodium. If sodium levels are reduced, such as
a chronic mood disturbance of at least 2 years'
from sweating or diuresis, lithium will be
duration marked by numerous periods of
reabsorbed by the kidneys, increasing the risk of
depression and hypomania. Atypical affective
toxicity. Clients taking lithium shouldn't restrict
disorder is characterized by manic signs and
their intake of sodium and should drink
symptoms. Major depression is a recurring,
adequate amounts of fluid each day. The other
persistent sadness or loss of interest or pleasure
electrolytes are important for normal body
in almost all activities, with signs and symptoms
functions but sodium is most important to the
recurring for at least 2 weeks.
absorption of lithium.
53. Answer: (C) 30 g mixed in 250 ml of water
56. Answer: (D) It's characterized by an acute
Rationale: The usual adult dosage of activated onset

charcoal is 5 to 10 times the estimated weight and lasts hours to a number of days
of
Rationale: Delirium has an acute onset and
the drug or chemical ingested, or a minimum
typically can last from several hours to several
dose of 30 g, mixed in 250 ml of water. Doses
days.
less than this will be ineffective; doses greater
57. Answer: (B) Impaired communication.
than this can increase the risk of adverse
Rationale: Initially, memory impairment may be
the only cognitive deficit in a client with tachycardia. Dietary restrictions, such as

Alzheimer's disease. During the early stage of avoiding aged cheeses, yogurt, and chicken

this disease, subtle personality changes may livers, are necessary for a client taking a
also
monoamine oxidase inhibitor, not a tricyclic
be present. However, other than occasional
antidepressant.
irritable outbursts and lack of spontaneity, the
59. Answer: (C) Monitor vital signs, serum
client is usually cooperative and exhibits socially
electrolyte levels, and acid-base balance.
appropriate behavior. Signs of advancement to
Rationale: An anorexic client who requires
the middle stage of Alzheimer's disease include
hospitalization is in poor physical condition from
exacerbated cognitive impairment with obvious
starvation and may die as a result of
personality changes and impaired
arrhythmias, hypothermia, malnutrition,
communication, such as inappropriate
infection, or cardiac abnormalities secondary to
conversation, actions, and responses. During the
electrolyte imbalances. Therefore, monitoring
late stage, the client can't perform self-care
the client's vital signs, serum electrolyte level,
activities and may become mute.
and acid base balance is crucial. Option A may
58. Answer: (D) This medication may initially
worsen anxiety. Option B is incorrect because a
cause
weight obtained after breakfast is more
tiredness, which should become less
accurate
bothersome over time.
348
Rationale: Sedation is a common early adverse
than one obtained after the evening meal.
effect of imipramine, a tricyclic antidepressant,
Option D would reward the client with attention
and usually decreases as tolerance develops.
for not eating and reinforce the control issues
Antidepressants aren't habit forming and don't
that are central to the underlying psychological
cause physical or psychological dependence.
problem; also, the client may record food and
However, after a long course of high-dose
fluid intake inaccurately.
therapy, the dosage should be decreased
60. Answer: (D) Opioid withdrawal
gradually to avoid mild withdrawal symptoms.
Rationale: The symptoms listed are specific to
Serious adverse effects, although rare, include
opioid withdrawal. Alcohol withdrawal would
myocardial infarction, heart failure, and
show elevated vital signs. There is no real
withdrawal from cannibis. Symptoms of cocaine and 2 mEq/L the client experiencing vomiting,

withdrawal include depression, anxiety, and diarrhea, muscle weakness, ataxia, dizziness,

agitation. slurred speech, and confusion. At lithium levels

61. Answer: (A) Regression of 2.5 to 3 mEq/L or higher, urinary and fecal

Rationale: An adult who throws temper incontinence occurs, as well as seizures, cardiac

tantrums, such as this one, is displaying dysrythmias, peripheral vascular collapse, and

regressive behavior, or behavior that is death.

appropriate at a younger age. In projection, the 64. Answer: (C) No acts of aggression have been

client blames someone or something other than observed within 1 hour after the release of two

the source. In reaction formation, the client acts of the extremity restraints.

in opposition to his feelings. In Rationale: The best indicator that the behavior
is
intellectualization, the client overuses rational
controlled, if the client exhibits no signs of
explanations or abstract thinking to decrease
the aggression after partial release of restraints.

significance of a feeling or event. Options , B, and D do not ensure that the client

62. Answer: (A) Abnormal movements and has controlled the behavior.

involuntary movements of the mouth, tongue, 65. Answer: (A) increased attention span and

and face. concentration

Rationale: Tardive dyskinesia is a severe reaction Rationale: The medication has a paradoxic effect

associated with long term use of antipsychotic that decreases hyperactivity and impulsivity

medication. The clinical manifestations include among children with ADHD. B, C, D. Side effects

abnormal movements (dyskinesia) and of Ritalin include anorexia, insomnia, diarrhea

involuntary movements of the mouth, tongue and irritability.

(fly catcher tongue), and face. 66. Answer: (C) Moderate

63. Answer: (C) Blurred vision Rationale: The child with moderate mental

Rationale: At lithium levels of 2 to 2.5 mEq/L the retardation has an I.Q. of 35- 50 Profound

client will experienced blurred vision, muscle Mental retardation has an I.Q. of below 20; Mild

twitching, severe hypotension, and persistent mental retardation 50-70 and Severe mental

nausea and vomiting. With levels between 1.5 retardation has an I.Q. of 20-35.
67. Answer: (D) Rearrange the environment to Rationale: Claustrophobia is fear of closed
space.
activate the child
A. Agoraphobia is fear of open space or being a
Rationale: The child with autistic disorder does
situation where escape is difficult. B. Social
not want change. Maintaining a consistent
phobia is fear of performing in the presence of
environment is therapeutic. A. Angry outburst
others in a way that will be humiliating or
can be re-channeling through safe activities. B.
embarrassing. D. Xenophobia is fear of
Acceptance enhances a trusting relationship. C.
strangers.
Ensure safety from self-destructive behaviors
71. Answer: (A) Revealing personal information
like head banging and hair pulling.
to
68. Answer: (B) cocaine
the client
Rationale: The manifestations indicate
Rationale: Counter-transference is an emotional
intoxication with cocaine, a CNS stimulant. A.
reaction of the nurse on the client based on her
Intoxication with heroine is manifested by
349
euphoria then impairment in judgment,
unconscious needs and conflicts. B and C. These
attention and the presence of papillary
are therapeutic approaches. D. This is
constriction. C. Intoxication with hallucinogen
transference reaction where a client has an
like LSD is manifested by grandiosity,
emotional reaction towards the nurse based on
hallucinations, synesthesia and increase in vital
her past.
signs D. Intoxication with Marijuana, a
72. Answer: (D) Hold the next dose and obtain
cannabinoid is manifested by sensation of an

slowed time, conjunctival redness, social order for a stat serum lithium level

withdrawal, impaired judgment and Rationale: Diarrhea and vomiting are

hallucinations. manifestations of Lithium toxicity. The next dose

69. Answer: (B) insidious onset of lithium should be withheld and test is done
to
Rationale: Dementia has a gradual onset and
validate the observation. A. The manifestations
progressive deterioration. It causes pronounced
are not due to drug interaction. B. Cogentin is
memory and cognitive disturbances. A,C and D
used to manage the extra pyramidal symptom
are all characteristics of delirium.
side effects of antipsychotics. C. The common
70. Answer: (C) Claustrophobia
side effects of Lithium are fine hand tremors, himself to the care of the nurse

nausea, polyuria and polydipsia. 75. Answer: (B) Adventitious

73. Answer: (C) A living, learning or working Rationale: Adventitious crisis is a crisis involving

environment. a traumatic event. It is not part of everyday life.

Rationale: A therapeutic milieu refers to a broad A. Situational crisis is from an external source

conceptual approach in which all aspects of the that upset ones psychological equilibrium C and

environment are channeled to provide a D. are the same. They are transitional or

therapeutic environment for the client. The six developmental periods in life

environmental elements include structure, 76. Answer: (C) Major depression

safety, norms; limit setting, balance and unit Rationale: The DSM-IV-TR classifies major

modification. A. Behavioral approach in depression as an Axis I disorder. Borderline

psychiatric care is based on the premise that personality disorder as an Axis II; obesity and

behavior can be learned or unlearned through hypertension, Axis III.

the use of reward and punishment. B. Cognitive 77. Answer: (B) Transference

approach to change behavior is done by Rationale: Transference is the unconscious

correcting distorted perceptions and irrational assignment of negative or positive feelings

beliefs to correct maladaptive behaviors. D. This evoked by a significant person in the client’s
past
is not congruent with therapeutic milieu.
to another person. Intellectualization is a
74. Answer: (B) Transference
defense mechanism in which the client avoids
Rationale: Transference is a positive or negative
dealing with emotions by focusing on facts.
feeling associated with a significant person in
Triangulation refers to conflicts involving three
the client’s past that are unconsciously assigned
family members. Splitting is a defense
to another A. Splitting is a defense mechanism
mechanism commonly seen in clients with
commonly seen in a client with personality
personality disorder in which the world is
disorder in which the world is perceived as all
perceived as all good or all bad.
good or all bad C. Countert-transference is a
78. Answer: (B) Hypochondriasis
phenomenon where the nurse shifts feelings
Rationale: Complains of vague physical
assigned to someone in her past to the patient

D. Resistance is the client’s refusal to submit

symptoms that have no apparent medical depression panic disorder, and
causes obsessivecompulsive

are characteristic of clients with disorder. Fluoxetine is a scrotoninspecific

hypochondriasis. In many cases, the GI system is reuptake inhibitor used for depressive

affected. Conversion disorders are characterized disorders and obsessive-compulsive disorders.

by one or more neurologic symptoms. The Risperidome is indicated for psychotic disorders.

client’s symptoms don’t suggest severe anxiety. 81. Answer: (D) It promotes emotional support
or
A client experiencing sublimation channels
attention for the client
maladaptive feelings or impulses into socially
350
acceptable behavior
Rationale: Secondary gain refers to the benefits
79. Answer: (C) Hypochondriasis
of the illness that allow the client to receive
Rationale: Hypochodriasis in this case is shown
emotional support or attention. Primary gain
by the client’s belief that she has a serious
enables the client to avoid some unpleasant
illness, although pathologic causes have been
activity. A dysfunctional family may disregard
eliminated. The disturbance usually lasts at least
the real issue, although some conflict is
6 with identifiable life stressor such as, in this
relieved.
case, course examinations. Conversion disorders
Somatoform pain disorder is a preoccupation
are characterized by one or more neurologic
with pain in the absence of physical disease.
symptoms. Depersonalization refers to
82. Answer: (A) “I went to the mall with my
persistent recurrent episodes of feeling friends

detached from one’s self or body. Somatoform last Saturday”

disorders generally have a chronic course with Rationale: Clients with panic disorder tent to be

few remissions. socially withdrawn. Going to the mall is a sign of

80. Answer: (A) Triazolam (Halcion) working on avoidance behaviors.

Rationale: Triazolam is one of a group of Hyperventilating is a key symptom of panic

sedative hypnotic medication that can be used disorder. Teaching breathing control is a major

for a limited time because of the risk of intervention for clients with panic disorder. The

dependence. Paroxetine is a scrotonin-specific client taking medications for panic disorder;

such
reutake inhibitor used for treatment of
as tricylic antidepressants and benzodiazepines Cognitive impairment is typically associated
with
must be weaned off these drugs. Most clients
delirium or dementia. Labile mood is more
with panic disorder with agoraphobia don’t
have characteristic of a client with cognitive

nutritional problems. impairment or bipolar disorder.

83. Answer: (A) “I’m sleeping better and don’t 86. Answer: (D) It’s a mood disorder similar to
have major

nightmares” depression but of mild to moderate severity

Rationale: MAO inhibitors are used to treat Rationale: Dysthymic disorder is a mood
sleep disorder

problems, nightmares, and intrusive daytime similar to major depression but it remains mild

thoughts in individual with posttraumatic stress to moderate in severity. Cyclothymic disorder is

disorder. MAO inhibitors aren’t used to help a mood disorder characterized by a mood range

control flashbacks or phobias or to decrease the from moderate depression to hypomania.

craving for alcohol. Bipolar I disorder is characterized by a single

84. Answer: (D) Stopping the drug can cause manic episode with no past major depressive

withdrawal symptoms episodes. Seasonal- affective disorder is a form

Rationale: Stopping antianxiety drugs such as of depression occurring in the fall and winter.

benzodiazepines can cause the client to have 87. Answer: (A) Vascular dementia has more
abrupt
withdrawal symptoms. Stopping a
onset
benzodiazepine doesn’t tend to cause
Rationale: Vascular dementia differs from
depression, increase cognitive abilities, or
Alzheimer’s disease in that it has a more abrupt
decrease sleeping difficulties.
onset and runs a highly variable course.
85. Answer: (B) Behavioral difficulties
Personally change is common in Alzheimer’s
Rationale: Adolescents tend to demonstrate
disease. The duration of delirium is usually brief.
severe irritability and behavioral problems
The inability to carry out motor activities is
rather than simply a depressed mood. Anxiety
common in Alzheimer’s disease.
disorder is more commonly associated with
88. Answer: (C) Drug intoxication
small children rather than with adolescents.
Rationale: This client was taking several
medications that have a propensity for implies highly definitive thought processes.

producing delirium; digoxin (a digitalis Flight of ideas is characterized by conversation

glycoxide), furosemide (a thiazide diuretic), and that’s disorganized from the onset. Loose

diazepam (a benzodiazepine). Sufficient associations don’t necessarily start in a cogently,

supporting data don’t exist to suspect the other then becomes loose.

options as causes. 92. Answer: (C) Paranoid

89. Answer: (D) The client is experiencing visual Rationale: Because of their suspiciousness,

hallucination paranoid personalities ascribe malevolent

Rationale: The presence of a sensory stimulus activities to others and tent to be defensive,

correlates with the definition of a hallucination, becoming quarrelsome and argumentative.

which is a false sensory perception. Aphasia 351

refers to a communication problem. Dysarthria Clients with antisocial personality disorder can
is
also be antagonistic and argumentative but are
difficulty in speech production. Flight of ideas is
less suspicious than paranoid personalities.
rapid shifting from one topic to another.
Clients with histrionic personality disorder are
90. Answer: (D) The client looks at the shadow
dramatic, not suspicious and argumentative.
on a
Clients with schizoid personality disorder are
wall and tells the nurse she sees frightening
usually detached from other and tend to have
faces on the wall.
eccentric behavior.
Rationale: Minor memory problems are
93. Answer: (C) Explain that the drug is less
distinguished from dementia by their minor
affective
severity and their lack of significant interference
if the client smokes
with the client’s social or occupational lifestyle.
Rationale: Olanzapine (Zyprexa) is less effective
Other options would be included in the history
for clients who smoke cigarettes. Serotonin
data but don’t directly correlate with the client’s
syndrome occurs with clients who take a
lifestyle.
combination of antidepressant medications.
91. Answer: (D) Loose association
Olanzapine doesn’t cause euphoria, and
Rationale: Loose associations are conversations
extrapyramidal adverse reactions aren’t a
that constantly shift in topic. Concrete thinking
problem. However, the client should be aware so fully in their fantasy world. They need to have
of
as in-depth assessment of physical complaints
adverse effects such as tardive dyskinesia.
that may spill over into their delusional
94. Answer: (A) Lack of honesty
symptoms. Talking with the client won’t provide
Rationale: Clients with antisocial personality
as assessment of his itching, and itching isn’t as
disorder tent to engage in acts of dishonesty,
adverse reaction of antipsychotic drugs, calling
shown by lying. Clients with schizotypal
the physician to get the client’s medication
personality disorder tend to be superstitious.
increased doesn’t address his physical
Clients with histrionic personality disorders tend
complaints.
to overreact to frustrations and
97. Answer: (B) Echopraxia
disappointments, have temper tantrums, and
Rationale: Echopraxia is the copying of
seek attention. another’s

95. Answer: (A) “I’m not going to look just at the behaviors and is the result of the loss of ego

negative things about myself” boundaries. Modeling is the conscious copying

Rationale: As the client makes progress on of someone’s behaviors. Ego-syntonicity refers

improving self-esteem, self- blame and negative to behaviors that correspond with the

self-evaluation will decrease. Clients with individual’s sense of self. Ritualism behaviors are

dependent personality disorder tend to feel repetitive and compulsive.

fragile and inadequate and would be extremely 98. Answer: (C) Hallucination

unlikely to discuss their level of competence and Rationale: Hallucinations are sensory

progress. These clients focus on self and aren’t experiences that are misrepresentations of

envious or jealous. Individuals with dependent reality or have no basis in reality. Delusions are

personality disorders don’t take over situations beliefs not based in reality. Disorganized speech

because they see themselves as inept and is characterized by jumping from one topic to

inadequate. the next or using unrelated words. An idea of

96. Answer: (C) Assess for possible physical reference is a belief that an unrelated situation

problems such as rash holds special meaning for the client.

Rationale: Clients with schizophrenia generally 99. Answer: (C) Regression

have poor visceral recognition because they live Rationale: Regression, a return to earlier
behavior to reduce anxiety, is the basic defense b. Reservoir

mechanism in schizophrenia. Projection is a c. Mode of transmission

defense mechanism in which one blames others d. Portal of entry

and attempts to justify actions; it’s used 2. Which of the following will probably result in
a
primarily by people with paranoid schizophrenia
break in sterile technique for respiratory
and delusional disorder. Rationalization is a
isolation?
defense mechanism used to justify one’s action.
a. Opening the patient’s window to the
Repression is the basic defense mechanism in
outside environment
the neuroses; it’s an involuntary exclusion of
b. Turning on the patient’s room ventilator
painful thoughts, feelings, or experiences from
c. Opening the door of the patient’s room
awareness.
leading into the hospital corridor
100. Answer: (A) Should report feelings of
d. Failing to wear gloves when
restlessness or agitation at once
administering a bed bath
Rationale: Agitation and restlessness are
adverse 3. Which of the following patients is at greater
risk
effect of haloperidol and can be treated with
for contracting an infection?
antocholinergic drugs. Haloperidol isn’t likely to
a. A patient with leukopenia
cause photosensitivity or control essential
b. A patient receiving broad-spectrum
hypertension. Although the client may
antibiotics
experience increased concentration and activity,
c. A postoperative patient who has
these effects are due to a decreased in
undergone orthopedic surgery
symptoms, not the drug itself.
d. A newly diagnosed diabetic patient
352
4. Effective hand washing requires the use of:
PART III
a. Soap or detergent to promote
PRACTICE TEST I FOUNDATION OF NURSING
emulsification
1. Which element in the circular chain of
infection b. Hot water to destroy bacteria

can be eliminated by preserving skin integrity? c. A disinfectant to increase surface

a. Host tension
d. All of the above (15 to 30 ml) before pouring the solution

5. After routine patient contact, hand washing into a sterile container

should last at least: 9. A natural body defense that plays an active

role
a. 30 seconds
in preventing infection is:
b. 1 minute
a. Yawning
c. 2 minute
b. Body hair
d. 3 minutes
c. Hiccupping
6. Which of the following procedures always
d. Rapid eye movements
requires surgical asepsis?
10. All of the following statement are true about
a. Vaginal instillation of conjugated
donning sterile gloves except:
estrogen
a. The first glove should be picked up by
b. Urinary catheterization
grasping the inside of the cuff.
c. Nasogastric tube insertion
b. The second glove should be picked up by
d. Colostomy irrigation
inserting the gloved fingers under the
7. Sterile technique is used whenever:
cuff outside the glove.
a. Strict isolation is required
c. The gloves should be adjusted by sliding
b. Terminal disinfection is performed
the gloved fingers under the sterile cuff
c. Invasive procedures are performed
and pulling the glove over the wrist
d. Protective isolation is necessary
d. The inside of the glove is considered
8. Which of the following constitutes a break in
sterile
sterile technique while preparing a sterile field
11. When removing a contaminated gown, the
for a dressing change?
nurse
a. Using sterile forceps, rather than sterile
should be careful that the first thing she touches
gloves, to handle a sterile item
is the:
b. Touching the outside wrapper of
a. Waist tie and neck tie at the back of the
sterilized material without sterile gloves
gown
c. Placing a sterile object on the edge of
b. Waist tie in front of the gown
the sterile field
c. Cuffs of the gown
d. Pouring out a small amount of solution
d. Inside of the gown 15. The primary purpose of a platelet count is to

12. Which of the following nursing interventions evaluate the:

is
a. Potential for clot formation
considered the most effective form or universal
b. Potential for bleeding
precautions?
c. Presence of an antigen-antibody
353
response
a. Cap all used needles before removing
d. Presence of cardiac enzymes
them from their syringes
16. Which of the following white blood cell
b. Discard all used uncapped needles and (WBC)

syringes in an impenetrable protective counts clearly indicates leukocytosis?

container a. 4,500/mm³

c. Wear gloves when administering IM b. 7,000/mm³

injections c. 10,000/mm³

d. Follow enteric precautions d. 25,000/mm³

13. All of the following measures are 17. After 5 days of diuretic therapy with 20mg of
recommended
furosemide (Lasix) daily, a patient begins to
to prevent pressure ulcers except:
exhibit fatigue, muscle cramping and muscle
a. Massaging the reddened are with lotion
weakness. These symptoms probably indicate
b. Using a water or air mattress
that the patient is experiencing:
c. Adhering to a schedule for positioning
a. Hypokalemia
and turning
b. Hyperkalemia
d. Providing meticulous skin care
c. Anorexia
14. Which of the following blood tests should be
d. Dysphagia
performed before a blood transfusion?
18. Which of the following statements about
a. Prothrombin and coagulation time chest

b. Blood typing and cross-matching X-ray is false?

c. Bleeding and clotting time a. No contradictions exist for this test

d. Complete blood count (CBC) and b. Before the procedure, the patient should

electrolyte levels. remove all jewelry, metallic objects, and

buttons above the waist d. Rub the site vigorously after the

c. A signed consent is not required injection to promote absorption

d. Eating, drinking, and medications are 22. The correct method for determining the
vastus
allowed before this test
lateralis site for I.M. injection is to:
19. The most appropriate time for the nurse to
a. Locate the upper aspect of the upper
obtain a sputum specimen for culture is:
outer quadrant of the buttock about 5 to
a. Early in the morning
8 cm below the iliac crest
b. After the patient eats a light breakfast
b. Palpate the lower edge of the acromion
c. After aerosol therapy
process and the midpoint lateral aspect
d. After chest physiotherapy
of the arm
20. A patient with no known allergies is to
receive c. Palpate a 1” circular area anterior to the

penicillin every 6 hours. When administering the umbilicus

medication, the nurse observes a fine rash on d. Divide the area between the greater

the patient’s skin. The most appropriate nursing femoral trochanter and the lateral

action would be to: femoral condyle into thirds, and select

a. Withhold the moderation and notify the the middle third on the anterior of the

physician thigh

b. Administer the medication and notify 354

the physician 23. The mid-deltoid injection site is seldom used

for
c. Administer the medication with an
I.M. injections because it:
antihistamine
a. Can accommodate only 1 ml or less of
d. Apply corn starch soaks to the rash
medication
21. All of the following nursing interventions are
b. Bruises too easily
correct when using the Z- track method of drug
c. Can be used only when the patient is
injection except:
lying down
a. Prepare the injection site with alcohol
d. Does not readily parenteral medication
b. Use a needle that’s a least 1” long
24. The appropriate needle size for insulin
c. Aspirate for blood before injection
injection
is: c. 25 gtt/minute

a. 18G, 1 ½” long d. 50 gtt/minute

b. 22G, 1” long 29. Which of the following is a sign or symptom

of a
c. 22G, 1 ½” long
hemolytic reaction to blood transfusion?
d. 25G, 5/8” long
a. Hemoglobinuria
25. The appropriate needle gauge for
intradermal b. Chest pain

injection is: c. Urticaria

a. 20G d. Distended neck veins

b. 22G 30. Which of the following conditions may

require
c. 25G
fluid restriction?
d. 26G
a. Fever
26. Parenteral penicillin can be administered as
an: b. Chronic Obstructive Pulmonary Disease

a. IM injection or an IV solution c. Renal Failure

b. IV or an intradermal injection d. Dehydration

c. Intradermal or subcutaneous injection 31. All of the following are common signs and

d. IM or a subcutaneous injection symptoms of phlebitis except:

27. The physician orders gr 10 of aspirin for a a. Pain or discomfort at the IV insertion site

patient. The equivalent dose in milligrams is: b. Edema and warmth at the IV insertion

a. 0.6 mg site

b. 10 mg c. A red streak exiting the IV insertion site

c. 60 mg d. Frank bleeding at the insertion site

d. 600 mg 32. The best way of determining whether a

patient
28. The physician orders an IV solution of
dextrose has learned to instill ear medication properly is

5% in water at 100ml/hour. What would the for the nurse to:

flow rate be if the drop factor is 15 gtt = 1 ml? a. Ask the patient if he/she has used ear

a. 5 gtt/minute drops before

b. 13 gtt/minute b. Have the patient repeat the nurse’s

instructions using her own words sanguineous drainage

c. Demonstrate the procedure to the c. Assess vital signs every 15 minutes for 2

patient and encourage to ask questions hours

d. Ask the patient to demonstrate the 355

procedure d. Order a hemoglobin and hematocrit

33. Which of the following types of medications count 1 hour after the arteriography
can
36. The nurse explains to a patient that a cough:
be administered via gastrostomy tube?
a. Is a protective response to clear the
a. Any oral medications
respiratory tract of irritants
b. Capsules whole contents are dissolve in
b. Is primarily a voluntary action
water
c. Is induced by the administration of an
c. Enteric-coated tablets that are
antitussive drug
thoroughly dissolved in water
d. Can be inhibited by “splinting” the
d. Most tablets designed for oral use,
abdomen
except for extended-duration
37. An infected patient has chills and begins
compounds
shivering. The best nursing intervention is to:
34. A patient who develops hives after receiving
a. Apply iced alcohol sponges
an
b. Provide increased cool liquids
antibiotic is exhibiting drug:
c. Provide additional bedclothes
a. Tolerance
d. Provide increased ventilation
b. Idiosyncrasy
38. A clinical nurse specialist is a nurse who has:
c. Synergism
a. Been certified by the National League for
d. Allergy
Nursing
35. A patient has returned to his room after
femoral b. Received credentials from the Philippine
arteriography. All of the following are Nurses’ Association
appropriate nursing interventions except: c. Graduated from an associate degree
a. Assess femoral, popliteal, and pedal program and is a registered professional
pulses every 15 minutes for 2 hours nurse
b. Check the pressure dressing for d. Completed a master’s degree in the
prescribed clinical area and is a intervention necessary for all patients with a

registered professional nurse. Foley Catheter in place?

39. The purpose of increasing urine acidity a. Maintain the drainage tubing and
through
collection bag level with the patient’s
dietary means is to:
bladder
a. Decrease burning sensations
b. Irrigate the patient with 1% Neosporin
b. Change the urine’s color
solution three times a daily
c. Change the urine’s concentration
c. Clamp the catheter for 1 hour every 4
d. Inhibit the growth of microorganisms
hours to maintain the bladder’s elasticity
40. Clay colored stools indicate:
d. Maintain the drainage tubing and
a. Upper GI bleeding
collection bag below bladder level to
b. Impending constipation
facilitate drainage by gravity
c. An effect of medication
44. The ELISA test is used to:
d. Bile obstruction
a. Screen blood donors for antibodies to
41. In which step of the nursing process would
human immunodeficiency virus (HIV)
the
b. Test blood to be used for transfusion for
nurse ask a patient if the medication she
HIV antibodies
administered relieved his pain?
c. Aid in diagnosing a patient with AIDS
a. Assessment
d. All of the above
b. Analysis
45. The two blood vessels most commonly used
c. Planning
for
d. Evaluation
TPN infusion are the:
42. All of the following are good sources of
a. Subclavian and jugular veins
vitamin A
b. Brachial and subclavian veins
except:
c. Femoral and subclavian veins
a. White potatoes
d. Brachial and femoral veins
b. Carrots
46. Effective skin disinfection before a surgical
c. Apricots
procedure includes which of the following
d. Egg yolks
methods?
43. Which of the following is a primary nursing
a. Shaving the site on the day before a. Respiratory acidosis, ateclectasis, and

surgery hypostatic pneumonia

b. Applying a topical antiseptic to the skin b. Appneustic breathing, atypical

on the evening before surgery pneumonia and respiratory alkalosis

c. Having the patient take a tub bath on c. Cheyne-Strokes respirations and

the morning of surgery spontaneous pneumothorax

d. Having the patient shower with an d. Kussmail’s respirations and

antiseptic soap on the evening v=before hypoventilation

and the morning of surgery 50. Immobility impairs bladder elimination,

resulting
47. When transferring a patient from a bed to a
in such disorders as
chair, the nurse should use which muscles to
a. Increased urine acidity and relaxation of
avoid back injury?
the perineal muscles, causing
a. Abdominal muscles
incontinence
356
b. Urine retention, bladder distention, and
b. Back muscles
infection
c. Leg muscles
c. Diuresis, natriuresis, and decreased
d. Upper arm muscles
urine specific gravity
48. Thrombophlebitis typically develops in
patients d. Decreased calcium and phosphate levels

with which of the following conditions? in the urine

a. Increases partial thromboplastin time 357

b. Acute pulsus paradoxus ANSWERS AND RATIONALE – FOUNDATION OF

c. An impaired or traumatized blood vessel NURSING

wall 1. D. In the circular chain of infection, pathogens

d. Chronic Obstructive Pulmonary Disease must be able to leave their reservoir and be

(COPD) transmitted to a susceptible host through a

49. In a recumbent, immobilized patient, lung portal of entry, such as broken skin.

ventilation can become altered, leading to such 2. C. Respiratory isolation, like strict isolation,

respiratory complications as: requires that the door to the door patient’s
room remain closed. However, the patient’s a bacteria-free state.

room should be well ventilated, so opening the 7. C. All invasive procedures, including surgery,

window or turning on the ventricular is catheter insertion, and administration of

desirable. The nurse does not need to wear parenteral therapy, require sterile technique to

gloves for respiratory isolation, but good hand maintain a sterile environment. All equipment

washing is important for all types of isolation. must be sterile, and the nurse and the physician

3. A. Leukopenia is a decreased number of must wear sterile gloves and maintain surgical

leukocytes (white blood cells), which are asepsis. In the operating room, the nurse and

important in resisting infection. None of the physician are required to wear sterile gowns,

other situations would put the patient at risk for gloves, masks, hair covers, and shoe covers for

contracting an infection; taking broad- spectrum all invasive procedures. Strict isolation requires

antibiotics might actually reduce the infection the use of clean gloves, masks, gowns and

risk. equipment to prevent the transmission of highly

4. A. Soaps and detergents are used to help communicable diseases by contact or by

remove bacteria because of their ability to airborne routes. Terminal disinfection is the
lower
disinfection of all contaminated supplies and
the surface tension of water and act as
equipment after a patient has been discharged
emulsifying agents. Hot water may lead to skin
to prepare them for reuse by another patient.
irritation or burns.
The purpose of protective (reverse) isolation is
5. A. Depending on the degree of exposure to
to prevent a person with seriously impaired
pathogens, hand washing may last from 10
resistance from coming into contact who
seconds to 4 minutes. After routine patient
potentially pathogenic organisms.
contact, hand washing for 30 seconds effectively
8. C. The edges of a sterile field are considered
minimizes the risk of pathogen transmission.
contaminated. When sterile items are allowed
6. B. The urinary system is normally free of to

microorganisms except at the urinary meatus. come in contact with the edges of the field, the

Any procedure that involves entering this sterile items also become contaminated.
system
9. B. Hair on or within body areas, such as the
must use surgically aseptic measures to
nose, traps and holds particles that contain
maintain
microorganisms. Yawning and hiccupping do not 13. A. Nurses and other health care
professionals
prevent microorganisms from entering or
previously believed that massaging a reddened
leaving the body. Rapid eye movement marks
area with lotion would promote venous return
the stage of sleep during which dreaming
occurs. and reduce edema to the area. However,

10. D. The inside of the glove is always research has shown that massage only increases
considered to
the likelihood of cellular ischemia and necrosis
be clean, but not sterile.
to the area.
11. A. The back of the gown is considered clean,
14. B. Before a blood transfusion is performed,
the
the
front is contaminated. So, after removing gloves
blood of the donor and recipient must be
and washing hands, the nurse should untie the
checked for compatibility. This is done by blood
back of the gown; slowly move backward away
typing (a test that determines a person’s blood
from the gown, holding the inside of the gown
type) and cross-matching (a procedure that
and keeping the edges off the floor; turn and
determines the compatibility of the donor’s and
fold the gown inside out; discard it in a
recipient’s blood after the blood types has been
contaminated linen container; then wash her
matched). If the blood specimens are
hands again.
incompatible, hemolysis and antigen-antibody
12. B. According to the Centers for Disease
reactions will occur.
Control
358
(CDC), blood-to-blood contact occurs most
15. A. Platelets are disk-shaped cells that are
commonly when a health care worker attempts
essential for blood coagulation. A platelet count
to cap a used needle. Therefore, used needles
determines the number of thrombocytes in
should never be recapped; instead they should
blood available for promoting hemostasis and
be inserted in a specially designed puncture
assisting with blood coagulation after injury. It
resistant, labeled container. Wearing gloves is
also is used to evaluate the patient’s potential
not always necessary when administering an
I.M. for bleeding; however, this is not its primary
injection. Enteric precautions prevent the purpose. The normal count ranges from 150,000
transfer of pathogens via feces. to 350,000/mm3. A count of 100,000/mm3 or
less indicates a potential for bleeding; count of medications are allowed because the X-ray is of

less than 20,000/mm3 is associated with the chest, not the abdominal region.

spontaneous bleeding. 19. A. Obtaining a sputum specimen early in this

16. D. Leukocytosis is any transient increase in morning ensures an adequate supply of bacteria
the
for culturing and decreases the risk of
number of white blood cells (leukocytes) in the
contamination from food or medication.
blood. Normal WBC counts range from 5,000 to
20. A. Initial sensitivity to penicillin is commonly
100,000/mm3. Thus, a count of 25,000/mm3
manifested by a skin rash, even in individuals
indicates leukocytosis.
who have not been allergic to it previously.
17. A. Fatigue, muscle cramping, and muscle
Because of the danger of anaphylactic shock, he
weaknesses are symptoms of hypokalemia (an
nurse should withhold the drug and notify the
inadequate potassium level), which is a
physician, who may choose to substitute
potential
another drug. Administering an antihistamine is
side effect of diuretic therapy. The physician
a dependent nursing intervention that requires
usually orders supplemental potassium to
a
prevent hypokalemia in patients receiving
written physician’s order. Although applying
diuretics. Anorexia is another symptom of
corn starch to the rash may relieve discomfort, it
hypokalemia. Dysphagia means difficulty
is not the nurse’s top priority in such a
swallowing.
potentially life-threatening situation.
18. A. Pregnancy or suspected pregnancy is the
21. D. The Z-track method is an I.M. injection
only
technique in which the patient’s skin is pulled in
contraindication for a chest X-ray. However, if a
such a way that the needle track is sealed off
chest X-ray is necessary, the patient can wear a
after the injection. This procedure seals
lead apron to protect the pelvic region from
medication deep into the muscle, thereby
radiation. Jewelry, metallic objects, and buttons
minimizing skin staining and irritation. Rubbing
would interfere with the X-ray and thus should
the injection site is contraindicated because it
not be worn above the waist. A signed consent
is may cause the medication to extravasate into
not required because a chest X-ray is not an the skin.
invasive examination. Eating, drinking and
22. D. The vastus lateralis, a long, thick muscle evaluate reactions for allergy or sensitivity
that
studies. A 20G needle is usually used for I.M.
extends the full length of the thigh, is viewed by
injections of oil- based medications; a 22G
many clinicians as the site of choice for I.M.
needle for I.M. injections; and a 25G needle, for
injections because it has relatively few major
I.M. injections; and a 25G needle, for
nerves and blood vessels. The middle third of
subcutaneous insulin injections.
the
26. A. Parenteral penicillin can be administered
muscle is recommended as the injection site.
I.M.
The patient can be in a supine or sitting position
or added to a solution and given I.V. It cannot be
for an injection into this site.
administered subcutaneously or intradermally.
23. A. The mid-deltoid injection site can
27. D. gr 10 x 60mg/gr 1 = 600 mg
accommodate only 1 ml or less of medication
28. C. 100ml/60 min X 15 gtt/ 1 ml = 25
because of its size and location (on the deltoid gtt/minute

muscle of the arm, close to the brachial artery 29. A. Hemoglobinuria, the abnormal presence
of
and radial nerve).
hemoglobin in the urine, indicates a hemolytic
24. D. A 25G, 5/8” needle is the recommended
size reaction (incompatibility of the donor’s and

for insulin injection because insulin is recipient’s blood). In this reaction, antibodies in

administered by the subcutaneous route. An the recipient’s plasma combine rapidly with

18G, 1 ½” needle is usually used for I.M. donor RBC’s; the cells are hemolyzed in either

injections in children, typically in the vastus circulatory or reticuloendothelial system.

lateralis. A 22G, 1 ½” needle is usually used for 359

adult I.M. injections, which are typically Hemolysis occurs more rapidly in ABO

administered in the vastus lateralis or incompatibilities than in Rh incompatibilities.

ventrogluteal site. Chest pain and urticarial may be symptoms of

25. D. Because an intradermal injection does impending anaphylaxis. Distended neck veins
not are

penetrate deeply into the skin, a small-bore 25G an indication of hypervolemia.

needle is recommended. This type of injection is 30. C. In real failure, the kidney loses their
ability to
used primarily to administer antigens to
effectively eliminate wastes and fluids. Because ordered medication is inappropriate for delivery

of this, limiting the patient’s intake of oral and by tube.

I.V. fluids may be necessary. Fever, chronic 34. D. A drug-allergy is an adverse reaction
resulting
obstructive pulmonary disease, and dehydration
from an immunologic response following a
are conditions for which fluids should be
previous sensitizing exposure to the drug. The
encouraged.
reaction can range from a rash or hives to
31. D. Phlebitis, the inflammation of a vein, can
be anaphylactic shock. Tolerance to a drug means

caused by chemical irritants (I.V. solutions or that the patient experiences a decreasing

medications), mechanical irritants (the needle physiologic response to repeated administration

or
of the drug in the same dosage. Idiosyncrasy is
catheter used during venipuncture or
an individual’s unique hypersensitivity to a drug,
cannulation), or a localized allergic reaction to
food, or other substance; it appears to be
the needle or catheter. Signs and symptoms of
genetically determined. Synergism, is a drug
phlebitis include pain or discomfort, edema and
interaction in which the sum of the drug’s
heat at the I.V. insertion site, and a red streak
combined effects is greater than that of their
going up the arm or leg from the I.V. insertion
separate effects.
site.
35. D. A hemoglobin and hematocrit count
32. D. Return demonstration provides the most would be

certain evidence for evaluating the effectiveness ordered by the physician if bleeding were

of patient teaching. suspected. The other answers are appropriate

33. D. Capsules, enteric-coated tablets, and nursing interventions for a patient who has
most
undergone femoral arteriography.
extended duration or sustained release
36. A. Coughing, a protective response that
products
clears
should not be dissolved for use in a gastrostomy
the respiratory tract of irritants, usually is
tube. They are pharmaceutically manufactured
involuntary; however it can be voluntary, as
in these forms for valid reasons, and altering
when a patient is taught to perform coughing
them destroys their purpose. The nurse should
exercises. An antitussive drug inhibits coughing.
seek an alternate physician’s order when an
Splinting the abdomen supports the abdominal
muscles when a patient coughs. degree program is not a clinical nurse specialist:

37. C. In an infected patient, shivering results however, she is prepared to provide bed side
from
nursing with a high degree of knowledge and
the body’s attempt to increase heat production
skill. She must successfully complete the
and the production of neutrophils and
licensing examination to become a registered
phagocytotic action through increased skeletal
professional nurse.
muscle tension and contractions. Initial
39. D. Microorganisms usually do not grow in an
vasoconstriction may cause skin to feel cold to
acidic environment.
the touch. Applying additional bed clothes helps
40. D. Bile colors the stool brown. Any
to equalize the body temperature and stop the inflammation

chills. Attempts to cool the body result in or obstruction that impairs bile flow will affect
further
the stool pigment, yielding light, clay-colored
shivering, increased metabloism, and thus
stool. Upper GI bleeding results in black or tarry
increased heat production.
stool. Constipation is characterized by small,
38. D. A clinical nurse specialist must have
hard masses. Many medications and foods will
completed a master’s degree in a clinical
discolor stool – for example, drugs containing
specialty and be a registered professional nurse.
iron turn stool black.; beets turn stool red.
The National League of Nursing accredits
41. D. In the evaluation step of the nursing
educational programs in nursing and provides a process,

testing service to evaluate student nursing the nurse must decide whether the patient has

competence but it does not certify nurses. The achieved the expected outcome that was

American Nurses Association identifies identified in the planning phase.

requirements for certification and offers 360

examinations for certification in many areas of 42. A. The main sources of vitamin A are yellow
and
nursing, such as medical surgical nursing. These
green vegetables (such as carrots, sweet
certification (credentialing) demonstrates that
potatoes, squash, spinach, collard greens,
the nurse has the knowledge and the ability to
broccoli, and cabbage) and yellow fruits (such as
provide high quality nursing care in the area of
apricots, and cantaloupe). Animal sources
her certification. A graduate of an associate
include liver, kidneys, cream, butter, and egg
yolks. antiseptic would not remove microorganisms

43. D. Maintaing the drainage tubing and and would be beneficial only after proper
collection
cleaning and rinsing. Tub bathing might transfer
bag level with the patient’s bladder could result
organisms to another body site rather than rinse
in reflux of urine into the kidney. Irrigating the
them away.
bladder with Neosporin and clamping the
47. C. The leg muscles are the strongest muscles
catheter for 1 hour every 4 hours must be in

prescribed by a physician. the body and should bear the greatest stress

44. D. The ELISA test of venous blood is used to when lifting. Muscles of the abdomen, back,
and
assess blood and potential blood donors to
upper arms may be easily injured.
human immunodeficiency virus (HIV). A positive
48. C. The factors, known as Virchow’s triad,
ELISA test combined with various signs and
collectively predispose a patient to
symptoms helps to diagnose acquired
thromboplebitis; impaired venous return to the
immunodeficiency syndrome (AIDS)
heart, blood hypercoagulability, and injury to a
45. D. Tachypnea (an abnormally rapid rate of
blood vessel wall. Increased partial
breathing) would indicate that the patient was
thromboplastin time indicates a prolonged
still hypoxic (deficient in oxygen).The partial
bleeding time during fibrin clot formation,
pressures of arterial oxygen and carbon dioxide
commonly the result of anticoagulant (heparin)
listed are within the normal range. Eupnea
refers therapy. Arterial blood disorders (such as pulsus

to normal respiration. paradoxus) and lung diseases (such as COPD) do

46. D. Studies have shown that showering with not necessarily impede venous return of injure
an
vessel walls.
antiseptic soap before surgery is the most
49. A. Because of restricted respiratory
effective method of removing microorganisms movement, a

from the skin. Shaving the site of the intended recumbent, immobilize patient is at particular

surgery might cause breaks in the skin, thereby risk for respiratory acidosis from poor gas

increasing the risk of infection; however, if exchange; atelectasis from reduced surfactant

indicated, shaving, should be done immediately and accumulated mucus in the bronchioles, and

before surgery, not the day before. A topical hypostatic pneumonia from bacterial growth
caused by stasis of mucus secretions. c. Condoms

50. B. The immobilized patient commonly d. Vasectomy

suffers
3. When preparing a woman who is 2 days
from urine retention caused by decreased
postpartum for discharge, recommendations for
muscle tone in the perineum. This leads to
which of the following contraceptive methods
bladder distention and urine stagnation, which
would be avoided?
provide an excellent medium for bacterial
a. Diaphragm
growth leading to infection. Immobility also
b. Female condom
results in more alkaline urine with excessive
c. Oral contraceptives
amounts of calcium, sodium and phosphate, a
d. Rhythm method
gradual decrease in urine production, and an
4. For which of the following clients would the
increased specific gravity.
nurse expect that an intrauterine device would
361
not be recommended?
PRACTICE TEST II Maternal and Child Health
a. Woman over age 35
1. For the client who is using oral
b. Nulliparous woman
contraceptives,
c. Promiscuous young adult
the nurse informs the client about the need to
d. Postpartum client
take the pill at the same time each day to
5. A client in her third trimester tells the nurse,
accomplish which of the following?
“I’m constipated all the time!” Which of the
a. Decrease the incidence of nausea
following should the nurse recommend?
b. Maintain hormonal levels
a. Daily enemas
c. Reduce side effects
b. Laxatives
d. Prevent drug interactions
c. Increased fiber intake
2. When teaching a client about contraception.
d. Decreased fluid intake
Which of the following would the nurse include
6. Which of the following would the nurse use
as the most effective method for preventing
as
sexually transmitted infections?
the basis for the teaching plan when caring for a
a. Spermicides
pregnant teenager concerned about gaining too
b. Diaphragm
much weight during pregnancy?
a. 10 pounds per trimester a. Stethoscope placed midline at the

b. 1 pound per week for 40 weeks umbilicus

c. ½ pound per week for 40 weeks b. Doppler placed midline at the

d. A total gain of 25 to 30 pounds suprapubic region

7. The client tells the nurse that her last c. Fetoscope placed midway between the
menstrual
umbilicus and the xiphoid process
period started on January 14 and ended on
d. External electronic fetal monitor placed
January 20. Using Nagele’s rule, the nurse
at the umbilicus
determines her EDD to be which of the
10. When developing a plan of care for a client
following?
newly diagnosed with gestational diabetes,
a. September 27
which of the following instructions would be the
b. October 21
priority?
c. November 7
a. Dietary intake
d. December 27
b. Medication
8. When taking an obstetrical history on a
c. Exercise
pregnant
d. Glucose monitoring
client who states, “I had a son born at 38 weeks
11. A client at 24 weeks gestation has gained 6
gestation, a daughter born at 30 weeks
gestation pounds in 4 weeks. Which of the following
would
and I lost a baby at about 8 weeks,” the nurse
be the priority when assessing the client?
should record her obstetrical history as which of
a. Glucosuria
the following?
b. Depression
a. G2 T2 P0 A0 L2
c. Hand/face edema
b. G3 T1 P1 A0 L2
d. Dietary intake
c. G3 T2 P0 A0 L2
12. A client 12 weeks’ pregnant come to the
d. G4 T1 P1 A1 L2
emergency department with abdominal
9. When preparing to listen to the fetal heart
rate 362
at 12 weeks’ gestation, the nurse would use cramping and moderate vaginal bleeding.
which of the following? Speculum examination reveals 2 to 3 cms
cervical dilation. The nurse would document brassiere

these findings as which of the following? d. Use soap and water to clean the nipples

a. Threatened abortion 16. The nurse assesses the vital signs of a client,
4
b. Imminent abortion
hours’ postpartum that are as follows: BP 90/60;
c. Complete abortion
temperature 100.4ºF; pulse 100 weak, thready;
d. Missed abortion
R 20 per minute. Which of the following should
13. Which of the following would be the priority
the nurse do first?
nursing diagnosis for a client with an ectopic
a. Report the temperature to the physician
pregnancy?
b. Recheck the blood pressure with
a. Risk for infection
another cuff
b. Pain
c. Assess the uterus for firmness and
c. Knowledge Deficit
position
d. Anticipatory Grieving
d. Determine the amount of lochia
14. Before assessing the postpartum client’s
uterus 17. The nurse assesses the postpartum vaginal

for firmness and position in relation to the discharge (lochia) on four clients. Which of the

umbilicus and midline, which of the following following assessments would warrant

should the nurse do first? notification of the physician?

a. Assess the vital signs a. A dark red discharge on a 2-day

b. Administer analgesia postpartum client

c. Ambulate her in the hall b. A pink to brownish discharge on a client

d. Assist her to urinate who is 5 days postpartum

15. Which of the following should the nurse do c. Almost colorless to creamy discharge on

when a primipara who is lactating tells the nurse a client 2 weeks after delivery

that she has sore nipples? d. A bright red discharge 5 days after

a. Tell her to breast feed more frequently delivery

b. Administer a narcotic before breast 18. A postpartum client has a temperature of

feeding 101.4ºF, with a uterus that is tender when

c. Encourage her to wear a nursing palpated, remains unusually large, and not
descending as normally expected. Which of the stockinette

following should the nurse assess next? 21. A newborn who has an asymmetrical Moro

a. Lochia reflex response should be further assessed for

b. Breasts which of the following?

c. Incision a. Talipes equinovarus

d. Urine b. Fractured clavicle

19. Which of the following is the priority focus c. Congenital hypothyroidism

of
d. Increased intracranial pressure
nursing practice with the current early
363
postpartum discharge?
22. During the first 4 hours after a male
a. Promoting comfort and restoration of
circumcision, assessing for which of the
health
following is the priority?
b. Exploring the emotional status of the
a. Infection
family
b. Hemorrhage
c. Facilitating safe and effective self-and
c. Discomfort
newborn care
d. Dehydration
d. Teaching about the importance of family
23. The mother asks the nurse. “What’s wrong
planning with

20. Which of the following actions would be my son’s breasts? Why are they so enlarged?”
least
Whish of the following would be the best
effective in maintaining a neutral thermal
response by the nurse?
environment for the newborn?
a. “The breast tissue is inflamed from the
a. Placing infant under radiant warmer
trauma experienced with birth”
after bathing
b. “A decrease in material hormones
b. Covering the scale with a warmed
present before birth causes
blanket prior to weighing
enlargement,”
c. Placing crib close to nursery window for
c. “You should discuss this with your
family viewing
doctor. It could be a malignancy”
d. Covering the infant’s head with a knit
d. “The tissue has hypertrophied while the
baby was in the uterus” formula should this newborn receive at each

24. Immediately after birth the nurse notes the feeding to meet nutritional needs?

following on a male newborn: respirations 78; a. 2 ounces

apical hearth rate 160 BPM, nostril flaring; mild b. 3 ounces

intercostal retractions; and grunting at the end c. 4 ounces

of expiration. Which of the following should the d. 6 ounces

nurse do? 27. The postterm neonate with meconium-

stained
a. Call the assessment data to the
amniotic fluid needs care designed to especially
physician’s attention
monitor for which of the following?
b. Start oxygen per nasal cannula at 2
a. Respiratory problems
L/min.
b. Gastrointestinal problems
c. Suction the infant’s mouth and nares
c. Integumentary problems
d. Recognize this as normal first period of
d. Elimination problems
reactivity
28. When measuring a client’s fundal height,
25. The nurse hears a mother telling a friend on
which
the
of the following techniques denotes the correct
telephone about umbilical cord care. Which of
method of measurement used by the nurse?
the following statements by the mother
a. From the xiphoid process to the
indicates effective teaching?
umbilicus
a. “Daily soap and water cleansing is best”
b. From the symphysis pubis to the xiphoid
b. ‘Alcohol helps it dry and kills germs”
process
c. “An antibiotic ointment applied daily
c. From the symphysis pubis to the fundus
prevents infection”
d. From the fundus to the umbilicus
d. “He can have a tub bath each day”
29. A client with severe preeclampsia is
26. A newborn weighing 3000 grams and
admitted
feeding
with of BP 160/110, proteinuria, and severe
every 4 hours needs 120 calories/kg of body
pitting edema. Which of the following would be
weight every 24 hours for proper growth and
most important to include in the client’s plan of
development. How many ounces of 20 cal/oz
care?
a. Daily weights following?

b. Seizure precautions a. Clitoris

c. Right lateral positioning b. Parotid gland

d. Stress reduction c. Skene’s gland

30. A postpartum primipara asks the nurse, d. Bartholin’s gland

“When
33. To differentiate as a female, the hormonal
can we have sexual intercourse again?” Which
stimulation of the embryo that must occur
of
involves which of the following?
the following would be the nurse’s best
a. Increase in maternal estrogen secretion
response?
b. Decrease in maternal androgen
a. “Anytime you both want to.”
secretion
b. “As soon as choose a contraceptive
c. Secretion of androgen by the fetal gonad
method.”
d. Secretion of estrogen by the fetal gonad
c. “When the discharge has stopped and
34. A client at 8 weeks’ gestation calls
the incision is healed.”
complaining
d. “After your 6 weeks examination.”
of slight nausea in the morning hours. Which of
31. When preparing to administer the vitamin K
the following client interventions should the
injection to a neonate, the nurse would select
nurse question?
which of the following sites as appropriate for
a. Taking 1 teaspoon of bicarbonate of
the injection?
soda in an 8-ounce glass of water
a. Deltoid muscle
b. Eating a few low-sodium crackers before
b. Anterior femoris muscle
getting out of bed
c. Vastus lateralis muscle
c. Avoiding the intake of liquids in the
d. Gluteus maximus muscle
morning hours
364
d. Eating six small meals a day instead of
32. When performing a pelvic examination, the
thee large meals
nurse observes a red swollen area on the right
35. The nurse documents positive ballottement
side of the vaginal orifice. The nurse would in

document this as enlargement of which of the the client’s prenatal record. The nurse
understands that this indicates which of the anesthesia are needed

following? 38. After 4 hours of active labor, the nurse notes

a. Palpable contractions on the abdomen that the contractions of a primigravida client are

b. Passive movement of the unengaged not strong enough to dilate the cervix. Which of

fetus the following would the nurse anticipate doing?

c. Fetal kicking felt by the client a. Obtaining an order to begin IV oxytocin

d. Enlargement and softening of the uterus infusion

36. During a pelvic exam the nurse notes a b. Administering a light sedative to allow
purpleblue
the patient to rest for several hour
tinge of the cervix. The nurse documents
c. Preparing for a cesarean section for
this as which of the following?
failure to progress
a. Braxton-Hicks sign
d. Increasing the encouragement to the
b. Chadwick’s sign
patient when pushing begins
c. Goodell’s sign
39. A multigravida at 38 weeks’ gestation is
d. McDonald’s sign
admitted with painless, bright red bleeding and
37. During a prenatal class, the nurse explains
mild contractions every 7 to 10 minutes. Which
the
of the following assessments should be
rationale for breathing techniques during
avoided?
preparation for labor based on the
a. Maternal vital sign
understanding that breathing techniques are
b. Fetal heart rate
most important in achieving which of the
c. Contraction monitoring
following?
d. Cervical dilation
a. Eliminate pain and give the expectant
40. Which of the following would be the nurse’s
parents something to do
most appropriate response to a client who asks
b. Reduce the risk of fetal distress by
why she must have a cesarean delivery if she
increasing uteroplacental perfusion has

c. Facilitate relaxation, possibly reducing a complete placenta previa?

the perception of pain a. “You will have to ask your physician

d. Eliminate pain so that less analgesia and when he returns.”

b. “You need a cesarean to prevent The nurse interprets this to be the result of

hemorrhage.” which of the following?

c. “The placenta is covering most of your a. Lanugo

cervix.” b. Hydramnio

d. “The placenta is covering the opening of c. Meconium

the uterus and blocking your baby.” d. Vernix

41. The nurse understands that the fetal head is 44. A patient is in labor and has just been told
in she

which of the following positions with a face has a breech presentation. The nurse should be

presentation? particularly alert for which of the following?

a. Completely flexed a. Quickening

b. Completely extended b. Ophthalmia neonatorum

c. Partially extended c. Pica

365 d. Prolapsed umbilical cord

d. Partially flexed 45. When describing dizygotic twins to a couple,

on
42. With a fetus in the left-anterior breech
which of the following would the nurse base the
presentation, the nurse would expect the fetal
explanation?
heart rate would be most audible in which of
the a. Two ova fertilized by separate sperm

following areas? b. Sharing of a common placenta

a. Above the maternal umbilicus and to the c. Each ova with the same genotype

right of midline d. Sharing of a common chorion

b. In the lower-left maternal abdominal 46. Which of the following refers to the single
cell
quadrant
that reproduces itself after conception?
c. In the lower-right maternal abdominal
a. Chromosome
quadrant
b. Blastocyst
d. Above the maternal umbilicus and to the
c. Zygote
left of midline
d. Trophoblast
43. The amniotic fluid of a client has a greenish
tint. 47. In the late 1950s, consumers and health care
professionals began challenging the routine use following would the nurse include as being

of analgesics and anesthetics during childbirth. produced by the Leydig cells?

Which of the following was an outgrowth of this a. Follicle-stimulating hormone

concept? b. Testosterone

a. Labor, delivery, recovery, postpartum c. Leuteinizing hormone

(LDRP) d. Gonadotropin releasing hormone

b. Nurse-midwifery 366

c. Clinical nurse specialist ANSWERS AND RATIONALE – MATERNAL AND

d. Prepared childbirth CHILD HEALTH

48. A client has a midpelvic contracture from a 1. B. Regular timely ingestion of oral
contraceptives
previous pelvic injury due to a motor vehicle
is necessary to maintain hormonal levels of the
accident as a teenager. The nurse is aware that
drugs to suppress the action of the
this could prevent a fetus from passing through
hypothalamus and anterior pituitary leading to
or around which structure during childbirth?
inappropriate secretion of FSH and LH.
a. Symphysis pubis
Therefore, follicles do not mature, ovulation is
b. Sacral promontory
inhibited, and pregnancy is prevented. The
c. Ischial spines
estrogen content of the oral site contraceptive
d. Pubic arch
may cause the nausea, regardless of when the
49. When teaching a group of adolescents about
pill is taken. Side effects and drug interactions
variations in the length of the menstrual cycle,
may occur with oral contraceptives regardless of
the nurse understands that the underlying
the time the pill is taken.
mechanism is due to variations in which of the
2. C. Condoms, when used correctly and
following phases?
consistently, are the most effective
a. Menstrual phase
contraceptive method or barrier against
b. Proliferative phase
bacterial and viral sexually transmitted
c. Secretory phase
infections. Although spermicides kill sperm,
d. Ischemic phase
they
50. When teaching a group of adolescents about
do not provide reliable protection against the
male hormone production, which of the
spread of sexually transmitted infections, ovulation. For the couple who has determined

especially intracellular organisms such as HIV. the female’s fertile period, using the rhythm

Insertion and removal of the diaphragm along method, avoidance of intercourse during this

with the use of the spermicides may cause period, is safe and effective.

vaginal irritations, which could place the client 4. C. An IUD may increase the risk of pelvic
at
inflammatory disease, especially in women with
risk for infection transmission. Male sterilization
more than one sexual partner, because of the
eliminates spermatozoa from the ejaculate, but
increased risk of sexually transmitted infections.
it does not eliminate bacterial and/or viral
An UID should not be used if the woman has an
microorganisms that can cause sexually
active or chronic pelvic infection, postpartum
transmitted infections.
infection, endometrial hyperplasia or
3. A. The diaphragm must be fitted individually carcinoma,
to
or uterine abnormalities. Age is not a factor in
ensure effectiveness. Because of the changes to
determining the risks associated with IUD use.
the reproductive structures during pregnancy
Most IUD users are over the age of 30. Although
and following delivery, the diaphragm must be
there is a slightly higher risk for infertility in
refitted, usually at the 6 weeks’ examination
women who have never been pregnant, the IUD
following childbirth or after a weight loss of 15
is an acceptable option as long as the riskbenefit
lbs or more. In addition, for maximum
ratio is discussed. IUDs may be inserted
effectiveness, spermicidal jelly should be placed
immediately after delivery, but this is not
in the dome and around the rim. However,
recommended because of the increased risk
spermicidal jelly should not be inserted into the and

vagina until involution is completed at rate of expulsion at this time.

approximately 6 weeks. Use of a female condom 5. C. During the third trimester, the enlarging

protects the reproductive system from the uterus places pressure on the intestines. This

introduction of semen or spermicides into the coupled with the effect of hormones on smooth

vagina and may be used after childbirth. Oral muscle relaxation causes decreased intestinal

contraceptives may be started within the first motility (peristalsis). Increasing fiber in the diet

postpartum week to ensure suppression of will help fecal matter pass more quickly through
the intestinal tract, thus decreasing the amount days to the first day of the last menstrual period

of water that is absorbed. As a result, stool is and count back 3 months, changing the year

softer and easier to pass. Enemas could appropriately. To obtain a date of September 27,

precipitate preterm labor and/or electrolyte loss 367

and should be avoided. Laxatives may cause 7 days have been added to the last day of the

preterm labor by stimulating peristalsis and may LMP (rather than the first day of the LMP), plus
4
interfere with the absorption of nutrients. Use
months (instead of 3 months) were counted
for more than 1 week can also lead to laxative
back. To obtain the date of November 7, 7 days
dependency. Liquid in the diet helps provide a
have been subtracted (instead of added) from
semisolid, soft consistency to the stool. Eight to
the first day of LMP plus November indicates
ten glasses of fluid per day are essential to
counting back 2 months (instead of 3 months)
maintain hydration and promote stool
from January. To obtain the date of December
evacuation.
27, 7 days were added to the last day of the
6. D. To ensure adequate fetal growth and
LMP
development during the 40 weeks of a
(rather than the first day of the LMP) and
pregnancy, a total weight gain 25 to 30 pounds
December indicates counting back only 1 month
is
(instead of 3 months) from January.
recommended: 1.5 pounds in the first 10 weeks;
8. D. The client has been pregnant four times,
9 pounds by 30 weeks; and 27.5 pounds by 40
including current pregnancy (G). Birth at 38
weeks. The pregnant woman should gain less
weeks’ gestation is considered full term (T),
weight in the first and second trimester than in
while birth form 20 weeks to 38 weeks is
the third. During the first trimester, the client
considered preterm (P). A spontaneous abortion
should only gain 1.5 pounds in the first 10
occurred at 8 weeks (A). She has two living
weeks, not 1 pound per week. A weight gain of
½ children (L).

pound per week would be 20 pounds for the 9. B. At 12 weeks gestation, the uterus rises out
of
total pregnancy, less than the recommended
the pelvis and is palpable above the symphysis
amount.
pubis. The Doppler intensifies the sound of the
7. B. To calculate the EDD by Nagele’s rule, add 7
fetal pulse rate so it is audible. The uterus has
merely risen out of the pelvis into the blood sugar level every 2 weeks.
abdominal
11. C. After 20 weeks’ gestation, when there is a
cavity and is not at the level of the umbilicus.
rapid weight gain, preeclampsia should be
The fetal heart rate at this age is not audible
suspected, which may be caused by fluid
with a stethoscope. The uterus at 12 weeks is
retention manifested by edema, especially of
just above the symphysis pubis in the abdominal the

cavity, not midway between the umbilicus and hands and face. The three classic signs of

the xiphoid process. At 12 weeks the FHR would preeclampsia are hypertension, edema, and

be difficult to auscultate with a fetoscope. proteinuria. Although urine is checked for

Although the external electronic fetal monitor glucose at each clinic visit, this is not the
priority.
would project the FHR, the uterus has not risen
Depression may cause either anorexia or
to the umbilicus at 12 weeks.
excessive food intake, leading to excessive
10. A. Although all of the choices are important
in weight gain or loss. This is not, however, the

the management of diabetes, diet therapy is the priority consideration at this time. Weight gain

mainstay of the treatment plan and should thought to be caused by excessive food intake

always be the priority. Women diagnosed with would require a 24-hour diet recall. However,

gestational diabetes generally need only diet excessive intake would not be the primary

therapy without medication to control their consideration for this client at this time.

blood sugar levels. Exercise, is important for all 12. B. Cramping and vaginal bleeding coupled
with
pregnant women and especially for diabetic
cervical dilation signifies that termination of the
women, because it burns up glucose, thus
pregnancy is inevitable and cannot be
decreasing blood sugar. However, dietary intake,
prevented. Thus, the nurse would document an
not exercise, is the priority. All pregnant women
imminent abortion. In a threatened abortion,
with diabetes should have periodic monitoring
cramping and vaginal bleeding are present, but
of serum glucose. However, those with
there is no cervical dilation. The symptoms may
gestational diabetes generally do not need daily
subside or progress to abortion. In a complete
glucose monitoring. The standard of care
abortion all the products of conception are
recommends a fasting and 2- hour postprandial
expelled. A missed abortion is early fetal
intrauterine death without expulsion of the engorgement, soften the breast, and promote

products of conception. 368

13. B. For the client with an ectopic pregnancy, ease of correct latching-on for feeding.
Narcotics
lower abdominal pain, usually unilateral, is the
administered prior to breast feeding are passed
primary symptom. Thus, pain is the priority.
through the breast milk to the infant, causing
Although the potential for infection is always
excessive sleepiness. Nipple soreness is not
present, the risk is low in ectopic pregnancy
severe enough to warrant narcotic analgesia. All
because pathogenic microorganisms have not
postpartum clients, especially lactating mothers,
been introduced from external sources. The
should wear a supportive brassiere with wide
client may have a limited knowledge of the
cotton straps. This does not, however, prevent
pathology and treatment of the condition and
or reduce nipple soreness. Soaps are drying to
will most likely experience grieving, but this is
the skin of the nipples and should not be used
not the priority at this time.
on the breasts of lactating mothers. Dry nipple
14. D. Before uterine assessment is performed,
it is skin predisposes to cracks and fissures, which

essential that the woman empty her bladder. A can become sore and painful.

full bladder will interfere with the accuracy of 16. D. A weak, thready pulse elevated to 100
BPM
the assessment by elevating the uterus and
may indicate impending hemorrhagic shock. An
displacing to the side of the midline. Vital sign
increased pulse is a compensatory mechanism
assessment is not necessary unless an
of
abnormality in uterine assessment is identified.
the body in response to decreased fluid volume.
Uterine assessment should not cause acute pain
Thus, the nurse should check the amount of
that requires administration of analgesia.
lochia present. Temperatures up to 100.48F in
Ambulating the client is an essential component
the first 24 hours after birth are related to the
of postpartum care, but is not necessary prior to
dehydrating effects of labor and are considered
assessment of the uterus.
normal. Although rechecking the blood pressure
15. A. Feeding more frequently, about every 2
may be a correct choice of action, it is not the
hours, will decrease the infant’s frantic, vigorous
first action that should be implemented in light
sucking from hunger and will decrease breast
of the other data. The data indicate a potential
impending hemorrhage. Assessing the uterus decidua, epithelial cells, fat, cervical mucus,
for
cholesterol crystals, and bacteria.
firmness and position in relation to the
18. A. The data suggests an infection of the
umbilicus
endometrial lining of the uterus. The lochia may
and midline is important, but the nurse should
be decreased or copious, dark brown in
check the extent of vaginal bleeding first. Then
it appearance, and foul smelling, providing further
would be appropriate to check the uterus, evidence of a possible infection. All the client’s
which
data indicate a uterine problem, not a breast
may be a possible cause of the hemorrhage.
problem. Typically, transient fever, usually
17. D. Any bright red vaginal discharge would be
101ºF, may be present with breast
considered abnormal, but especially 5 days after
engorgement. Symptoms of mastitis include
delivery, when the lochia is typically pink to
influenza-like manifestations. Localized infection
brownish. Lochia rubra, a dark red discharge, is
of an episiotomy or C-section incision rarely
present for 2 to 3 days after delivery. Bright red
causes systemic symptoms, and uterine
vaginal bleeding at this time suggests late
involution would not be affected. The client
postpartum hemorrhage, which occurs after the data
first 24 hours following delivery and is generally do not include dysuria, frequency, or urgency,
caused by retained placental fragments or symptoms of urinary tract infections, which
bleeding disorders. Lochia rubra is the normal would necessitate assessing the client’s urine.
dark red discharge occurring in the first 2 to 3 19. C. Because of early postpartum discharge
and
days after delivery, containing epithelial cells,
limited time for teaching, the nurse’s priority is
erythrocyes, leukocytes and decidua. Lochia
to facilitate the safe and effective care of the
serosa is a pink to brownish serosanguineous
client and newborn. Although promoting
discharge occurring from 3 to 10 days after
comfort and restoration of health, exploring the
delivery that contains decidua, erythrocytes,
family’s emotional status, and teaching about
leukocytes, cervical mucus, and microorganisms.
family planning are important in
Lochia alba is an almost colorless to yellowish
postpartum/newborn nursing care, they are not
discharge occurring from 10 days to 3 weeks
the priority focus in the limited time presented
after delivery and containing leukocytes,
by early post-partum discharge. surgical procedure. Although the infant has
been
20. C. Heat loss by radiation occurs when the
given vitamin K to facilitate clotting, the
infant’s crib is placed too near cold walls or
369
windows. Thus placing the newborn’s crib close
prophylactic dose is often not sufficient to
to the viewing window would be least effective.
prevent bleeding. Although infection is a
Body heat is lost through evaporation during
possibility, signs will not appear within 4 hours
bathing. Placing the infant under the radiant
after the surgical procedure. The primary
warmer after bathing will assist the infant to be
discomfort of circumcision occurs during the
rewarmed. Covering the scale with a warmed
surgical procedure, not afterward. Although
blanket prior to weighing prevents heat loss
feedings are withheld prior to the circumcision,
through conduction. A knit cap prevents heat
the chances of dehydration are minimal.
loss from the head a large head, a large body
23. B. The presence of excessive estrogen and
surface area of the newborn’s body.
progesterone in the maternal- fetal blood
21. B. A fractured clavicle would prevent the
normal followed by prompt withdrawal at birth

Moro response of symmetrical sequential precipitates breast engorgement, which will

extension and abduction of the arms followed spontaneously resolve in 4 to 5 days after birth.
by
The trauma of the birth process does not cause
flexion and adduction. In talipes equinovarus
inflammation of the newborn’s breast tissue.
(clubfoot) the foot is turned medially, and in
Newborns do not have breast malignancy. This
plantar flexion, with the heel elevated. The feet
reply by the nurse would cause the mother to
are not involved with the Moro reflex.
have undue anxiety. Breast tissue does not
Hypothyroiddism has no effect on the primitive
hypertrophy in the fetus or newborns.
reflexes. Absence of the Moror reflex is the
24. D. The first 15 minutes to 1 hour after birth
most
is
significant single indicator of central nervous
the first period of reactivity involving respiratory
system status, but it is not a sign of increased
and circulatory adaptation to extrauterine life.
intracranial pressure.
The data given reflect the normal changes
22. B. Hemorrhage is a potential risk following during
any
this time period. The infant’s assessment data
reflect normal adaptation. Thus, the physician into the amniotic fluid. At birth some of the

does not need to be notified and oxygen is not meconium fluid may be aspirated, causing

needed. The data do not indicate the presence mechanical obstruction or chemical

of choking, gagging or coughing, which are signs pneumonitis. The infant is not at increased risk

of excessive secretions. Suctioning is not for gastrointestinal problems. Even though the

necessary. skin is stained with meconium, it is

noninfectious
25. B. Application of 70% isopropyl alcohol to
the (sterile) and nonirritating. The postterm

cord minimizes microorganisms (germicidal) and meconium- stained infant is not at additional
risk
promotes drying. The cord should be kept dry
for bowel or urinary problems.
until it falls off and the stump has healed.
28. C. The nurse should use a nonelastic,
Antibiotic ointment should only be used to treat
flexible,
an infection, not as a prophylaxis. Infants should
paper measuring tape, placing the zero point on
not be submerged in a tub of water until the
the superior border of the symphysis pubis and
cord falls off and the stump has completely
stretching the tape across the abdomen at the
healed.
midline to the top of the fundus. The xiphoid
26. B. To determine the amount of formula and
needed,
umbilicus are not appropriate landmarks to use
do the following mathematical calculation. 3 kg
when measuring the height of the fundus
x
(McDonald’s measurement).
120 cal/kg per day = 360 calories/day feeding q
4 29. B. Women hospitalized with severe

hours = 6 feedings per day = 60 calories per preeclampsia need decreased CNS stimulation
to
feeding: 60 calories per feeding; 60 calories per
prevent a seizure. Seizure precautions provide
feeding with formula 20 cal/oz = 3 ounces per
environmental safety should a seizure occur.
feeding. Based on the calculation. 2, 4 or 6
Because of edema, daily weight is important but
ounces are incorrect.
not the priority. Preclampsia causes vasospasm
27. A. Intrauterine anoxia may cause relaxation
of and therefore can reduce utero-placental

the anal sphincter and emptying of meconium perfusion. The client should be placed on her
left
side to maximize blood flow, reduce blood the proximity of the sciatic nerve, the gluteus

pressure, and promote diuresis. Interventions to maximus muscle should not be until the child

reduce stress and anxiety are very important to has been walking 2 years.

facilitate coping and a sense of control, but 32. D. Bartholin’s glands are the glands on either

seizure precautions are the priority. side of the vaginal orifice. The clitoris is female

30. C. Cessation of the lochial discharge signifies 370

healing of the endometrium. Risk of erectile tissue found in the perineal area above
hemorrhage
the urethra. The parotid glands are open into
and infection are minimal 3 weeks after a the

normal vaginal delivery. Telling the client mouth. Skene’s glands open into the posterior

anytime is inappropriate because this response wall of the female urinary meatus.

does not provide the client with the specific 33. D. The fetal gonad must secrete estrogen for
the
information she is requesting. Choice of a
embryo to differentiate as a female. An increase
contraceptive method is important, but not the
in maternal estrogen secretion does not affect
specific criteria for safe resumption of sexual
differentiation of the embryo, and maternal
activity. Culturally, the 6- weeks’ examination
estrogen secretion occurs in every pregnancy.
has been used as the time frame for resuming
Maternal androgen secretion remains the same
sexual activity, but it may be resumed earlier.
as before pregnancy and does not affect
31. C. The middle third of the vastus lateralis is
the differentiation. Secretion of androgen by the

preferred injection site for vitamin K fetal gonad would produce a male fetus.

administration because it is free of blood vessels 34. A. Using bicarbonate would increase the
amount
and nerves and is large enough to absorb the
of sodium ingested, which can cause
medication. The deltoid muscle of a newborn is
complications. Eating low-sodium crackers
not large enough for a newborn IM injection.
would be appropriate. Since liquids can increase
Injections into this muscle in a small child might
nausea avoiding them in the morning hours
cause damage to the radial nerve. The anterior
when nausea is usually the strongest is
femoris muscle is the next safest muscle to use
appropriate. Eating six small meals a day would
in a newborn but is not the safest. Because of
keep the stomach full, which often decrease
nausea. increase the uterine contractions and hopefully

35. B. Ballottement indicates passive movement progress labor before a cesarean would be
of
necessary. It is too early to anticipate client
the unengaged fetus. Ballottement is not a
pushing with contractions.
contraction. Fetal kicking felt by the client
39. D. The signs indicate placenta previa and
represents quickening. Enlargement and vaginal

softening of the uterus is known as Piskacek’s exam to determine cervical dilation would not

sign. be done because it could cause hemorrhage.

36. B. Chadwick’s sign refers to the purple-blue Assessing maternal vital signs can help
tinge
determine maternal physiologic status. Fetal
of the cervix. Braxton Hicks contractions are
heart rate is important to assess fetal well-being
painless contractions beginning around the 4th
and should be done. Monitoring the
month. Goodell’s sign indicates softening of the contractions

cervix. Flexibility of the uterus against the cervix will help evaluate the progress of labor.

is known as McDonald’s sign. 40. D. A complete placenta previa occurs when

the
37. C. Breathing techniques can raise the pain
placenta covers the opening of the uterus, thus
threshold and reduce the perception of pain.
blocking the passageway for the baby. This
They also promote relaxation. Breathing
response explains what a complete previa is and
techniques do not eliminate pain, but they can
the reason the baby cannot come out except by
reduce it. Positioning, not breathing, increases
cesarean delivery. Telling the client to ask the
uteroplacental perfusion.
physician is a poor response and would increase
38. A. The client’s labor is hypotonic. The nurse
the patient’s anxiety. Although a cesarean
should call the physical and obtain an order for
would
an infusion of oxytocin, which will assist the
help to prevent hemorrhage, the statement
uterus to contact more forcefully in an attempt does

to dilate the cervix. Administering light sedative not explain why the hemorrhage could occur.

would be done for hypertonic uterine With a complete previa, the placenta is covering

contractions. Preparing for cesarean section is the entire cervix, not just most of it.

unnecessary at this time. Oxytocin would 41. B. With a face presentation, the head is
completely extended. With a vertex 46. C. The zygote is the single cell that
reproduces
presentation, the head is completely or partially
itself after conception. The chromosome is the
flexed. With a brow (forehead) presentation, the
material that makes up the cell and is gained
head would be partially extended.
from each parent. Blastocyst and trophoblast
42. D. With this presentation, the fetal upper
are
torso
later terms for the embryo after zygote.
and back face the left upper maternal
abdominal 371

wall. The fetal heart rate would be most audible 47. D. Prepared childbirth was the direct result
of
above the maternal umbilicus and to the left of
the 1950’s challenging of the routine use of
the middle. The other positions would be
analgesic and anesthetics during childbirth. The
incorrect.
LDRP was a much later concept and was not a
43. C. The greenish tint is due to the presence of
direct result of the challenging of routine use of
meconium. Lanugo is the soft, downy hair on
the analgesics and anesthetics during childbirth.

shoulders and back of the fetus. Hydramnios Roles for nurse midwives and clinical nurse

represents excessive amniotic fluid. Vernix is the specialists did not develop from this challenge.

white, cheesy substance covering the fetus. 48. C. The ischial spines are located in the mid-
pelvic
44. D. In a breech position, because of the space
region and could be narrowed due to the
between the presenting part and the cervix,
previous pelvic injury. The symphysis pubis,
prolapse of the umbilical cord is common.
sacral promontory, and pubic arch are not part
Quickening is the woman’s first perception of
of the mid-pelvis.
fetal movement. Ophthalmia neonatorum
49. B. Variations in the length of the menstrual
usually results from maternal gonorrhea and is
cycle
conjunctivitis. Pica refers to the oral intake of
are due to variations in the proliferative phase.
nonfood substances.
The menstrual, secretory and ischemic phases
45. A. Dizygotic (fraternal) twins involve two ova
do not contribute to this variation.
fertilized by separate sperm. Monozygotic
50. B. Testosterone is produced by the Leyding
(identical) twins involve a common placenta, cells

same genotype, and common chorion. in the seminiferous tubules. Follicle-stimulating

hormone and leuteinzing hormone are released opportunistic infection

by the anterior pituitary gland. The d. Evidence of extreme weight loss and

hypothalamus is responsible for releasing high fever

gonadotropin-releasing hormone. 4. Nurse Maureen is aware that a client who has

372 been diagnosed with chronic renal failure

MEDICAL SURGICAL NURSING recognizes an adequate amount of high-

biologicvalue
1. Marco who was diagnosed with brain tumor
was protein when the food the client selected

scheduled for craniotomy. In preventing the from the menu was:

development of cerebral edema after surgery, a. Raw carrots

the nurse should expect the use of: b. Apple juice

a. Diuretics c. Whole wheat bread

b. Antihypertensive d. Cottage cheese

c. Steroids 5. Kenneth who has diagnosed with uremic

d. Anticonvulsants syndrome has the potential to develop

2. Halfway through the administration of blood, complications. Which among the following

the female client complains of lumbar pain. complications should the nurse anticipates:
After
a. Flapping hand tremors
stopping the infusion Nurse Hazel should:
b. An elevated hematocrit level
a. Increase the flow of normal saline
c. Hypotension
b. Assess the pain further
d. Hypokalemia
c. Notify the blood bank
6. A client is admitted to the hospital with
d. Obtain vital signs. benign

3. Nurse Maureen knows that the positive prostatic hyperplasia, the nurse most relevant

diagnosis for HIV infection is made based on assessment would be:

which of the following: a. Flank pain radiating in the groin

a. A history of high risk sexual behaviors. b. Distention of the lower abdomen

b. Positive ELISA and western blot tests c. Perineal edema

c. Identification of an associated d. Urethral discharge

7. A client has undergone with penile implant. c. Deficient fluid volume

After 24 hrs of surgery, the client’s scrotum was d. Pain

edematous and painful. The nurse should: 11. Nurse Hazel teaches the client with angina
about
a. Assist the client with sitz bath
common expected side effects of nitroglycerin
b. Apply war soaks in the scrotum
including:
c. Elevate the scrotum using a soft support
a. high blood pressure
d. Prepare for a possible incision and
b. stomach cramps
drainage.
c. headache
8. Nurse hazel receives emergency laboratory
d. shortness of breath
results for a client with chest pain and
12. The following are lipid abnormalities. Which
immediately informs the physician. An increased
of
myoglobin level suggests which of the
the following is a risk factor for the
following?
development
a. Liver disease
of atherosclerosis and PVD?
b. Myocardial damage
a. High levels of low density lipid (LDL)
c. Hypertension
cholesterol
d. Cancer
b. High levels of high density lipid (HDL)
9. Nurse Maureen would expect the client with
cholesterol
mitral stenosis would demonstrate symptoms
c. Low concentration triglycerides
associated with congestion in the:
d. Low levels of LDL cholesterol.
a. Right atrium
373
b. Superior vena cava
13. Which of the following represents a
c. Aorta significant

d. Pulmonary risk immediately after surgery for repair of

aortic
10. A client has been diagnosed with
hypertension. aneurysm?

The nurse priority nursing diagnosis would be: a. Potential wound infection

a. Ineffective health maintenance b. Potential ineffective coping

b. Impaired skin integrity c. Potential electrolyte balance

d. Potential alteration in renal perfusion d. 60 60 70 years

14. Nurse Josie should instruct the client to eat 18. Marie with acute lymphocytic leukemia
suffers
which of the following foods to obtain the best
from nausea and headache. These clinical
supply of Vitamin B12?
manifestations may indicate all of the following
a. dairy products
except
b. vegetables
a. effects of radiation
c. Grains
b. chemotherapy side effects
d. Broccoli
c. meningeal irritation
15. Karen has been diagnosed with aplastic
anemia. d. gastric distension

The nurse monitors for changes in which of the 19. A client has been diagnosed with
Disseminated
following physiologic functions?
Intravascular Coagulation (DIC). Which of the
a. Bowel function
following is contraindicated with the client?
b. Peripheral sensation
a. Administering Heparin
c. Bleeding tendencies
b. Administering Coumadin
d. Intake and out put
c. Treating the underlying cause
16. Lydia is scheduled for elective splenectomy.
d. Replacing depleted blood products
Before the clients goes to surgery, the nurse in
20. Which of the following findings is the best
charge final assessment would be:
indication that fluid replacement for the client
a. signed consent
with hypovolemic shock is adequate?
b. vital signs
a. Urine output greater than 30ml/hr
c. name band
b. Respiratory rate of 21 breaths/minute
d. empty bladder
c. Diastolic blood pressure greater than 90
17. What is the peak age range in acquiring
acute mmhg

lymphocytic leukemia (ALL)? d. Systolic blood pressure greater than 110

a. 4 to 12 years. mmhg

b. 20 to 30 years 21. Which of the following signs and symptoms

c. 40 to 50 years would Nurse Maureen include in teaching plan

as an early manifestation of laryngeal cancer? information about the advantages of using a
pen
a. Stomatitis
like insulin delivery devices. The nurse explains
b. Airway obstruction
that the advantages of these devices over
c. Hoarseness
syringes include:
d. Dysphagia
a. Accurate dose delivery
22. Karina a client with myasthenia gravis is to
b. Shorter injection time
receive immunosuppressive therapy. The nurse
374
understands that this therapy is effective
c. Lower cost with reusable insulin
because it:
cartridges
a. Promotes the removal of antibodies that
d. Use of smaller gauge needle.
impair the transmission of impulses
25. A male client’s left tibia is fractures in an
b. Stimulates the production of
automobile accident, and a cast is applied. To
acetylcholine at the neuromuscular
assess for damage to major blood vessels from
junction.
the fracture tibia, the nurse in charge should
c. Decreases the production of
monitor the client for:
autoantibodies that attack the
a. Swelling of the left thigh
acetylcholine receptors.
b. Increased skin temperature of the foot
d. Inhibits the breakdown of acetylcholine
c. Prolonged reperfusion of the toes after
at the neuromuscular junction.
blanching
23. A female client is receiving IV Mannitol. An
d. Increased blood pressure
assessment specific to safe administration of the
26. After a long leg cast is removed, the male
said drug is:
client
a. Vital signs q4h
should:
b. Weighing daily
a. Cleanse the leg by scrubbing with a brisk
c. Urine output hourly
motion
d. Level of consciousness q4h
b. Put leg through full range of motion
24. Patricia a 20 year old college student with
twice daily
diabetes mellitus requests additional
c. Report any discomfort or stiffness to the
physician 30. A male client has undergone spinal surgery,
the
d. Elevate the leg when sitting for long
nurse should:
periods of time.
a. Observe the client’s bowel movement
27. While performing a physical assessment of a
and voiding patterns
male client with gout of the great toe,
b. Log-roll the client to prone position
NurseVivian should assess for additional tophi
c. Assess the client’s feet for sensation and
(urate deposits) on the:
circulation
a. Buttocks
d. Encourage client to drink plenty of fluids
b. Ears
31. Marina with acute renal failure moves into
c. Face
the
d. Abdomen
diuretic phase after one week of therapy. During
28. Nurse Katrina would recognize that the
this phase the client must be assessed for signs
demonstration of crutch walking with tripod gait
of developing:
was understood when the client places weight
a. Hypovolemia
on the:
b. renal failure
a. Palms of the hands and axillary regions
c. metabolic acidosis
b. Palms of the hand
d. hyperkalemia
c. Axillary regions
32. Nurse Judith obtains a specimen of clear
d. Feet, which are set apart nasal

29. Mang Jose with rheumatoid arthritis states, drainage from a client with a head injury. Which
“the
of the following tests differentiates mucus from
only time I am without pain is when I lie in bed
cerebrospinal fluid (CSF)?
perfectly still”. During the convalescent stage,
a. Protein
the nurse in charge with Mang Jose should
b. Specific gravity
encourage:
c. Glucose
a. Active joint flexion and extension
d. Microorganism
b. Continued immobility until pain subsides
33. A 22 year old client suffered from his first
c. Range of motion exercises twice daily tonicclonic

d. Flexion exercises three times daily seizure. Upon awakening the client asks
the nurse, “What caused me to have a seizure? d. “You will need to accept the necessity

Which of the following would the nurse include for a quiet and inactive lifestyle”.

in the primary cause of tonic-clonic seizures in 36. The nurse is aware the early indicator of
hypoxia
adults more the 20 years?
in the unconscious client is:
a. Electrolyte imbalance
a. Cyanosis
b. Head trauma
b. Increased respirations
c. Epilepsy
c. Hypertension
d. Congenital defect
d. Restlessness
34. What is the priority nursing assessment in
the 37. A client is experiencing spinal shock. Nurse

first 24 hours after admission of the client with Myrna should expect the function of the
bladder
thrombotic CVA?
to be which of the following?
a. Pupil size and papillary response
a. Normal
b. cholesterol level
b. Atonic
c. Echocardiogram
c. Spastic
d. Bowel sounds
d. Uncontrolled
35. Nurse Linda is preparing a client with
multiple 38. Which of the following stage the carcinogen
is
sclerosis for discharge from the hospital to
irreversible?
home. Which of the following instruction is
most a. Progression stage

appropriate? b. Initiation stage

375 c. Regression stage

a. “Practice using the mechanical aids that d. Promotion stage

you will need when future disabilities 39. Among the following components thorough
pain
arise”.
assessment, which is the most significant?
b. “Follow good health habits to change
a. Effect
the course of the disease”.
b. Cause
c. “Keep active, use stress reduction
c. Causing factors
strategies, and avoid fatigue.
d. Intensity a. Headache

40. A 65 year old female is experiencing flare up b. Bladder distension

of
c. Dizziness
pruritus. Which of the client’s action could
d. Ability to move legs
aggravate the cause of flare ups?
45. Nurse Katrina should anticipate that all of
a. Sleeping in cool and humidified the

environment following drugs may be used in the attempt to

b. Daily baths with fragrant soap control the symptoms of Meniere's disease

c. Using clothes made from 100% cotton except:

d. Increasing fluid intake a. Antiemetics

41. Atropine sulfate (Atropine) is b. Diuretics

contraindicated in
c. Antihistamines
all but one of the following client?
d. Glucocorticoids
a. A client with high blood
46. Which of the following complications
b. A client with bowel obstruction associated

c. A client with glaucoma with tracheostomy tube?

d. A client with U.T.I a. Increased cardiac output

42. Among the following clients, which among b. Acute respiratory distress syndrome
them
(ARDS)
is high risk for potential hazards from the
c. Increased blood pressure
surgical experience?
d. Damage to laryngeal nerves
a. 67-year-old client
47. Nurse Faith should recognize that fluid shift
b. 49-year-old client in a

c. 33-year-old client client with burn injury results from increase in

d. 15-year-old client the:

43. Nurse Jon assesses vital signs on a client a. Total volume of circulating whole blood

undergone epidural anesthesia. b. Total volume of intravascular plasma

44. Which of the following would the nurse c. Permeability of capillary walls
assess
d. Permeability of kidney tubules
next?
48. An 83-year-old woman has several d. Promote means of communication
ecchymotic
377
areas on her right arm. The bruises are probably
ANSWERS AND RATIONALE – MEDICAL
caused by: SURGICAL

a. increased capillary fragility and NURSING

permeability 1. C. Glucocorticoids (steroids) are used for their

b. increased blood supply to the skin anti-inflammatory action, which decreases the

c. self-inflicted injury development of edema.

d. elder abuse 2. A. The blood must be stopped at once, and

then
376
normal saline should be infused to keep the line
49. Nurse Anna is aware that early adaptation of
patent and maintain blood volume.
client with renal carcinoma is:
3. B. These tests confirm the presence of HIV
a. Nausea and vomiting
antibodies that occur in response to the
b. flank pain
presence of the human immunodeficiency virus
c. weight gain
(HIV).
d. intermittent hematuria
4. D. One cup of cottage cheese contains
50. A male client with tuberculosis asks Nurse
Brian approximately 225 calories, 27g of protein, 9g of

how long the chemotherapy must be continued. fat, 30mg cholesterol, and 6g of carbohydrate.

Nurse Brian’s accurate reply would be: Proteins of high biologic value (HBV) contain

a. 1 to 3 weeks optimal levels of amino acids essential for life.

b. 6 to 12 months 5. A. Elevation of uremic waste products causes

c. 3 to 5 months irritation of the nerves, resulting in flapping

d. 3 years and more hand tremors.

51. A client has undergone laryngectomy. The 6. B. This indicates that the bladder is distended

immediate nursing priority would be: with urine, therefore palpable.

a. Keep trachea free of secretions 7. C. Elevation increases lymphatic drainage,

b. Monitor for signs of infection reducing edema and pain.

c. Provide emotional support 8. B. Detection of myoglobin is a diagnostic tool

to
determine whether myocardial damage has or prolonged aortic cross-clamping during the

occurred. surgery.

9. D. When mitral stenosis is present, the left 14. A. Good source of vitamin B12 are dairy

atrium has difficulty emptying its contents into products and meats.

the left ventricle because there is no valve to 15. C. Aplastic anemia decreases the bone
marrow
prevent back ward flow into the pulmonary
vein, production of RBC’s, white blood cells, and

the pulmonary circulation is under pressure. platelets. The client is at risk for bruising and

10. A. Managing hypertension is the priority for bleeding tendencies.

the
16. B. An elective procedure is scheduled in
client with hypertension. Clients with advance

hypertension frequently do not experience pain, so that all preparations can be completed ahead

deficient volume, or impaired skin integrity. It is of time. The vital signs are the final check that

the asymptomatic nature of hypertension that must be completed before the client leaves the

makes it so difficult to treat. room so that continuity of care and assessment

11. C. Because of its widespread vasodilating is provided for.

effects,
17. A. The peak incidence of Acute Lymphocytic
nitroglycerin often produces side effects such as
Leukemia (ALL) is 4 years of age. It is uncommon
headache, hypotension and dizziness.
after 15 years of age.
12. A. An increased in LDL cholesterol
18. D. Acute Lymphocytic Leukemia (ALL) does
concentration
not
has been documented at risk factor for the
cause gastric distention. It does invade the
development of atherosclerosis. LDL cholesterol
central nervous system, and clients experience
is not broken down into the liver but is
headaches and vomiting from meningeal
deposited into the wall of the blood vessels.
irritation.
13. D. There is a potential alteration in renal
19. B. Disseminated Intravascular Coagulation
perfusion manifested by decreased urine (DIC)
output.
has not been found to respond to oral
The altered renal perfusion may be related to
anticoagulants such as Coumadin.
renal artery embolism, prolonged hypotension,
20. A. Urine output provides the most sensitive
indication of the client’s response to therapy for 27. B. Uric acid has a low solubility, it tends to

hypovolemic shock. Urine output should be precipitate and form deposits at various sites

consistently greater than 30 to 35 mL/hr. 378

21. C. Early warning signs of laryngeal cancer where blood flow is least active, including
can
cartilaginous tissue such as the ears.
vary depending on tumor location. Hoarseness
28. B. The palms should bear the client’s weight
lasting 2 weeks should be evaluated because it to
is
avoid damage to the nerves in the axilla.
one of the most common warning signs.
29. A. Active exercises, alternating extension,
22. C. Steroids decrease the body’s immune
flexion, abduction, and adduction, mobilize
response thus decreasing the production of
exudates in the joints relieves stiffness and pain.
antibodies that attack the acetylcholine
30. C. Alteration in sensation and circulation
receptors at the neuromuscular junction
indicates damage to the spinal cord, if these
23. C. The osmotic diuretic mannitol is
occurs notify physician immediately.
contraindicated in the presence of inadequate
31. A. In the diuretic phase fluid retained during
renal function or heart failure because it the

increases the intravascular volume that must be oliguric phase is excreted and may reach 3 to 5

filtered and excreted by the kidney. liters daily, hypovolemia may occur and fluids

24. A. These devices are more accurate because should be replaced.

they are easily to used and have improved 32. C. The constituents of CSF are similar to
those of
adherence in insulin regimens by young people
blood plasma. An examination for glucose
because the medication can be administered
content is done to determine whether a body
discreetly.
fluid is a mucus or a CSF. A CSF normally
25. C. Damage to blood vessels may decrease
contains
the
glucose.
circulatory perfusion of the toes, this would
33. B. Trauma is one of the primary causes of
indicate the lack of blood supply to the
brain
extremity.
damage and seizure activity in adults. Other
26. D. Elevation will help control the edema that
common causes of seizure activity in adults
usually occurs.
include neoplasms, withdrawal from drugs and 41. C. Atropine sulfate is contraindicated with

alcohol, and vascular disease. glaucoma patients because it increases

34. A. It is crucial to monitor the pupil size and intraocular pressure.

papillary response to indicate changes around 42. A. A 67 year old client is greater risk because
the
the cranial nerves.
older adult client is more likely to have a
35. C. The nurse most positive approach is to
lesseffective
encourage the client with multiple sclerosis to
immune system.
stay active, use stress reduction techniques and
43. B. The last area to return sensation is in the
avoid fatigue because it is important to support
perineal area, and the nurse in charge should
the immune system while remaining active.
monitor the client for distended bladder.
36. D. Restlessness is an early indicator of
44. D. Glucocorticoids play no significant role in
hypoxia.
disease treatment.
The nurse should suspect hypoxia in
unconscious 45. D. Tracheostomy tube has several potential

client who suddenly becomes restless. complications including bleeding, infection and

37. B. In spinal shock, the bladder becomes laryngeal nerve damage.

completely atonic and will continue to fill unless 46. C. In burn, the capillaries and small vessels

the client is catheterized. dilate, and cell damage cause the release of a

38. A. Progression stage is the change of tumor histamine-like substance. The substance causes
from
the capillary walls to become more permeable
the preneoplastic state or low degree of
and significant quantities of fluid are lost.
malignancy to a fast growing tumor that cannot
47. A. Aging process involves increased capillary
be reversed.
fragility and permeability. Older adults have a
39. D. Intensity is the major indicative of
decreased amount of subcutaneous fat and
severity of
cause an increased incidence of bruise like
pain and it is important for the evaluation of the
lesions caused by collection of extravascular
treatment.
blood in loosely structured dermis.
40. B. The use of fragrant soap is very drying to
skin 48. D. Intermittent pain is the classic sign of
renal
hence causing the pruritus.
carcinoma. It is primarily due to capillary 3. Nurse Monet is caring for a female client who
erosion
has suicidal tendency. When accompanying the
by the cancerous growth.
client to the restroom, Nurse Monet should…
49. B. Tubercle bacillus is a drug resistant
a. Give her privacy
organism
b. Allow her to urinate
and takes a long time to be eradicated. Usually a
c. Open the window and allow her to get
combination of three drugs is used for minimum
some fresh air
of 6 months and at least six months beyond
d. Observe her
culture conversion.
4. Nurse Maureen is developing a plan of care
50. A. Patent airway is the most priority;
for a
therefore
female client with anorexia nervosa. Which
removal of secretions is necessary
action should the nurse include in the plan?
379
a. Provide privacy during meals
PSYCHIATRIC NURSING
b. Set-up a strict eating plan for the client
1. Marco approached Nurse Trish asking for
advice c. Encourage client to exercise to reduce
on how to deal with his alcohol addiction. Nurse anxiety
Trish should tell the client that the only effective d. Restrict visits with the family
treatment for alcoholism is: 5. A client is experiencing anxiety attack. The
most
a. Psychotherapy
appropriate nursing intervention should
b. Alcoholics anonymous (A.A.)
include?
c. Total abstinence
a. Turning on the television
d. Aversion Therapy
b. Leaving the client alone
2. Nurse Hazel is caring for a male client who
c. Staying with the client and speaking in
experience false sensory perceptions with no
short sentences
basis in reality. This perception is known as:
d. Ask the client to play with other clients
a. Hallucinations
6. A female client is admitted with a diagnosis of
b. Delusions
delusions of GRANDEUR. This diagnosis reflects
c. Loose associations a

d. Neologisms belief that one is:

a. Being Killed 10. Nurse Tony was caring for a 41 year old
female
b. Highly famous and important
client. Which behavior by the client indicates
c. Responsible for evil world
adult cognitive development?
d. Connected to client unrelated to oneself
a. Generates new levels of awareness
7. A 20 year old client was diagnosed with
b. Assumes responsibility for her actions
dependent personality disorder. Which behavior
c. Has maximum ability to solve problems
is not likely to be evidence of ineffective
and learn new skills
individual coping?
d. Her perception are based on reality
a. Recurrent self-destructive behavior
11. A neuromuscular blocking agent is
b. Avoiding relationship
administered
c. Showing interest in solitary activities
to a client before ECT therapy. The Nurse should
d. Inability to make choices and decision
carefully observe the client for?
without advise
a. Respiratory difficulties
8. A male client is diagnosed with schizotypal
b. Nausea and vomiting
personality disorder. Which signs would this
c. Dizziness
client exhibit during social situation?
d. Seizures
a. Paranoid thoughts
12. A 75 year old client is admitted to the
b. Emotional affect hospital

c. Independence need with the diagnosis of dementia of the

d. Aggressive behavior Alzheimer’s type and depression. The symptom

9. Nurse Claire is caring for a client diagnosed that is unrelated to depression would be?
with
a. Apathetic response to the environment
bulimia. The most appropriate initial goal for a
b. “I don’t know” answer to questions
client diagnosed with bulimia is?
c. Shallow of labile effect
a. Encourage to avoid foods
d. Neglect of personal hygiene
b. Identify anxiety causing situations
380
c. Eat only three meals a day
13. Nurse Trish is working in a mental health
d. Avoid shopping plenty of groceries facility;

the nurse priority nursing intervention for a

newly admitted client with bulimia nervosa Nurse Trish recognizes that the basis of O.C.

would be to? disorder is often:

a. Teach client to measure I & O a. Problems with being too conscientious

b. Involve client in planning daily meal b. Problems with anger and remorse

c. Observe client during meals c. Feelings of guilt and inadequacy

d. Monitor client continuously d. Feeling of unworthiness and

14. Nurse Patricia is aware that the major health hopelessness

complication associated with intractable 17. Mario is complaining to other clients about
not
anorexia nervosa would be?
being allowed by staff to keep food in his room.
a. Cardiac dysrhythmias resulting to
Which of the following interventions would be
cardiac arrest
most appropriate?
b. Glucose intolerance resulting in
a. Allowing a snack to be kept in his room
protracted hypoglycemia
b. Reprimanding the client
c. Endocrine imbalance causing cold
c. Ignoring the clients behavior
amenorrhea
d. Setting limits on the behavior
d. Decreased metabolism causing cold
18. Conney with borderline personality disorder
intolerance
who
15. Nurse Anna can minimize agitation in a
is to be discharge soon threatens to “do
disturbed client by?
something” to herself if discharged. Which of
a. Increasing stimulation the

b. limiting unnecessary interaction following actions by the nurse would be most

c. increasing appropriate sensory important?

perception a. Ask a family member to stay with the

d. ensuring constant client and staff client at home temporarily

contact b. Discuss the meaning of the client’s

16. A 39 year old mother with obsessive- statement with her

compulsive
c. Request an immediate extension for the
disorder has become immobilized by her
client
elaborate hand washing and walking rituals.
d. Ignore the clients statement because it’s
a sign of manipulation d. Haloperidol (Haldol)

19. Joey a client with antisocial personality 22. Which of the following foods would the
disorder nurse

belches loudly. A staff member asks Joey, “Do Trish eliminate from the diet of a client in

you know why people find you repulsive?” this alcohol withdrawal?

statement most likely would elicit which of the a. Milk

following client reaction? b. Orange Juice

a. Depensiveness c. Soda

b. Embarrassment d. Regular Coffee

c. Shame 23. Which of the following would Nurse Hazel

d. Remorsefulness expect to assess for a client who is exhibiting

20. Which of the following approaches would be late signs of heroin withdrawal?

most appropriate to use with a client suffering a. Yawning & diaphoresis

from narcissistic personality disorder when 381

discrepancies exist between what the client b. Restlessness & Irritability

states and what actually exist? c. Constipation & steatorrhea

a. Rationalization d. Vomiting and Diarrhea

b. Supportive confrontation 24. To establish open and trusting relationship

with
c. Limit setting
a female client who has been hospitalized with
d. Consistency
severe anxiety, the nurse in charge should?
21. Cely is experiencing alcohol withdrawal
exhibits a. Encourage the staff to have frequent

tremors, diaphoresis and hyperactivity. Blood interaction with the client

pressure is 190/87 mmhg and pulse is 92 bpm. b. Share an activity with the client

Which of the medications would the nurse c. Give client feedback about behavior

expect to administer? d. Respect client’s need for personal space

a. Naloxone (Narcan) 25. Nurse Monette recognizes that the focus of

b. Benzlropine (Cogentin) environmental (MILIEU) therapy is to:

c. Lorazepam (Ativan) a. Manipulate the environment to bring

about positive changes in behavior b. Speech lag

b. Allow the client’s freedom to determine c. Shuttering

whether or not they will be involved in d. Echolalia

activities 29. A 60 year old female client who lives alone

tells
c. Role play life events to meet individual
the nurse at the community health center “I
needs
really don’t need anyone to talk to”. The TV is
d. Use natural remedies rather than drugs
my best friend. The nurse recognizes that the
to control behavior
client is using the defense mechanism known
26. Nurse Trish would expect a child with a
as?
diagnosis
a. Displacement
of reactive attachment disorder to:
b. Projection
a. Have more positive relation with the
c. Sublimation
father than the mother
d. Denial
b. Cling to mother & cry on separation
30. When working with a male client suffering
c. Be able to develop only superficial
phobia about black cats, Nurse Trish should
relation with the others
anticipate that a problem for this client would
d. Have been physically abuse
be?
27. When teaching parents about childhood
a. Anxiety when discussing phobia
depression Nurse Trina should say?
b. Anger toward the feared object
a. It may appear acting out behavior
c. Denying that the phobia exist
b. Does not respond to conventional
d. Distortion of reality when completing
treatment
daily routines
c. Is short in duration & resolves easily
31. Linda is pacing the floor and appears
d. Looks almost identical to adult
extremely
depression
anxious. The duty nurse approaches in an
28. Nurse Perry is aware that language
attempt to alleviate Linda’s anxiety. The most
development
therapeutic question by the nurse would be?
in autistic child resembles:
a. Would you like to watch TV?
a. Scanning speech
b. Would you like me to talk with you?
c. Are you feeling upset now? b. Slow pulse, 10% weight loss & alopecia

d. Ignore the client 382

32. Nurse Penny is aware that the symptoms c. Compulsive behavior, excessive fears &
that
nausea
distinguish post-traumatic stress disorder from
d. Excessive activity, memory lapses & an
other anxiety disorder would be:
increased pulse
a. Avoidance of situation & certain
35. A characteristic that would suggest to Nurse
activities that resemble the stress
Anne that an adolescent may have bulimia
b. Depression and a blunted affect when
would be:
discussing the traumatic situation
a. Frequent regurgitation & re-swallowing
c. Lack of interest in family & others
of food
d. Re-experiencing the trauma in dreams or
b. Previous history of gastritis
flashback
c. Badly stained teeth
33. Nurse Benjie is communicating with a male
d. Positive body image
client
36. Nurse Monette is aware that extremely
with substance-induced persisting dementia;
the depressed clients seem to do best in settings
client cannot remember facts and fills in the where they have:
gaps with imaginary information. Nurse Benjie is a. Multiple stimuli
aware that this is typical of? b. Routine Activities
a. Flight of ideas c. Minimal decision making
b. Associative looseness d. Varied Activities
c. Confabulation 37. To further assess a client’s suicidal potential.
d. Concretism Nurse Katrina should be especially alert to the
34. Nurse Joey is aware that the signs & client expression of:
symptoms
a. Frustration & fear of death
that would be most specific for diagnosis
b. Anger & resentment
anorexia are?
c. Anxiety & loneliness
a. Excessive weight loss, amenorrhea &
d. Helplessness & hopelessness
abdominal distension
38. A nursing care plan for a male client with d. Weak ego
bipolar
41. A 23 year old client has been admitted with
I disorder should include: a

a. Providing a structured environment diagnosis of schizophrenia says to the nurse

b. Designing activities that will require the “Yes, its march, March is little woman”. That’s

client to maintain contact with reality literal you know”. These statement illustrate:

c. Engaging the client in conversing about a. Neologisms

current affairs b. Echolalia

d. Touching the client provide assurance c. Flight of ideas

39. When planning care for a female client using d. Loosening of association

ritualistic behavior, Nurse Gina must recognize 42. A long term goal for a paranoid male client
who
that the ritual:
has unjustifiably accused his wife of having
a. Helps the client focus on the inability to
many
deal with reality
extramarital affairs would be to help the client
b. Helps the client control the anxiety
develop:
c. Is under the client’s conscious control
a. Insight into his behavior
d. Is used by the client primarily for
b. Better self-control
secondary gains
c. Feeling of self-worth
40. A 32 year old male graduate student, who
d. Faith in his wife
has
43. A male client who is experiencing disordered
become increasingly withdrawn and neglectful
thinking about food being poisoned is admitted
of his work and personal hygiene, is brought to
to the mental health unit. The nurse uses which
the psychiatric hospital by his parents. After
communication technique to encourage the
detailed assessment, a diagnosis of
client to eat dinner?
schizophrenia is made. It is unlikely that the
a. Focusing on self-disclosure of own food
client will demonstrate:
preference
a. Low self esteem
b. Using open ended question and silence
b. Concrete thinking
c. Offering opinion about the need to eat
c. Effective self-boundaries
d. Verbalizing reasons that the client may
not choose to eat indicate a need to provide additional

44. Nurse Nina is assigned to care for a client information?

diagnosed with Catatonic Stupor. When Nurse a. “Abuse occurs more in low-income

Nina enters the client’s room, the client is found families”

lying on the bed with a body pulled into a fetal b. “Abuser Are often jealous or selfcentered”

position. Nurse Nina should? c. “Abuser use fear and intimidation”

a. Ask the client direct questions to d. “Abuser usually have poor self-esteem”

encourage talking 47. During electroconvulsive therapy (ECT) the

client
b. Rake the client into the dayroom to be
receives oxygen by mask via positive pressure
with other clients
ventilation. The nurse assisting with this
c. Sit beside the client in silence and
procedure knows that positive pressure
occasionally ask open-ended question
ventilation is necessary because?
d. Leave the client alone and continue with
a. Anesthesia is administered during the
providing care to the other clients
procedure
383
b. Decrease oxygen to the brain increases
45. Nurse Tina is caring for a client with delirium
and confusion and disorientation

states that “look at the spiders on the wall”. c. Grand mal seizure activity depresses

What should the nurse respond to the client? respirations

a. “You’re having hallucination, there are d. Muscle relaxations given to prevent

no spiders in this room at all” injury during seizure activity depress

b. “I can see the spiders on the wall, but respirations.

they are not going to hurt you” 48. When planning the discharge of a client with

c. “Would you like me to kill the spiders” chronic anxiety, Nurse Chris evaluates

d. “I know you are frightened, but I do not achievement of the discharge maintenance

see spiders on the wall” goals. Which goal would be most appropriately

46. Nurse Jonel is providing information to a having been included in the plan of care

community group about violence in the family. requiring evaluation?

Which statement by a group member would a. The client eliminates all anxiety from
daily situations NURSING

b. The client ignores feelings of anxiety 1. Answer: C

c. The client identifies anxiety producing Rationale: Total abstinence is the only effective

situations treatment for alcoholism

d. The client maintains contact with a crisis 2. Answer: A

counselor Rationale: Hallucinations are visual, auditory,

49. Nurse Tina is caring for a client with gustatory, tactile or olfactory perceptions that
depression
have no basis in reality.
who has not responded to antidepressant
3. Answer: D
medication. The nurse anticipates that what
Rationale: The Nurse has a responsibility to
treatment procedure may be prescribed.
observe continuously the acutely suicidal client.
a. Neuroleptic medication
The Nurse should watch for clues, such as
b. Short term seclusion
communicating suicidal thoughts, and
c. Psychosurgery messages;

d. Electroconvulsive therapy hoarding medications and talking about death.

50. Mario is admitted to the emergency room 4. Answer: B

with
Rationale: Establishing a consistent eating plan
drug-included anxiety related to over ingestion
and monitoring client’s weight are important to
of prescribed antipsychotic medication. The
this disorder.
most important piece of information the nurse
5. Answer: C
in charge should obtain initially is the:
Rationale: Appropriate nursing interventions for
a. Length of time on the med.
an anxiety attack include using short sentences,
b. Name of the ingested medication & the
staying with the client, decreasing stimuli,
amount ingested
remaining calm and medicating as needed.
c. Reason for the suicide attempt
6. Answer:B
d. Name of the nearest relative & their
Rationale: Delusion of grandeur is a false belief
phone number
that one is highly famous and important.
384
7. Answer: D
ANSWERS AND RATIONALE – PSYCHIATRIC
Rationale: Individual with dependent Rationale: These clients often hide food or force
personality
vomiting; therefore they must be carefully
disorder typically shows indecisiveness
monitored.
submissiveness and clinging behavior so that
14. Answer: A
others will make decisions with them.
Rationale: These clients have severely depleted
8. Answer: A
levels of sodium and potassium because of their
Rationale: Clients with schizotypal personality
starvation diet and energy expenditure, these
disorder experience excessive social anxiety that
electrolytes are necessary for cardiac
can lead to paranoid thoughts
functioning.
9. Answer: B
15. Answer: B
Rationale: Bulimia disorder generally is a
Rationale: Limiting unnecessary interaction will
maladaptive coping response to stress and
decrease stimulation and agitation.
underlying issues. The client should identify
16. Answer: C
anxiety causing situation that stimulate the
Rationale: Ritualistic behavior seen in this
bulimic behavior and then learn new ways of
disorder is aimed at controlling guilt and
coping with the anxiety.
inadequacy by maintaining an absolute set
10. Answer: A
pattern of behavior.
Rationale: An adult age 31 to 45 generates new
17. Answer: D
level of awareness.
Rationale: The nurse needs to set limits in the
11. Answer: A
client’s manipulative behavior to help the client
Rationale: Neuromuscular Blocker, such as
control dysfunctional behavior. A consistent
SUCCINYLCHOLINE (Anectine) produces
approach by the staff is necessary to decrease
respiratory depression because it inhibits
manipulation.
contractions of respiratory muscles.
18. Answer: B
12. Answer: C
Rationale: Any suicidal statement must be
Rationale: With depression, there is little or no
assessed by the nurse. The nurse should discuss
emotional involvement therefore little alteration
the client’s statement with her to determine its
in affect.
meaning in terms of suicide.
13. Answer: D
19. Answer: A
Rationale: When the staff member ask the client late signs of heroin withdrawal, along with

if he wonders why others find him repulsive, the muscle spasm, fever, nausea, repetitive,

client is likely to feel defensive because the abdominal cramps and backache.

question is belittling. The natural tendency is to 24. Answer: D

counterattack the threat to self-image. Rationale: Moving to a client’s personal space

20. Answer: B increases the feeling of threat, which increases

Rationale: The nurse would specifically use anxiety.

supportive confrontation with the client to point 25. Answer: A

out discrepancies between what the client Rationale: Environmental (MILIEU) therapy aims
states
at having everything in the client’s surrounding
and what actually exists to increase
area toward helping the client.
responsibility for self.
26. Answer: C
21. Answer: C
Rationale: Children who have experienced
Rationale: The nurse would most likely
attachment difficulties with primary caregiver
administer benzodiazepine, such as lorazepan
are not able to trust others and therefore relate
(ativan) to the client who is experiencing
superficially
symptom: The client’s experiences symptoms of
27. Answer: A
withdrawal because of the rebound
Rationale: Children have difficulty verbally
phenomenon when the sedation of the CNS
expressing their feelings, acting out behavior,
from alcohol begins to decrease.
such as temper tantrums, may indicate
22. Answer: D
underlying depression.
385
28. Answer: D
Rationale: Regular coffee contains caffeine
Rationale: The autistic child repeats sounds or
which acts as psychomotor stimulants and leads
words spoken by others.
to feelings of anxiety and agitation. Serving
29. Answer: D
coffee top the client may add to tremors or
Rationale: The client statement is an example of
wakefulness.
the use of denial, a defense that blocks problem
23. Answer: D
by unconscious refusing to admit they exist
Rationale: Vomiting and diarrhea are usually the
30. Answer: A
Rationale: Discussion of the feared object indicate that this client is unable to continue the

triggers an emotional response to the object. struggle of life.

31. Answer: B 38. Answer: A

Rationale: The nurse presence may provide the Rationale: Structure tends to decrease agitation

client with support & feeling of control. and anxiety and to increase the client’s feeling
of
32. Answer: D
security.
Rationale: Experiencing the actual trauma in
39. Answer: B
dreams or flashback is the major symptom that
Rationale: The rituals used by a client with
distinguishes post-traumatic stress disorder
from obsessive compulsive disorder help control the

other anxiety disorder. anxiety level by maintaining a set pattern of

33. Answer: C action.

Rationale: Confabulation or the filling in of 40. Answer: C

memory gaps with imaginary facts is a defense Rationale: A person with this disorder would not

mechanism used by people experiencing have adequate self-boundaries

memory deficits. 41. Answer: D

34. Answer: A Rationale: Loose associations are thoughts that

Rationale: These are the major signs of anorexia are presented without the logical connections

nervosa. Weight loss is excessive (15% of usually necessary for the listening to interpret

expected weight) the message.

35. Answer: C 42. Answer: C

Rationale: Dental enamel erosion occurs from Rationale: Helping the client to develop feeling

repeated self-induced vomiting. of self-worth would reduce the client’s need to

36. Answer: B use pathologic defenses.

Rationale: Depression usually is both emotional 43. Answer: B

& physical. A simple daily routine is the best, Rationale: Open ended questions and silence
are
least stressful and least anxiety producing.
strategies used to encourage clients to discuss
37. Answer: D
their problem in descriptive manner.
Rationale: The expression of these feeling may
44. Answer: C Rationale: Electroconvulsive therapy is an

Rationale: Clients who are withdrawn may be effective treatment for depression that has not

immobile and mute, and require consistent, responded to medication

repeated interventions. Communication with 50. Answer: B

withdrawn clients requires much patience from Rationale: In an emergency, lives saving facts
are
the nurse. The nurse facilitates communication
obtained first. The name and the amount of
with the client by sitting in silence, asking
openended medication ingested are of outmost important
in
question and pausing to provide
treating this potentially life threatening
opportunities for the client to respond.
situation.
45. Answer: D
387
Rationale: When hallucination is present, the
FUNDAMENTALS OF NURSING PART 1
nurse should reinforce reality with the client.
1. Using the principles of standard precautions,
46. Answer: A
the
386
nurse would wear gloves in what nursing
Rationale: Personal characteristics of abuser
interventions?
include low self-esteem, immaturity,
a. Providing a back massage
dependence, insecurity and jealousy.
b. Feeding a client
47. Answer: D
c. Providing hair care
Rationale: A short acting skeletal muscle
d. Providing oral hygiene
relaxant
2. The nurse is preparing to take vital sign in an
such as succinylcholine (Anectine) is
alert client admitted to the hospital with
administered during this procedure to prevent
dehydration secondary to vomiting and
injuries during seizure.
diarrhea.
48. Answer: C
What is the best method used to assess the
Rationale: Recognizing situations that produce
client’s temperature?
anxiety allows the client to prepare to cope with
a. Oral
anxiety or avoid specific stimulus.
b. Axillary
49. Answer: D
c. Radial
d. Heat sensitive tape mouth care. When performing a mouth care,
the
3. A nurse obtained a client’s pulse and found
the best position of a client is:

rate to be above normal. The nurse document a. Fowler’s position

this findings as: b. Side lying

a. Tachypnea c. Supine

b. Hyper pyrexia d. Trendelenburg

c. Arrythmia 7. A client is hospitalized for the first time,

which of
d. Tachycardia
the following actions ensure the safety of the
4. Which of the following actions should the
nurse client?

take to use a wide base support when assisting a. Keep unnecessary furniture out of the
a
way
client to get up in a chair?
b. Keep the lights on at all time
a. Bend at the waist and place arms under
c. Keep side rails up at all time
the client’s arms and lift
d. Keep all equipment out of view
b. Face the client, bend knees and place
8. A walk-in client enters into the clinic with a
hands on client’s forearm and lift chief

c. Spread his or her feet apart complaint of abdominal pain and diarrhea. The

d. Tighten his or her pelvic muscles nurse takes the client’s vital sign hereafter. What

5. A client had oral surgery following a motor phrase of nursing process is being implemented

vehicle accident. The nurse assessing the client here by the nurse?

finds the skin flushed and warm. Which of the a. Assessment

following would be the best method to take the b. Diagnosis

client’s body temperature? c. Planning

a. Oral d. Implementation

b. Axillary 9. It is best describe as a systematic, rational

c. Arterial line method of planning and providing nursing care

d. Rectal for individual, families, group and community

6. A client who is unconscious needs frequent a. Assessment

b. Nursing Process c. Immunity

c. Diagnosis d. Glands

d. Implementation 14. Hormones secreted by Islets of Langerhans

10. Exchange of gases takes place in which of a. Progesterone

the
b. Testosterone
following organ?
c. Insulin
a. Kidney
d. Hemoglobin
b. Lungs
388
c. Liver
15. It is a transparent membrane that focuses
d. Heart the

11. The Chamber of the heart that receives light that enters the eyes to the retina.

oxygenated blood from the lungs is the? a. Lens

a. Left atrium b. Sclera

b. Right atrium c. Cornea

c. Left ventricle d. Pupils

d. Right ventricle 16. Which of the following is included in Orem’s

12. A muscular enlarge pouch or sac that lies theory?

slightly
a. Maintenance of a sufficient intake of air
to the left which is used for temporary storage
b. Self perception
of food…
c. Love and belonging
a. Gallbladder
d. Physiologic needs
b. Urinary bladder
17. Which of the following cluster of data
c. Stomach belong to

d. Lungs Maslow’s hierarchy of needs

13. The ability of the body to defend itself a. Love and belonging
against
b. Physiologic needs
scientific invading agent such as baceria, toxin,
c. Self actualization
viruses and foreign body
d. All of the above
a. Hormones
18. This is characterized by severe symptoms
b. Secretion
relatively of short duration. c. 180

a. Chronic Illness d. 2800

b. Acute Illness 23. Which of the following is the abbreviation of

c. Pain drops?

d. Syndrome a. Gtt.

19. Which of the following is the nurse’s role in b. Gtts.

the
c. Dp.
health promotion
d. Dr.
a. Health risk appraisal
24. The abbreviation for micro drop is…
b. Teach client to be effective health
a. μgtt
consumer
b. gtt
c. Worksite wellness
c. mdr
d. None of the above
d. mgts
20. It is describe as a collection of people who
25. Which of the following is the meaning of
share
PRN?
some attributes of their lives.
a. When advice
a. Family
b. Immediately
b. Illness
c. When necessary
c. Community
d. Now
d. Nursing
26. Which of the following is the appropriate
21. Five teaspoon is equivalent to how many
meaning of CBR?
milliliters (ml)?
a. Cardiac Board Room
a. 30 ml
b. Complete Bathroom
b. 25 ml
c. Complete Bed Rest
c. 12 ml
d. Complete Board Room
d. 75 ml
27. 1 tsp is equals to how many drops?
22. 1800 ml is equal to how many liters?
a. 15
a. 1.8
b. 60
b. 18000
c. 10
d. 30 b. Dorsal Recumbent

28. 20 cc is equal to how many ml? c. Supine

a. 2 d. Prone

b. 20 389

c. 2000 33. A client complains of difficulty of

swallowing,
d. 20000
when the nurse try to administer capsule
29. 1 cup is equal to how many ounces?
medication. Which of the following measures
a. 8
the nurse should do?
b. 80
a. Dissolve the capsule in a glass of water
c. 800
b. Break the capsule and give the content
d. 8000
with an applesauce
30. The nurse must verify the client’s identity
before c. Check the availability of a liquid

administration of medication. Which of the preparation

following is the safest way to identify the client? d. Crash the capsule and place it under the

a. Ask the client his name tongue

b. Check the client’s identification band 34. Which of the following is the appropriate
route
c. State the client’s name aloud and have
of administration for insulin?
the client repeat it
a. Intramuscular
d. Check the room number
b. Intradermal
31. The nurse prepares to administer buccal
c. Subcutaneous
medication. The medicine should be placed…
d. Intravenous
a. On the client’s skin
35. The nurse is ordered to administer ampicillin
b. Between the client’s cheeks and gums
capsule TIP p.o. The nurse shoud give the
c. Under the client’s tongue
medication…
d. On the client’s conjuctiva
a. Three times a day orally
32. The nurse administers cleansing enema. The
b. Three times a day after meals
common position for this procedure is…
c. Two time a day by mouth
a. Sims left lateral
d. Two times a day before meals 40. The most important purpose of cleansing
bed
36. Back Care is best describe as:
bath is:
a. Caring for the back by means of massage
a. To cleanse, refresh and give comfort to
b. Washing of the back
the client who must remain in bed
c. Application of cold compress at the back
b. To expose the necessary parts of the
d. Application of hot compress at the back
body
37. It refers to the preparation of the bed with a
c. To develop skills in bed bath
new set of linens
d. To check the body temperature of the
a. Bed bath
client in bed
b. Bed making
41. Which of the following technique involves
c. Bed shampoo
the
d. Bed lining
sense of sight?
38. Which of the following is the most
a. Inspection
important
b. Palpation
purpose of handwashing
c. Percussion
a. To promote hand circulation
d. Auscultation
b. To prevent the transfer of
42. The first techniques used examining the
microorganism
abdomen of a client is:
c. To avoid touching the client with a dirty
a. Palpation
hand
b. Auscultation
d. To provide comfort
c. Percussion
39. What should be done in order to prevent
d. Inspection
contaminating of the environment in bed
43. A technique in physical examination that is
making?
use
a. Avoid funning soiled linens
to assess the movement of air through the
b. Strip all linens at the same time
tracheobronchial tree:
c. Finished both sides at the time
a. Palpation
d. Embrace soiled linen
b. Auscultation

c. Inspection
d. Percussion 49. Another name for knee-chest position is:

44. An instrument used for auscultation is: 390

a. Percussion-hammer a. Genu-dorsal

b. Audiometer b. Genu-pectoral

c. Stethoscope c. Lithotomy

d. Sphygmomanometer d. Sim’s

45. Resonance is best describe as: 50. The nurse prepares IM injection that is
irritating
a. Sounds created by air filled lungs
to the subcutaneous tissue. Which of the
b. Short, high pitch and thudding
following is the best action in order to prevent
c. Moderately loud with musical quality
tracking of the medication
d. Drum-like
a. Use a small gauge needle
46. The best position for examining the rectum
is: b. Apply ice on the injection site

a. Prone c. Administer at a 45° angle

b. Sim’s d. Use the Z-track technique

c. Knee-chest 391

d. Lithotomy 1.d 11.a 21.b 31.b 41 .a

47. It refers to the manner of walking 2.b 12.c 22.a 32.a 42.d

a. Gait 3.d 13.c 23.b 33.c 43.b

b. Range of motion 4 b 14.c 24.a 34.c 44.c

c. Flexion and extension 5.b 15.c 25.c 35.a 45.a

d. Hopping 6.b 16.a 26.c 36.a 46.c

48. The nurse asked the client to read the 7.c 17.d 27.b 37.b 47.a
Snellen
8.a 18.b 28.b 38.b 48.a
chart. Which of the following is tested:
9.b 19.b 29.a 39.a 49.b
a. Optic
10.b 20.c 30.a 40.a 50.d
b. Olfactory
392
c. Oculomotor
FUNDAMENTALS OF NURSING PART 2
d. Troclear
1. The most appropriate nursing order for a 4. Mrs. Mitchell has been given a copy of her
patient diet.

who develops dyspnea and shortness of breath The nurse discusses the foods allowed on a 500-

would be… mg low sodium diet. These include:

a. Maintain the patient on strict bed rest at a. A ham and Swiss cheese sandwich on

all times whole wheat bread

b. Maintain the patient in an orthopneic b. Mashed potatoes and broiled chicken

position as needed c. A tossed salad with oil and vinegar and

c. Administer oxygen by Venturi mask at olives

24%, as needed d. Chicken bouillon

d. Allow a 1 hour rest period between 5. The physician orders a maintenance dose of

activities 5,000 units of subcutaneous heparin (an

2. The nurse observes that Mr. Adams begins to anticoagulant) daily. Nursing responsibilities for

have increased difficulty breathing. She elevates Mrs. Mitchell now include:

the head of the bed to the high Fowler position, a. Reviewing daily activated partial

which decreases his respiratory distress. The thromboplastin time (APTT) and

nurse documents this breathing as: prothrombin time.

a. Tachypnea b. Reporting an APTT above 45 seconds to

b. Eupnca the physician

c. Orthopnea c. Assessing the patient for signs and

d. Hyperventilation symptoms of frank and occult bleeding

3. The physician orders a platelet count to be d. All of the above

performed on Mrs. Smith after breakfast. The 6. The four main concepts common to nursing
that
nurse is responsible for:
appear in each of the current conceptual
a. Instructing the patient about this
models
diagnostic test
are:
b. Writing the order for this test
a. Person, nursing, environment, medicine
c. Giving the patient breakfast
b. Person, health, nursing, support systems
d. All of the above
c. Person, health, psychology, nursing
d. Person, environment, health, nursing 10. Which of the following principles of primary

7. In Maslow’s hierarchy of physiologic needs, nursing has proven the most satisfying to the
the
patient and nurse?
human need of greatest priority is:
a. Continuity of patient care promotes
a. Love
efficient, cost-effective nursing care
b. Elimination
b. Autonomy and authority for planning
c. Nutrition
are best delegated to a nurse who
d. Oxygen
knows the patient well
8. The family of an accident victim who has
c. Accountability is clearest when one
been
nurse is responsible for the overall plan
declared brain-dead seems amenable to organ
and its implementation.
donation. What should the nurse do?
d. The holistic approach provides for a
a. Discourage them from making a decision
therapeutic relationship, continuity, and
until their grief has eased
efficient nursing care.
b. Listen to their concerns and answer their
11. If nurse administers an injection to a patient
questions honestly
who refuses that injection, she has committed:
c. Encourage them to sign the consent
a. Assault and battery
form right away
b. Negligence
d. Tell them the body will not be available
c. Malpractice
for a wake or funeral
393
9. A new head nurse on a unit is distressed
about 393
the poor staffing on the 11 p.m. to 7 a.m. shift. d. None of the above
What should she do? 12. If patient asks the nurse her opinion about a
a. Complain to her fellow nurses particular physicians and the nurse replies that
b. Wait until she knows more about the the physician is incompetent, the nurse could be
unit held liable for:
c. Discuss the problem with her supervisor a. Slander
d. Inform the staff that they must b. Libel
volunteer to rotate c. Assault
d. Respondent superior and reported to the physician and the

13. A registered nurse reaches to answer the nursing supervisor.

telephone on a busy pediatric unit, momentarily 15. Which of the following signs and symptoms

turning away from a 3 month-old infant she has would the nurse expect to find when assessing

been weighing. The infant falls off the scale, an Asian patient for postoperative pain
following
suffering a skull fracture. The nurse could be
abdominal surgery?
charged with:
a. Decreased blood pressure and heart rate
a. Defamation
and shallow respirations
b. Assault
b. Quiet crying
c. Battery
c. Immobility, diaphoresis, and avoidance
d. Malpractice
of deep breathing or coughing
14. Which of the following is an example of
nursing d. Changing position every 2 hours

malpractice? 16. A patient is admitted to the hospital with

a. The nurse administers penicillin to a complaints of nausea, vomiting, diarrhea, and

patient with a documented history of severe abdominal pain. Which of the following

allergy to the drug. The patient would immediately alert the nurse that the

experiences an allergic reaction and has patient has bleeding from the GI tract?

cerebral damage resulting from anoxia. a. Complete blood count

b. The nurse applies a hot water bottle or a b. Guaiac test

heating pad to the abdomen of a patient c. Vital signs

with abdominal cramping. d. Abdominal girth

c. The nurse assists a patient out of bed 17. The correct sequence for assessing the
abdomen
with the bed locked in position; the
is:
patient slips and fractures his right
a. Tympanic percussion, measurement of
humerus.
abdominal girth, and inspection
d. The nurse administers the wrong
b. Assessment for distention, tenderness,
medication to a patient and the patient
and discoloration around the umbilicus.
vomits. This information is documented
c. Percussions, palpation, and auscultation 22. If a patient’s blood pressure is 150/96, his
pulse
d. Auscultation, percussion, and palpation
pressure is:
18. High-pitched gurgles head over the right
lower a. 54

quadrant are: b. 96

a. A sign of increased bowel motility c. 150

b. A sign of decreased bowel motility d. 246

c. Normal bowel sounds 23. A patient is kept off food and fluids for 10
hours
d. A sign of abdominal cramping
before surgery. His oral temperature at 8 a.m. is
19. A patient about to undergo abdominal
99.8 F (37.7 C) This temperature reading
inspection is best placed in which of the
probably indicates:
following positions?
a. Infection
a. Prone
b. Hypothermia
b. Trendelenburg
394
c. Supine
394
d. Side-lying
c. Anxiety
20. For a rectal examination, the patient can be
d. Dehydration
directed to assume which of the following
24. Which of the following parameters should
positions?
be
a. Genupecterol
checked when assessing respirations?
b. Sims
a. Rate
c. Horizontal recumbent
b. Rhythm
d. All of the above
c. Symmetry
21. During a Romberg test, the nurse asks the
d. All of the above
patient to assume which position?
25. A 38-year old patient’s vital signs at 8 a.m.
a. Sitting are

b. Standing axillary temperature 99.6 F (37.6 C); pulse rate,

c. Genupectoral 88; respiratory rate, 30. Which findings should

d. Trendelenburg be reported?
a. Respiratory rate only b. An 88-year old incontinent patient with

b. Temperature only gastric cancer who is confined to his bed

c. Pulse rate and temperature at home

d. Temperature and respiratory rate c. An apathetic 63-year old COPD patient

26. All of the following can cause tachycardia receiving nasal oxygen via cannula

except: d. A confused 78-year old patient with

a. Fever congestive heart failure (CHF) who

b. Exercise requires assistance to get out of bed.

c. Sympathetic nervous system stimulation 30. The physician orders the administration of
highhumidity
d. Parasympathetic nervous system
oxygen by face mask and placement of
stimulation
the patient in a high Fowler’s position. After
27. Palpating the midclavicular line is the correct
assessing Mrs. Paul, the nurse writes the
technique for assessing
following nursing diagnosis: Impaired gas
a. Baseline vital signs
exchange related to increased secretions. Which
b. Systolic blood pressure
of the following nursing interventions has the
c. Respiratory rate
greatest potential for improving this situation?
d. Apical pulse
a. Encourage the patient to increase her
28. The absence of which pulse may not be a
fluid intake to 200 ml every 2 hours
significant finding when a patient is admitted to
b. Place a humidifier in the patient’s room.
the hospital?
c. Continue administering oxygen by high
a. Apical
humidity face mask
b. Radial
d. Perform chest physiotheraphy on a
c. Pedal
regular schedule
d. Femoral
31. The most common deficiency seen in
29. Which of the following patients is at greatest
alcoholics
risk
is:
for developing pressure ulcers?
a. Thiamine
a. An alert, chronic arthritic patient treated
b. Riboflavin
with steroids and aspirin
c. Pyridoxine d. Kaolin with pectin (Kaopectate)

d. Pantothenic acid 35. A male patient who had surgery 2 days ago
for
32. Which of the following statement is
incorrect head and neck cancer is about to make his first

about a patient with dysphagia? attempt to ambulate outside his room. The

a. The patient will find pureed or soft nurse notes that he is steady on his feet and
that
foods, such as custards, easier to
his vision was unaffected by the surgery. Which
swallow than water
of the following nursing interventions would be
b. Fowler’s or semi Fowler’s position
appropriate?
reduces the risk of aspiration during
a. Encourage the patient to walk in the hall
swallowing
alone
c. The patient should always feed himself
395
d. The nurse should perform oral hygiene
395
before assisting with feeding.
b. Discourage the patient from walking in
33. To assess the kidney function of a patient
with the hall for a few more days

an indwelling urinary (Foley) catheter, the nurse c. Accompany the patient for his walk.

measures his hourly urine output. She should d. Consuit a physical therapist before

notify the physician if the urine output is: allowing the patient to ambulate

a. Less than 30 ml/hour 36. A patient has exacerbation of chronic

b. 64 ml in 2 hours obstructive pulmonary disease (COPD)

c. 90 ml in 3 hours manifested by shortness of breath; orthopnea:

d. 125 ml in 4 hours thick, tenacious secretions; and a dry hacking

34. Certain substances increase the amount of cough. An appropriate nursing diagnosis would
urine
be:
produced. These include:
a. Ineffective airway clearance related to
a. Caffeine-containing drinks, such as
thick, tenacious secretions.
coffee and cola.
b. Ineffective airway clearance related to
b. Beets
dry, hacking cough.
c. Urinary analgesics
c. Ineffective individual coping to COPD. stimulus

d. Pain related to immobilization of 40. After 1 week of hospitalization, Mr. Gray

affected leg. develops hypokalemia. Which of the following is

37. Mrs. Lim begins to cry as the nurse discusses the most significant symptom of his disorder?
hair
a. Lethargy
loss. The best response would be:
b. Increased pulse rate and blood pressure
a. “Don’t worry. It’s only temporary”
c. Muscle weakness
b. “Why are you crying? I didn’t get to the
d. Muscle irritability
bad news yet”
41. Which of the following nursing interventions
c. “Your hair is really pretty”
promotes patient safety?
d. “I know this will be difficult for you, but
a. Asses the patient’s ability to ambulate
your hair will grow back after the
and transfer from a bed to a chair
completion of chemotheraphy”
b. Demonstrate the signal system to the
38. An additional Vitamin C is required during all
patient
of
c. Check to see that the patient is wearing
the following periods except:
his identification band
a. Infancy
d. All of the above
b. Young adulthood
42. Studies have shown that about 40% of
c. Childhood
patients
d. Pregnancy
fall out of bed despite the use of side rails; this
39. A prescribed amount of oxygen s needed for
has led to which of the following conclusions?
a
a. Side rails are ineffective
patient with COPD to prevent:
b. Side rails should not be used
a. Cardiac arrest related to increased
c. Side rails are a deterrent that prevent a
partial pressure of carbon dioxide in
patient from falling out of bed.
arterial blood (PaCO2)
d. Side rails are a reminder to a patient not
b. Circulatory overload due to
to get out of bed
hypervolemia
43. Examples of patients suffering from
c. Respiratory excitement
impaired
d. Inhibition of the respiratory hypoxic
awareness include all of the following except: c. Increased work load of the left ventricle

a. A semiconscious or over fatigued patient d. All of the above

b. A disoriented or confused patient 47. Which of the following is the most common

c. A patient who cannot care for himself at cause of dementia among elderly persons?

home a. Parkinson’s disease

d. A patient demonstrating symptoms of b. Multiple sclerosis

drugs or alcohol withdrawal c. Amyotrophic lateral sclerosis (Lou

44. The most common injury among elderly Gerhig’s disease)

persons
396
is:
396
a. Atheroscleotic changes in the blood
d. Alzheimer’s disease
vessels
48. The nurse’s most important legal
b. Increased incidence of gallbladder responsibility

disease after a patient’s death in a hospital is:

c. Urinary Tract Infection a. Obtaining a consent of an autopsy

d. Hip fracture b. Notifying the coroner or medical

45. The most common psychogenic disorder examiner

among
c. Labeling the corpse appropriately
elderly person is:
d. Ensuring that the attending physician
a. Depression
issues the death certification
b. Sleep disturbances (such as bizarre
49. Before rigor mortis occurs, the nurse is
dreams)
responsible for:
c. Inability to concentrate
a. Providing a complete bath and dressing
d. Decreased appetite
change
46. Which of the following vascular system
b. Placing one pillow under the body’s
changes
head and shoulders
results from aging?
c. Removing the body’s clothing and
a. Increased peripheral resistance of the
wrapping the body in a shroud
blood vessels
d. Allowing the body to relax normally
b. Decreased blood flow
50. When a patient in the terminal stages of 3. C. A platelet count evaluates the number of
lung
platelets in the circulating blood volume. The
cancer begins to exhibit loss of consciousness, a
nurse is responsible for giving the patient
major nursing priority is to:
breakfast at the scheduled time. The physician is
a. Protect the patient from injury
responsible for instructing the patient about the
b. Insert an airway
test and for writing the order for the test.
c. Elevate the head of the bed
4. B. Mashed potatoes and broiled chicken are
d. Withdraw all pain medications low

397 in natural sodium chloride. Ham, olives, and

397 chicken bouillon contain large amounts of

ANSWERS and RATIONALES for FUNDAMENTALS sodium and are contraindicated on a low
OF sodium

NURSING PART 2 diet.

1. B. When a patient develops dyspnea and 5. D. All of the identified nursing responsibilities

shortness of breath, the orthopneic position are pertinent when a patient is receiving

encourages maximum chest expansion and heparin. The normal activated partial

keeps the abdominal organs from pressing thromboplastin time is 16 to 25 seconds and the

against the diaphragm, thus improving normal prothrombin time is 12 to 15 seconds;

ventilation. Bed rest and oxygen by Venturi these levels must remain within two to two and
mask
one half the normal levels. All patients receiving
at 24% would improve oxygenation of the
anticoagulant therapy must be observed for
tissues and cells but must be ordered by a
signs and symptoms of frank and occult
physician. Allowing for rest periods decreases bleeding

the possibility of hypoxia. (including hemorrhage, hypotension,

2. C. Orthopnea is difficulty of breathing except tachycardia, tachypnea, restlessness, pallor, cold

in
and clammy skin, thirst and confusion); blood
the upright position. Tachypnea is rapid
pressure should be measured every 4 hours and
respiration characterized by quick, shallow
the patient should be instructed to report
breaths. Eupnea is normal respiration – quiet,
promptly any bleeding that occurs with tooth
rhythmic, and without effort.
brushing, bowel movements, urination or heavy
prolonged menstruation. 9. C. Although a new head nurse should initially

6. D. The focus concepts that have been spend time observing the unit for its strengths
accepted
and weakness, she should take action if a
by all theorists as the focus of nursing practice
problem threatens patient safety. In this case,
from the time of Florence Nightingale include
the supervisor is the resource person to
the person receiving nursing care, his
approach.
environment, his health on the health illness
10. D. Studies have shown that patients and
continuum, and the nursing actions necessary to nurses

meet his needs. both respond well to primary nursing care units.

7. D. Maslow, who defined a need as a Patients feel less anxious and isolated and more
satisfaction
secure because they are allowed to participate
whose absence causes illness, considered
in planning their own care. Nurses feel personal
oxygen to be the most important physiologic
satisfaction, much of it related to positive
need; without it, human life could not exist.
feedback from the patients. They also seem to
According to this theory, other physiologic
gain a greater sense of achievement and esprit
needs
de corps.
(including food, water, elimination, shelter, rest
11. A. Assault is the unjustifiable attempt or
and sleep, activity and temperature regulation)
threat
must be met before proceeding to the next
to touch or injure another person. Battery is the
hierarchical levels on psychosocial needs.
unlawful touching of another person or the
8. B. The brain-dead patient’s family needs
carrying out of threatened physical harm. Thus,
support
any act that a nurse performs on the patient
and reassurance in making a decision about
against his will is considered assault and battery.
organ donation. Because transplants are done
12. A. Oral communication that injures an
within hours of death, decisions about organ
individual’s reputation is considered slander.
donation must be made as soon as possible.
Written communication that does the same is
However, the family’s concerns must be
considered libel.
addressed before members are asked to sign a
13. D. Malpractice is defined as injurious or
consent form. The body of an organ donor is
unprofessional actions that harm another. It
available for burial.
involves professional misconduct, such as these might include immobility, diaphoresis, and

omission or commission of an act that a avoidance of deep breathing or coughing, as

well
reasonable and prudent nurse would or would
as increased heart rate, shallow respirations
not do. In this example, the standard of care
was (stemming from pain upon moving the

398 diaphragm and respiratory muscles), and

398 guarding or rigidity of the abdominal wall. Such

a
breached; a 3-month-old infant should never be
patient is unlikely to display emotion, such as
left unattended on a scale.
crying.
14. A. The three elements necessary to establish
a 16. B. To assess for GI tract bleeding when frank

nursing malpractice are nursing error blood is absent, the nurse has two options: She

(administering penicillin to a patient with a can test for occult blood in vomitus, if present,

documented allergy to the drug), injury or in stool – through guaiac (Hemoccult) test. A
(cerebral
complete blood count does not provide
damage), and proximal cause (administering the
immediate results and does not always
penicillin caused the cerebral damage). Applying
immediately reflect blood loss. Changes in vital
a hot water bottle or heating pad to a patient
signs may be cause by factors other than blood
without a physician’s order does not include the
loss. Abdominal girth is unrelated to blood loss.
three required components. Assisting a patient
17. D. Because percussion and palpation can
out of bed with the bed locked in position is the affect

correct nursing practice; therefore, the fracture bowel motility and thus bowel sounds, they

was not the result of malpractice. Administering should follow auscultation in abdominal

an incorrect medication is a nursing error; assessment. Tympanic percussion,

measurement
however, if such action resulted in a serious
of abdominal girth, and inspection are methods
illness or chronic problem, the nurse could be
of assessing the abdomen. Assessing for
sued for malpractice.
distention, tenderness and discoloration around
15. C. An Asian patient is likely to hide his pain.
the umbilicus can indicate various bowel-related
Consequently, the nurse must observe for
conditions, such as cholecystitis, appendicitis
objective signs. In an abdominal surgery patient,
and peritonitis. 21. B. During a Romberg test, which evaluates
for
18. C. Hyperactive sounds indicate increased
bowel sensory or cerebellar ataxia, the patient must

motility; two or three sounds per minute stand with feet together and arms resting at the

indicate decreased bowel motility. Abdominal sides—first with eyes open, then with eyes

cramping with hyperactive, high pitched tinkling closed. The need to move the feet apart to

bowel sounds can indicate a bowel obstruction. maintain this stance is an abnormal finding.

19. C. The supine position (also called the dorsal 22. A. The pulse pressure is the difference
between
position), in which the patient lies on his back
the systolic and diastolic blood pressure
with his face upward, allows for easy access to
readings
the abdomen. In the prone position, the patient
– in this case, 54.
lies on his abdomen with his face turned to the
23. D. A slightly elevated temperature in the
side. In the Trendelenburg position, the head of
immediate preoperative or post operative
the bed is tilted downward to 30 to 40 degrees
period may result from the lack of fluids before
so that the upper body is lower than the legs. In
surgery rather than from infection. Anxiety will
the lateral position, the patient lies on his side.
not cause an elevated temperature.
20. D. All of these positions are appropriate for
Hypothermia is an abnormally low body
a
temperature.
rectal examination. In the genupectoral
(kneechest) 24. D. The quality and efficiency of the
respiratory
position, the patient kneels and rests his
process can be determined by appraising the
chest on the table, forming a 90 degree angle
rate, rhythm, depth, ease, sound, and symmetry
between the torso and upper legs. In Sims’
of respirations.
position, the patient lies on his left side with the
25. D. Under normal conditions, a healthy adult
left arm behind the body and his right leg
flexed. breathes in a smooth uninterrupted pattern 12

In the horizontal recumbent position, the to 20 times a minute. Thus, a respiratory rate of
patient
30 would be abnormal. A normal adult body
lies on his back with legs extended and hips
temperature, as measured on an oral
rotated outward.
thermometer, ranges between 97° and 100°F
(36.1° and 37.8°C); an axillary temperature is in 10% to 20% of the population, its absence is

approximately one degree lower and a rectal not necessarily a significant finding. However,

temperature, one degree higher. Thus, an the presence or absence of the pedal pulse

axillary temperature of 99.6°F (37.6°C) would be should be documented upon admission so that

considered abnormal. The resting pulse rate in changes can be identified during the hospital

399 stay. Absence of the apical, radial, or femoral

399 pulse is abnormal and should be investigated.

an adult ranges from 60 to 100 beats/minute, so 29. B. Pressure ulcers are most likely to develop
in
a rate of 88 is normal.
patients with impaired mental status, mobility,
26. D. Parasympathetic nervous system
stimulation activity level, nutrition, circulation and bladder

of the heart decreases the heart rate as well as or bowel control. Age is also a factor. Thus, the

the force of contraction, rate of impulse 88-year old incontinent patient who has

conduction and blood flow through the impaired nutrition (from gastric cancer) and is
coronary
confined to bed is at greater risk.
vessels. Fever, exercise, and sympathetic
30. A. Adequate hydration thins and loosens
stimulation all increase the heart rate.
pulmonary secretions and also helps to replace
27. D. The apical pulse (the pulse at the apex of
fluids lost from elevated temperature,
the
diaphoresis, dehydration and dyspnea.
heart) is located on the midclavicular line at the
Highhumidity
fourth, fifth, or sixth intercostal space. Base line
air and chest physiotherapy help
vital signs include pulse rate, temperature,
liquefy and mobilize secretions.
respiratory rate, and blood pressure. Blood
31. A. Chronic alcoholism commonly results in
pressure is typically assessed at the antecubital
thiamine deficiency and other symptoms of
fossa, and respiratory rate is assessed best by
malnutrition.
observing chest movement with each
32. C. A patient with dysphagia (difficulty
inspiration
swallowing) requires assistance with feeding.
and expiration.
Feeding himself is a long-range expected
28. C. Because the pedal pulse cannot be
detected outcome. Soft foods, Fowler’s or semi-Fowler’s
position, and oral hygiene before eating should because no data indicate that the patient is

be part of the feeding regimen. coping ineffectively. Pain related to

33. A. A urine output of less than 30ml/hour immobilization of affected leg would be an

indicates hypovolemia or oliguria, which is appropriate nursing diagnosis for a patient with

related to kidney function and inadequate fluid a leg fracture.

intake. 37. D. “I know this will be difficult”

acknowledges
34. A. Fluids containing caffeine have a diuretic
the problem and suggests a resolution to it.
effect. Beets and urinary analgesics, such as
“Don’t worry..” offers some relief but doesn’t
pyridium, can color urine red. Kaopectate is an
recognize the patient’s feelings. “..I didn’t get to
anti diarrheal medication.
the bad news yet” would be inappropriate at
35. C. A hospitalized surgical patient leaving his
any
room for the first time fears rejection and others
time. “Your hair is really pretty” offers no
staring at him, so he should not walk alone.
consolation or alternatives to the patient.
Accompanying him will offer moral support,
38. B. Additional Vitamin C is needed in growth
enabling him to face the rest of the world.
periods, such as infancy and childhood, and
Patients should begin ambulation as soon as
during pregnancy to supply demands for fetal
possible after surgery to decrease complications
growth and maternal tissues. Other conditions
and to regain strength and confidence. Waiting
requiring extra vitamin C include wound healing,
to consult a physical therapist is unnecessary.
fever, infection and stress.
36. A. Thick, tenacious secretions, a dry, hacking
39. D. Delivery of more than 2 liters of oxygen
cough, orthopnea, and shortness of breath are per

signs of ineffective airway clearance. Ineffective minute to a patient with chronic obstructive

airway clearance related to dry, hacking cough is pulmonary disease (COPD), who is usually in a

incorrect because the cough is not the reason state of compensated respiratory acidosis
for
(retaining carbon dioxide (CO2)), can inhibit the
the ineffective airway clearance. Ineffective
hypoxic stimulus for respiration. An increased
individual coping related to COPD is wrong
partial pressure of carbon dioxide in arterial
because the etiology for a nursing diagnosis
blood (PACO2) would not initially result in
should not be a medical diagnosis (COPD) and
cardiac arrest. Circulatory overload and
respiratory excitement have no relevance to the bed. The other answers are incorrect

question. interpretations of the statistical data.

400 43. C. A patient who cannot care for himself at

400 home does not necessarily have impaired

40. C. Presenting symptoms of hypokalemia ( a awareness; he may simply have some degree of

serum potassium level below 3.5 mEq/liter) immobility.

include muscle weakness, chronic fatigue, and 44. D. Hip fracture, the most common injury
among
cardiac dysrhythmias. The combined effects of
elderly persons, usually results from
inadequate food intake and prolonged diarrhea
osteoporosis. The other answers are diseases
can deplete the potassium stores of a patient
that can occur in the elderly from physiologic
with GI problems.
changes.
41. D. Assisting a patient with ambulation and
45. A. Sleep disturbances, inability to
transfer from a bed to a chair allows the nurse
concentrate
to
and decreased appetite are symptoms of
evaluate the patient’s ability to carry out these
depression, the most common psychogenic
functions safely. Demonstrating the signal
disorder among elderly persons. Other
system and providing an opportunity for a
return symptoms include diminished memory, apathy,

demonstration ensures that the patient knows disinterest in appearance, withdrawal, and

how to operate the equipment and encourages irritability. Depression typically begins before
the
him to call for assistance when needed.
Checking onset of old age and usually is caused by

the patient’s identification band verifies the psychosocial, genetic, or biochemical factors

patient’s identity and prevents identification 46. D. Aging decreases elasticity of the blood

mistakes in drug administration. vessels, which leads to increased peripheral

42. D. Since about 40% of patients fall out of resistance and decreased blood flow. These
bed
changes, in turn, increase the work load of the
despite the use of side rails, side rails cannot be
left ventricle.
said to prevent falls; however, they do serve as a
47. D. Alzheimer;s disease, sometimes known as
reminder that the patient should not get out of
senile dementia of the Alzheimer’s type or
primary degenerative dementia, is an insidious; decreased person’s head and shoulders to

progressive, irreversible, and degenerative prevent blood from settling in the face and

disease of the brain whose etiology is still discoloring it. She is required to bathe only

unknown. Parkinson’s disease is a neurologic soiled areas of the body since the mortician will

disorder caused by lesions in the wash the entire body. Before wrapping the body
extrapyramidial
in a shroud, the nurse places a clean gown on
system and manifested by tremors, muscle
the body and closes the eyes and mouth.
rigidity, hypokinesis, dysphagia, and dysphonia.
50. A. Ensuring the patient’s safety is the most
Multiple sclerosis, a progressive, degenerative
essential action at this time. The other nursing
disease involving demyelination of the nerve
actions may be necessary but are not a major
fibers, usually begins in young adulthood and is
priority.
marked by periods of remission and
401
exacerbation. Amyotrophic lateral sclerosis, a
401
disease marked by progressive degeneration of
FUNDAMENTALS OF NURSING PART 3
the neurons, eventually results in atrophy of all
1. Which element in the circular chain of
the muscles; including those necessary for infection

respiration. can be eliminated by preserving skin integrity?

48. C. The nurse is legally responsible for a. Host

labeling
b. Reservoir
the corpse when death occurs in the hospital.
c. Mode of transmission
She may be involved in obtaining consent for an
d. Portal of entry
autopsy or notifying the coroner or medical
2. Which of the following will probably result in
examiner of a patient’s death; however, she is a

not legally responsible for performing these break in sterile technique for respiratory

functions. The attending physician may need isolation?

information from the nurse to complete the a. Opening the patient’s window to the

death certificate, but he is responsible for outside environment

issuing
b. Turning on the patient’s room ventilator
it.
c. Opening the door of the patient’s room
49. B. The nurse must place a pillow under the
leading into the hospital corridor b. Urinary catheterization

d. Failing to wear gloves when c. Nasogastric tube insertion

administering a bed bath d. Colostomy irrigation

3. Which of the following patients is at greater 7. Sterile technique is used whenever:

risk
a. Strict isolation is required
for contracting an infection?
b. Terminal disinfection is performed
a. A patient with leukopenia
c. Invasive procedures are performed
b. A patient receiving broad-spectrum
d. Protective isolation is necessary
antibiotics
8. Which of the following constitutes a break in
c. A postoperative patient who has
sterile technique while preparing a sterile field
undergone orthopedic surgery
for a dressing change?
d. A newly diagnosed diabetic patient
a. Using sterile forceps, rather than sterile
4. Effective hand washing requires the use of:
gloves, to handle a sterile item
a. Soap or detergent to promote
b. Touching the outside wrapper of
emulsification
sterilized material without sterile gloves
b. Hot water to destroy bacteria
c. Placing a sterile object on the edge of
c. A disinfectant to increase surface
the sterile field
tension
d. Pouring out a small amount of solution
d. All of the above
(15 to 30 ml) before pouring the solution
5. After routine patient contact, hand washing
into a sterile container
should last at least:
9. A natural body defense that plays an active
a. 30 seconds role

b. 1 minute in preventing infection is:

c. 2 minute a. Yawning

d. 3 minutes b. Body hair

6. Which of the following procedures always c. Hiccupping

requires surgical asepsis? d. Rapid eye movements

a. Vaginal instillation of conjugated 10. All of the following statement are true about

estrogen donning sterile gloves except:

a. The first glove should be picked up by injections

grasping the inside of the cuff. d. Follow enteric precautions

b. The second glove should be picked up by 13. All of the following measures are
recommended
inserting the gloved fingers under the
to prevent pressure ulcers except:
cuff outside the glove.
a. Massaging the reddened are with lotion
c. The gloves should be adjusted by sliding
402
the gloved fingers under the sterile cuff
402
and pulling the glove over the wrist
b. Using a water or air mattress
d. The inside of the glove is considered
c. Adhering to a schedule for positioning
sterile
and turning
11. When removing a contaminated gown, the
nurse d. Providing meticulous skin care

should be careful that the first thing she touches 14. Which of the following blood tests should be

is the: performed before a blood transfusion?

a. Waist tie and neck tie at the back of the a. Prothrombin and coagulation time

gown b. Blood typing and cross-matching

b. Waist tie in front of the gown c. Bleeding and clotting time

c. Cuffs of the gown d. Complete blood count (CBC) and

d. Inside of the gown electrolyte levels.

12. Which of the following nursing interventions 15. The primary purpose of a platelet count is to
is
evaluate the:
considered the most effective form or universal
a. Potential for clot formation
precautions?
b. Potential for bleeding
a. Cap all used needles before removing
c. Presence of an antigen-antibody
them from their syringes
response
b. Discard all used uncapped needles and
d. Presence of cardiac enzymes
syringes in an impenetrable protective
16. Which of the following white blood cell
container (WBC)

c. Wear gloves when administering IM counts clearly indicates leukocytosis?

a. 4,500/mm³ 20. A patient with no known allergies is to
receive
b. 7,000/mm³
penicillin every 6 hours. When administering the
c. 10,000/mm³
medication, the nurse observes a fine rash on
d. 25,000/mm³
the patient’s skin. The most appropriate nursing
17. After 5 days of diuretic therapy with 20mg of
action would be to:
furosemide (Lasix) daily, a patient begins to
a. Withhold the moderation and notify the
exhibit fatigue, muscle cramping and muscle
physician
weakness. These symptoms probably indicate
b. Administer the medication and notify
that the patient is experiencing:
the physician
a. Hypokalemia
c. Administer the medication with an
b. Hyperkalemia
antihistamine
c. Anorexia
d. Apply corn starch soaks to the rash
d. Dysphagia
21. All of the following nursing interventions are
18. Which of the following statements about
chest correct when using the Z-track method of drug

X-ray is false? injection except:

a. No contradictions exist for this test a. Prepare the injection site with alcohol

b. Before the procedure, the patient should b. Use a needle that’s a least 1” long

remove all jewelry, metallic objects, and c. Aspirate for blood before injection

buttons above the waist d. Rub the site vigorously after the

c. A signed consent is not required injection to promote absorption

d. Eating, drinking, and medications are 22. The correct method for determining the
vastus
allowed before this test
lateralis site for I.M. injection is to:
19. The most appropriate time for the nurse to
a. Locate the upper aspect of the upper
obtain a sputum specimen for culture is:
outer quadrant of the buttock about 5 to
a. Early in the morning
8 cm below the iliac crest
b. After the patient eats a light breakfast
b. Palpate the lower edge of the acromion
c. After aerosol therapy
process and the midpoint lateral aspect
d. After chest physiotherapy
of the arm d. 26G

c. Palpate a 1” circular area anterior to the 403

umbilicus 403

d. Divide the area between the greater 26. Parenteral penicillin can be administered as
an:
femoral trochanter and the lateral
a. IM injection or an IV solution
femoral condyle into thirds, and select
b. IV or an intradermal injection
the middle third on the anterior of the
c. Intradermal or subcutaneous injection
thigh
d. IM or a subcutaneous injection
23. The mid-deltoid injection site is seldom used
for 27. The physician orders gr 10 of aspirin for a

I.M. injections because it: patient. The equivalent dose in milligrams is:

a. Can accommodate only 1 ml or less of a. 0.6 mg

medication b. 10 mg

b. Bruises too easily c. 60 mg

c. Can be used only when the patient is d. 600 mg

lying down 28. The physician orders an IV solution of

dextrose
d. Does not readily parenteral medication
5% in water at 100ml/hour. What would the
24. The appropriate needle size for insulin
injection flow rate be if the drop factor is 15 gtt = 1 ml?

is: a. 5 gtt/minute

a. 18G, 1 ½” long b. 13 gtt/minute

b. 22G, 1” long c. 25 gtt/minute

c. 22G, 1 ½” long d. 50 gtt/minute

d. 25G, 5/8” long 29. Which of the following is a sign or symptom

of a
25. The appropriate needle gauge for
intradermal hemolytic reaction to blood transfusion?

injection is: a. Hemoglobinuria

a. 20G b. Chest pain

b. 22G c. Urticaria

c. 25G d. Distended neck veins

30. Which of the following conditions may b. Capsules whole contents are dissolve in
require
water
fluid restriction?
c. Enteric-coated tablets that are
a. Fever
thoroughly dissolved in water
b. Chronic Obstructive Pulmonary Disease
d. Most tablets designed for oral use,
c. Renal Failure
except for extended-duration
d. Dehydration
compounds
31. All of the following are common signs and
34. A patient who develops hives after receiving
symptoms of phlebitis except: an

a. Pain or discomfort at the IV insertion site antibiotic is exhibiting drug:

b. Edema and warmth at the IV insertion a. Tolerance

site b. Idiosyncrasy

c. A red streak exiting the IV insertion site c. Synergism

d. Frank bleeding at the insertion site d. Allergy

32. The best way of determining whether a 35. A patient has returned to his room after
patient femoral

has learned to instill ear medication properly is arteriography. All of the following are

for the nurse to: appropriate nursing interventions except:

a. Ask the patient if he/she has used ear a. Assess femoral, popliteal, and pedal

drops before pulses every 15 minutes for 2 hours

b. Have the patient repeat the nurse’s b. Check the pressure dressing for

instructions using her own words sanguineous drainage

c. Demonstrate the procedure to the c. Assess a vital signs every 15 minutes for

patient and encourage to ask questions 2 hours

d. Ask the patient to demonstrate the d. Order a hemoglobin and hematocrit

procedure count 1 hour after the arteriography

33. Which of the following types of medications 36. The nurse explains to a patient that a cough:
can
a. Is a protective response to clear the
be administered via gastrostomy tube?
respiratory tract of irritants
a. Any oral medications
b. Is primarily a voluntary action c. Change the urine’s concentration

c. Is induced by the administration of an d. Inhibit the growth of microorganisms

antitussive drug 40. Clay colored stools indicate:

d. Can be inhibited by “splinting” the a. Upper GI bleeding

abdomen b. Impending constipation

37. An infected patient has chills and begins c. An effect of medication

shivering. The best nursing intervention is to: d. Bile obstruction

a. Apply iced alcohol sponges 41. In which step of the nursing process would
the
b. Provide increased cool liquids
nurse ask a patient if the medication she
c. Provide additional bedclothes
administered relieved his pain?
d. Provide increased ventilation
a. Assessment
38. A clinical nurse specialist is a nurse who has:
b. Analysis
a. Been certified by the National League for
c. Planning
Nursing
d. Evaluation
b. Received credentials from the Philippine
42. All of the following are good sources of
Nurses’ Association
vitamin A
c. Graduated from an associate degree
except:
program and is a registered professional
a. White potatoes
nurse
b. Carrots
d. Completed a master’s degree in the
c. Apricots
prescribed clinical area and is a
d. Egg yolks
registered professional nurse.
43. Which of the following is a primary nursing
39. The purpose of increasing urine acidity
intervention necessary for all patients with a
through
Foley Catheter in place?
dietary means is to:
a. Maintain the drainage tubing and
a. Decrease burning sensations
collection bag level with the patient’s
404
bladder
404
b. Irrigate the patient with 1% Neosporin
b. Change the urine’s color
solution three times a daily d. Having the patient shower with an

c. Clamp the catheter for 1 hour every 4 antiseptic soap on the evening v=before

hours to maintain the bladder’s elasticity and the morning of surgery

d. Maintain the drainage tubing and 47. When transferring a patient from a bed to a

collection bag below bladder level to chair, the nurse should use which muscles to

facilitate drainage by gravity avoid back injury?

44. The ELISA test is used to: a. Abdominal muscles

a. Screen blood donors for antibodies to b. Back muscles

human immunodeficiency virus (HIV) c. Leg muscles

b. Test blood to be used for transfusion for d. Upper arm muscles

HIV antibodies 48. Thrombophlebitis typically develops in

patients
c. Aid in diagnosing a patient with AIDS
with which of the following conditions?
d. All of the above
a. Increases partial thromboplastin time
45. The two blood vessels most commonly used
for b. Acute pulsus paradoxus

TPN infusion are the: c. An impaired or traumatized blood vessel

a. Subclavian and jugular veins wall

b. Brachial and subclavian veins d. Chronic Obstructive Pulmonary Disease

c. Femoral and subclavian veins (COPD)

d. Brachial and femoral veins 49. In a recumbent, immobilized patient, lung

46. Effective skin disinfection before a surgical ventilation can become altered, leading to such

procedure includes which of the following respiratory complications as:

methods? a. Respiratory acidosis, ateclectasis, and

a. Shaving the site on the day before hypostatic pneumonia

surgery b. Appneustic breathing, atypical

b. Applying a topical antiseptic to the skin pneumonia and respiratory alkalosis

on the evening before surgery c. Cheyne-Strokes respirations and

c. Having the patient take a tub bath on spontaneous pneumothorax

the morning of surgery d. Kussmail’s respirations and

hypoventilation washing is important for all types of isolation.

50. Immobility impairs bladder elimination, 3. A. Leukopenia is a decreased number of

resulting
leukocytes (white blood cells), which are
in such disorders as
important in resisting infection. None of the
a. Increased urine acidity and relaxation of
other situations would put the patient at risk for
the perineal muscles, causing
contracting an infection; taking broad-spectrum
incontinence
antibiotics might actually reduce the infection
b. Urine retention, bladder distention, and
risk.
infection
4. A. Soaps and detergents are used to help
c. Diuresis, natriuresis, and decreased
remove bacteria because of their ability to
urine specific gravity lower

d. Decreased calcium and phosphate levels the surface tension of water and act as

in the urine emulsifying agents. Hot water may lead to skin

405 irritation or burns.

405 5. A. Depending on the degree of exposure to

ANSWERS and RATIONALES for FUNDAMENTALS pathogens, hand washing may last from 10
OF
seconds to 4 minutes. After routine patient
NURSING PART 3
contact, hand washing for 30 seconds effectively
1. D. In the circular chain of infection, pathogens
minimizes the risk of pathogen transmission.
must be able to leave their reservoir and be
6. B. The urinary system is normally free of
transmitted to a susceptible host through a
microorganisms except at the urinary meatus.
portal of entry, such as broken skin.
Any procedure that involves entering this
2. C. Respiratory isolation, like strict isolation, system

requires that the door to the door patient’s must use surgically aseptic measures to
maintain
room remain closed. However, the patient’s
a bacteria-free state.
room should be well ventilated, so opening the
7. C. All invasive procedures, including surgery,
window or turning on the ventricular is
catheter insertion, and administration of
desirable. The nurse does not need to wear
parenteral therapy, require sterile technique to
gloves for respiratory isolation, but good hand
maintain a sterile environment. All equipment
must be sterile, and the nurse and the physician 10. D. The inside of the glove is always
considered to
must wear sterile gloves and maintain surgical
be clean, but not sterile.
asepsis. In the operating room, the nurse and
11. A. The back of the gown is considered clean,
physician are required to wear sterile gowns,
the
gloves, masks, hair covers, and shoe covers for
front is contaminated. So, after removing gloves
all invasive procedures. Strict isolation requires
and washing hands, the nurse should untie the
the use of clean gloves, masks, gowns and
back of the gown; slowly move backward away
equipment to prevent the transmission of highly
from the gown, holding the inside of the gown
communicable diseases by contact or by
and keeping the edges off the floor; turn and
airborne routes. Terminal disinfection is the
fold the gown inside out; discard it in a
disinfection of all contaminated supplies and
contaminated linen container; then wash her
equipment after a patient has been discharged
hands again.
to prepare them for reuse by another patient.
12. B. According to the Centers for Disease
The purpose of protective (reverse) isolation is Control

to prevent a person with seriously impaired (CDC), blood-to-blood contact occurs most

resistance from coming into contact who commonly when a health care worker attempts

potentially pathogenic organisms. to cap a used needle. Therefore, used needles

8. C. The edges of a sterile field are considered should never be recapped; instead they should

contaminated. When sterile items are allowed be inserted in a specially designed puncture
to
resistant, labeled container. Wearing gloves is
come in contact with the edges of the field, the
not always necessary when administering an
sterile items also become contaminated. I.M.

9. B. Hair on or within body areas, such as the injection. Enteric precautions prevent the

nose, traps and holds particles that contain transfer of pathogens via feces.

microorganisms. Yawning and hiccupping do not 13. A. Nurses and other health care
professionals
prevent microorganisms from entering or
previously believed that massaging a reddened
leaving the body. Rapid eye movement marks
area with lotion would promote venous return
the stage of sleep during which dreaming
occurs. and reduce edema to the area. However,
research has shown that massage only increases 16. D. Leukocytosis is any transient increase in
the
the likelihood of cellular ischemia and necrosis
number of white blood cells (leukocytes) in the
to the area.
blood. Normal WBC counts range from 5,000 to
14. B. Before a blood transfusion is performed,
the 100,000/mm3. Thus, a count of 25,000/mm3

blood of the donor and recipient must be indicates leukocytosis.

checked for compatibility. This is done by blood 17. A. Fatigue, muscle cramping, and muscle

typing (a test that determines a person’s blood weaknesses are symptoms of hypokalemia (an

type) and cross-matching (a procedure that inadequate potassium level), which is a

potential
determines the compatibility of the donor’s and
side effect of diuretic therapy. The physician
recipient’s blood after the blood types has been
usually orders supplemental potassium to
matched). If the blood specimens are
prevent hypokalemia in patients receiving
406
diuretics. Anorexia is another symptom of
406
hypokalemia. Dysphagia means difficulty
incompatible, hemolysis and antigen-antibody
swallowing.
reactions will occur.
18. A. Pregnancy or suspected pregnancy is the
15. A. Platelets are disk-shaped cells that are
only
essential for blood coagulation. A platelet count
contraindication for a chest X-ray. However, if a
determines the number of thrombocytes in
chest X-ray is necessary, the patient can wear a
blood available for promoting hemostasis and
lead apron to protect the pelvic region from
assisting with blood coagulation after injury. It
radiation. Jewelry, metallic objects, and buttons
also is used to evaluate the patient’s potential
would interfere with the X-ray and thus should
for bleeding; however, this is not its primary
not be worn above the waist. A signed consent
purpose. The normal count ranges from 150,000 is

to 350,000/mm3. A count of 100,000/mm3 or not required because a chest X-ray is not an

less indicates a potential for bleeding; count of invasive examination. Eating, drinking and

less than 20,000/mm3 is associated with medications are allowed because the X-ray is of

spontaneous bleeding. the chest, not the abdominal region.

19. A. Obtaining a sputum specimen early in this

morning ensures an adequate supply of bacteria injections because it has relatively few major

for culturing and decreases the risk of nerves and blood vessels. The middle third of
the
contamination from food or medication.
muscle is recommended as the injection site.
20. A. Initial sensitivity to penicillin is commonly
The patient can be in a supine or sitting position
manifested by a skin rash, even in individuals
for an injection into this site.
who have not been allergic to it previously.
23. A. The mid-deltoid injection site can
Because of the danger of anaphylactic shock, he
accommodate only 1 ml or less of medication
nurse should withhold the drug and notify the
because of its size and location (on the deltoid
physician, who may choose to substitute
muscle of the arm, close to the brachial artery
another drug. Administering an antihistamine is
and radial nerve).
a dependent nursing intervention that requires
a 24. D. A 25G, 5/8” needle is the recommended
size
written physician’s order. Although applying
for insulin injection because insulin is
corn starch to the rash may relieve discomfort, it
administered by the subcutaneous route. An
is not the nurse’s top priority in such a
18G, 1 ½” needle is usually used for I.M.
potentially life-threatening situation.
injections in children, typically in the vastus
21. D. The Z-track method is an I.M. injection
lateralis. A 22G, 1 ½” needle is usually used for
technique in which the patient’s skin is pulled in
adult I.M. injections, which are typically
such a way that the needle track is sealed off
administered in the vastus lateralis or
after the injection. This procedure seals
ventrogluteal site.
medication deep into the muscle, thereby
25. D. Because an intradermal injection does
minimizing skin staining and irritation. Rubbing
not
the injection site is contraindicated because it
penetrate deeply into the skin, a small-bore 25G
may cause the medication to extravasate into
needle is recommended. This type of injection is
the skin.
used primarily to administer antigens to
22. D. The vastus lateralis, a long, thick muscle
evaluate reactions for allergy or sensitivity
that
studies. A 20G needle is usually used for I.M.
extends the full length of the thigh, is viewed by
injections of oil-based medications; a 22G
many clinicians as the site of choice for I.M.
needle
for I.M. injections; and a 25G needle, for I.M. I.V. fluids may be necessary. Fever, chronic

injections; and a 25G needle, for subcutaneous obstructive pulmonary disease, and dehydration

insulin injections. are conditions for which fluids should be

26. A. Parenteral penicillin can be administered encouraged.

I.M.
31. D. Phlebitis, the inflammation of a vein, can
or added to a solution and given I.V. It cannot be be

administered subcutaneously or intradermally. caused by chemical irritants (I.V. solutions or

27. D. gr 10 x 60mg/gr 1 = 600 mg medications), mechanical irritants (the needle

or
28. C. 100ml/60 min X 15 gtt/ 1 ml = 25
gtt/minute catheter used during venipuncture or

29. A. Hemoglobinuria, the abnormal presence cannulation), or a localized allergic reaction to

of
the needle or catheter. Signs and symptoms of
hemoglobin in the urine, indicates a hemolytic
phlebitis include pain or discomfort, edema and
reaction (incompatibility of the donor’s and
heat at the I.V. insertion site, and a red streak
407
going up the arm or leg from the I.V. insertion
407
site.
recipient’s blood). In this reaction, antibodies in
32. D. Return demonstration provides the most
the recipient’s plasma combine rapidly with
certain evidence for evaluating the effectiveness
donor RBC’s; the cells are hemolyzed in either
of patient teaching.
circulatory or reticuloendothelial system.
33. D. Capsules, enteric-coated tablets, and
Hemolysis occurs more rapidly in ABO most

incompatibilities than in Rh incompatibilities. extended duration or sustained release

products
Chest pain and urticaria may be symptoms of
should not be dissolved for use in a gastrostomy
impending anaphylaxis. Distended neck veins
are tube. They are pharmaceutically manufactured

an indication of hypervolemia. in these forms for valid reasons, and altering

30. C. In real failure, the kidney loses their them destroys their purpose. The nurse should
ability to
seek an alternate physician’s order when an
effectively eliminate wastes and fluids. Because
ordered medication is inappropriate for delivery
of this, limiting the patient’s intake of oral and
by tube.
34. D. A drug-allergy is an adverse reaction 37. C. In an infected patient, shivering results
resulting from

from an immunologic response following a the body’s attempt to increase heat production

previous sensitizing exposure to the drug. The and the production of neutrophils and

reaction can range from a rash or hives to phagocytotic action through increased skeletal

anaphylactic shock. Tolerance to a drug means muscle tension and contractions. Initial

that the patient experiences a decreasing vasoconstriction may cause skin to feel cold to

physiologic response to repeated administration the touch. Applying additional bed clothes helps

of the drug in the same dosage. Idiosyncrasy is to equalize the body temperature and stop the

an individual’s unique hypersensitivity to a drug, chills. Attempts to cool the body result in
further
food, or other substance; it appears to be
shivering, increased metabloism, and thus
genetically determined. Synergism, is a drug
increased heat production.
interaction in which the sum of the drug’s
38. D. A clinical nurse specialist must have
combined effects is greater than that of their
completed a master’s degree in a clinical
separate effects.
specialty and be a registered professional nurse.
35. D. A hemoglobin and hematocrit count
would be The National League of Nursing accredits

ordered by the physician if bleeding were educational programs in nursing and provides a

suspected. The other answers are appropriate testing service to evaluate student nursing

nursing interventions for a patient who has competence but it does not certify nurses. The

undergone femoral arteriography. American Nurses Association identifies

36. A. Coughing, a protective response that requirements for certification and offers
clears
examinations for certification in many areas of
the respiratory tract of irritants, usually is
nursing., such as medical surgical nursing. These
involuntary; however it can be voluntary, as
certification (credentialing) demonstrates that
when a patient is taught to perform coughing
the nurse has the knowledge and the ability to
exercises. An antitussive drug inhibits coughing.
provide high quality nursing care in the area of
Splinting the abdomen supports the abdominal
her certification. A graduate of an associate
muscles when a patient coughs.
degree program is not a clinical nurse specialist:
however, she is prepared to provide bed side yolks.

nursing with a high degree of knowledge and 43. D. Maintaing the drainage tubing and
collection
skill. She must successfully complete the
bag level with the patient’s bladder could result
licensing examination to become a registered
in reflux of urine into the kidney. Irrigating the
professional nurse.
bladder with Neosporin and clamping the
39. D. Microorganisms usually do not grow in an
catheter for 1 hour every 4 hours must be
acidic environment.
prescribed by a physician.
40. D. Bile colors the stool brown. Any
inflammation 44. D. The ELISA test of venous blood is used to

or obstruction that impairs bile flow will affect assess blood and potential blood donors to

the stool pigment, yielding light, clay-colored human immunodeficiency virus (HIV). A positive

stool. Upper GI bleeding results in black or tarry ELISA test combined with various signs and

stool. Constipation is characterized by small, symptoms helps to diagnose acquired

hard masses. Many medications and foods will immunodeficiency syndrome (AIDS)

408 45. D. Tachypnea (an abnormally rapid rate of

408 breathing) would indicate that the patient was

discolor stool – for example, drugs containing still hypoxic (deficient in oxygen).The partial

iron turn stool black.; beets turn stool red. pressures of arterial oxygen and carbon dioxide

41. D. In the evaluation step of the nursing listed are within the normal range. Eupnea
process, refers

the nurse must decide whether the patient has to normal respiration.

achieved the expected outcome that was 46. D. Studies have shown that showering with
an
identified in the planning phase.
antiseptic soap before surgery is the most
42. A. The main sources of vitamin A are yellow
and effective method of removing microorganisms

green vegetables (such as carrots, sweet from the skin. Shaving the site of the intended

potatoes, squash, spinach, collard greens, surgery might cause breaks in the skin, thereby

broccoli, and cabbage) and yellow fruits (such as increasing the risk of infection; however, if

apricots, and cantaloupe). Animal sources indicated, shaving, should be done immediately

include liver, kidneys, cream, butter, and egg before surgery, not the day before. A topical
antiseptic would not remove microorganisms caused by stasis of mucus secretions.

and would be beneficial only after proper 50. B. The immobilized patient commonly
suffers
cleaning and rinsing. Tub bathing might transfer
from urine retention caused by decreased
organisms to another body site rather than rinse
muscle tone in the perineum. This leads to
them away.
bladder distention and urine stagnation, which
47. C. The leg muscles are the strongest muscles
in provide an excellent medium for bacterial

the body and should bear the greatest stress growth leading to infection. Immobility also

when lifting. Muscles of the abdomen, back, results in more alkaline urine with excessive
and
amounts of calcium, sodium and phosphate, a
upper arms may be easily injured.
gradual decrease in urine production, and an
48. C. The factors, known as Virchow’s triad,
increased specific gravity
collectively predispose a patient to
409
thromboplebitis; impaired venous return to the
409
heart, blood hypercoagulability, and injury to a
MATERNITY NURSING Part 1
blood vessel wall. Increased partial
1. When assessing the adequacy of sperm for
thromboplastin time indicates a prolonged
conception to occur, which of the following is
bleeding time during fibrin clot formation,
the most useful criterion?
commonly the result of anticoagulant (heparin)
a. Sperm count
therapy. Arterial blood disorders (such as pulsus
b. Sperm motility
paradoxus) and lung diseases (such as COPD) do
c. Sperm maturity
not necessarily impede venous return of injure
d. Semen volume
vessel walls.
2. A couple who wants to conceive but has been
49. A. Because of restricted respiratory
unsuccessful during the last 2 years has
movement,
undergone many diagnostic procedures. When
a recumbent, immobilize patient is at particular
discussing the situation with the nurse, one
risk for respiratory acidosis from poor gas
partner states, “We know several friends in our
exchange; atelectasis from reduced surfactant
age group and all of them have their own child
and accumulated mucus in the bronchioles, and
already, Why can’t we have one?”. Which of the
hypostatic pneumonia from bacterial growth
following would be the most pertinent nursing d. Cheeks, forehead, and nose

diagnosis for this couple? 6. A pregnant client states that she “waddles”

a. Fear related to the unknown when she walks. The nurse’s explanation is

b. Pain related to numerous procedures. based on which of the following as the cause?

c. Ineffective family coping related to a. The large size of the newborn

infertility. b. Pressure on the pelvic muscles

d. Self-esteem disturbance related to c. Relaxation of the pelvic joints

infertility. d. Excessive weight gain

3. Which of the following urinary symptoms 7. Which of the following represents the
does average

the pregnant woman most frequently amount of weight gained during pregnancy?

experience during the first trimester? a. 12 to 22 lb

a. Dysuria b. 15 to 25 lb

b. Frequency c. 24 to 30 lb

c. Incontinence d. 25 to 40 lb

d. Burning 8. When talking with a pregnant client who is

4. Heartburn and flatulence, common in the experiencing aching swollen, leg veins, the
nurse
second trimester, are most likely the result of
would explain that this is most probably the
which of the following?
result of which of the following?
a. Increased plasma HCG levels
a. Thrombophlebitis
b. Decreased intestinal motility
b. Pregnancy-induced hypertension
c. Decreased gastric acidity
c. Pressure on blood vessels from the
d. Elevated estrogen levels
enlarging uterus
5. On which of the following areas would the
nurse d. The force of gravity pulling down on the

expect to observe chloasma? uterus

a. Breast, areola, and nipples 9. Cervical softening and uterine souffle are

b. Chest, neck, arms, and legs classified as which of the following?

c. Abdomen, breast, and thighs a. Diagnostic signs

b. Presumptive signs a. Involution occurs more rapidly

c. Probable signs b. The incidence of allergies increases due

d. Positive signs to maternal antibodies

10. Which of the following would the nurse c. The father may resent the infant’s
identify
demands on the mother’s body
as a presumptive sign of pregnancy?
410
a. Hegar sign
410
b. Nausea and vomiting
d. There is a greater chance for error
c. Skin pigmentation changes
during preparation
d. Positive serum pregnancy test
14. Which of the following would cause a
11. Which of the following common emotional falsepositive

reactions to pregnancy would the nurse expect result on a pregnancy test?

to occur during the first trimester? a. The test was performed less than 10

a. Introversion, egocentrism, narcissism days after an abortion

b. Awkwardness, clumsiness, and b. The test was performed too early or too

unattractiveness late in the pregnancy

c. Anxiety, passivity, extroversion c. The urine sample was stored too long at

d. Ambivalence, fear, fantasies room temperature

12. During which of the following would the d. A spontaneous abortion or a missed
focus of
abortion is impending
classes be mainly on physiologic changes, fetal
15. FHR can be auscultated with a fetoscope as
development, sexuality, during pregnancy, and early

nutrition? as which of the following?

a. Prepregnant period a. 5 weeks gestation

b. First trimester b. 10 weeks gestation

c. Second trimester c. 15 weeks gestation

d. Third trimester d. 20 weeks gestation

13. Which of the following would be 16. A client LMP began July 5. Her EDD should
disadvantage of be

breast feeding? which of the following?

a. January 2 client experiencing true labor?

b. March 28 a. Occurring at irregular intervals

c. April 12 b. Starting mainly in the abdomen

d. October 12 c. Gradually increasing intervals

17. Which of the following fundal heights d. Increasing intensity with walking
indicates
21. During which of the following stages of labor
less than 12 weeks’ gestation when the date of
would the nurse assess “crowning”?
the LMP is unknown?
a. First stage
a. Uterus in the pelvis
b. Second stage
b. Uterus at the xiphoid
c. Third stage
c. Uterus in the abdomen
d. Fourth stage
d. Uterus at the umbilicus
22. Barbiturates are usually not given for pain
18. Which of the following danger signs should relief
be
during active labor for which of the following
reported promptly during the antepartum
reasons?
period?
a. The neonatal effects include hypotonia,
a. Constipation
hypothermia, generalized drowsiness,
b. Breast tenderness
and reluctance to feed for the first few
c. Nasal stuffiness
days.
d. Leaking amniotic fluid
b. These drugs readily cross the placental
19. Which of the following prenatal laboratory
barrier, causing depressive effects in the
test
newborn 2 to 3 hours after
values would the nurse consider as significant?
intramuscular injection.
a. Hematocrit 33.5%
c. They rapidly transfer across the
b. Rubella titer less than 1:8
placenta, and lack of an antagonist make
c. White blood cells 8,000/mm3
them generally inappropriate during
d. One hour glucose challenge test 110
labor.
g/dL
d. Adverse reactions may include maternal
20. Which of the following characteristics of
hypotension, allergic or toxic reaction or
contractions would the nurse expect to find in a
partial or total respiratory failure b. Foramen ovale

23. Which of the following nursing interventions c. Ductus arteriosus

would the nurse perform during the third stage 411

of labor? 411

a. Obtain a urine specimen and other d. Ductus venosus

laboratory tests. 27. Which of the following when present in the

b. Assess uterine contractions every 30 urine may cause a reddish stain on the diaper of

minutes. a newborn?

c. Coach for effective client pushing a. Mucus

d. Promote parent-newborn interaction. b. Uric acid crystals

24. Which of the following actions demonstrates c. Bilirubin

the
d. Excess iron
nurse’s understanding about the newborn’s
28. When assessing the newborn’s heart rate,
thermoregulatory ability? which

a. Placing the newborn under a radiant of the following ranges would be considered

warmer. normal if the newborn were sleeping?

b. Suctioning with a bulb syringe a. 80 beats per minute

c. Obtaining an Apgar score b. 100 beats per minute

d. Inspecting the newborn’s umbilical cord c. 120 beats per minute

25. Immediately before expulsion, which of the d. 140 beats per minute

following cardinal movements occur? 29. Which of the following is true regarding the

a. Descent fontanels of the newborn?

b. Flexion a. The anterior is triangular shaped; the

c. Extension posterior is diamond shaped.

d. External rotation b. The posterior closes at 18 months; the

26. Before birth, which of the following anterior closes at 8 to 12 weeks.

structures
c. The anterior is large in size when
connects the right and left auricles of the heart?
compared to the posterior fontanel.
a. Umbilical vein
d. The anterior is bulging; the posterior
appears sunken. describes hyperemesis gravidarum?

30. Which of the following groups of newborn a. Severe anemia leading to electrolyte,

reflexes below are present at birth and remain metabolic, and nutritional imbalances in

unchanged through adulthood? the absence of other medical problems.

a. Blink, cough, rooting, and gag b. Severe nausea and vomiting leading to

b. Blink, cough, sneeze, gag electrolyte, metabolic, and nutritional

c. Rooting, sneeze, swallowing, and cough imbalances in the absence of other

d. Stepping, blink, cough, and sneeze medical problems.

31. Which of the following describes the c. Loss of appetite and continuous
Babinski
vomiting that commonly results in
reflex?
dehydration and ultimately decreasing
a. The newborn’s toes will hyperextend
maternal nutrients
and fan apart from dorsiflexion of the
d. Severe nausea and diarrhea that can
big toe when one side of foot is stroked
cause gastrointestinal irritation and
upward from the ball of the heel and
possibly internal bleeding
across the ball of the foot.
33. Which of the following would the nurse
b. The newborn abducts and flexes all identify

extremities and may begin to cry when as a classic sign of PIH?

exposed to sudden movement or loud a. Edema of the feet and ankles

noise. b. Edema of the hands and face

c. The newborn turns the head in the c. Weight gain of 1 lb/week

direction of stimulus, opens the mouth, d. Early morning headache

and begins to suck when cheek, lip, or 34. In which of the following types of
spontaneous
corner of mouth is touched.
abortions would the nurse assess dark brown
d. The newborn will attempt to crawl
vaginal discharge and a negative pregnancy
forward with both arms and legs when
tests?
he is placed on his abdomen on a flat
a. Threatened
surface
b. Imminent
32. Which of the following statements best
c. Missed 38. Which of the following may happen if the
uterus
d. Incomplete
becomes overstimulated by oxytocin during the
35. Which of the following factors would the
nurse induction of labor?

suspect as predisposing a client to placenta a. Weak contraction prolonged to more

previa? than 70 seconds

a. Multiple gestation b. Tetanic contractions prolonged to more

b. Uterine anomalies than 90 seconds

c. Abdominal trauma c. Increased pain with bright red vaginal

d. Renal or vascular disease bleeding

36. Which of the following would the nurse d. Increased restlessness and anxiety
assess in
39. When preparing a client for cesarean
a client experiencing abruptio placenta? delivery,

a. Bright red, painless vaginal bleeding which of the following key concepts should be

b. Concealed or external dark red bleeding considered when implementing nursing care?

c. Palpable fetal outline a. Instruct the mother’s support person to

d. Soft and nontender abdomen remain in the family lounge until after

37. Which of the following is described as the delivery

premature
b. Arrange for a staff member of the
separation of a normally implanted placenta
anesthesia department to explain what
during the second half of pregnancy, usually
to expect postoperatively
with
c. Modify preoperative teaching to meet
severe hemorrhage?
the needs of either a planned or
a. Placenta previa
emergency cesarean birth
b. Ectopic pregnancy
d. Explain the surgery, expected outcome,
c. Incompetent cervix
and kind of anesthetics
d. Abruptio placentae
40. Which of the following best describes
412
preterm
412
labor?

a. Labor that begins after 20 weeks

gestation and before 37 weeks gestation b. Obtaining blood specimens

b. Labor that begins after 15 weeks c. Instituting complete bed rest

gestation and before 37 weeks gestation d. Inserting a urinary catheter

c. Labor that begins after 24 weeks 44. Which of the following is the nurse’s initial

gestation and before 28 weeks gestation action when umbilical cord prolapse occurs?

d. Labor that begins after 28 weeks a. Begin monitoring maternal vital signs

gestation and before 40 weeks gestation and FHR

41. When PROM occurs, which of the following b. Place the client in a knee-chest position

provides evidence of the nurse’s understanding in bed

of the client’s immediate needs? c. Notify the physician and prepare the

a. The chorion and amnion rupture 4 hours client for delivery

before the onset of labor. d. Apply a sterile warm saline dressing to

b. PROM removes the fetus most effective the exposed cord

defense against infection 45. Which of the following amounts of blood

loss
c. Nursing care is based on fetal viability
following birth marks the criterion for describing
and gestational age.
postpartum hemorrhage?
d. PROM is associated with
a. More than 200 ml
malpresentation and possibly
b. More than 300 ml
incompetent cervix
c. More than 400 ml
42. Which of the following factors is the
underlying d. More than 500 ml

cause of dystocia? 46. Which of the following is the primary

a. Nurtional predisposing factor related to mastitis?

b. Mechanical a. Epidemic infection from nosocomial

c. Environmental sources localizing in the lactiferous

d. Medical glands and ducts

43. When uterine rupture occurs, which of the b. Endemic infection occurring randomly

following would be the priority? and localizing in the periglandular

a. Limiting hypovolemic shock connective tissue

c. Temporary urinary retention due to sign, and swelling in the affected limb

decreased perception of the urge to d. Chills, fever, stiffness, and pain occurring

avoid 10 to 14 days after delivery

d. Breast injury caused by overdistention, 49. Which of the following are the most
commonly
stasis, and cracking of the nipples
assessed findings in cystitis?
47. Which of the following best describes
a. Frequency, urgency, dehydration,
thrombophlebitis?
nausea, chills, and flank pain
a. Inflammation and clot formation that
b. Nocturia, frequency, urgency dysuria,
result when blood components combine
hematuria, fever and suprapubic pain
to form an aggregate body
c. Dehydration, hypertension, dysuria,
b. Inflammation and blood clots that
suprapubic pain, chills, and fever
eventually become lodged within the
d. High fever, chills, flank pain nausea,
pulmonary blood vessels
vomiting, dysuria, and frequency
c. Inflammation and blood clots that
50. Which of the following best reflects the
eventually become lodged within the
frequency of reported postpartum “blues”?
femoral vein
a. Between 10% and 40% of all new
d. Inflammation of the vascular
mothers report some form of
endothelium with clot formation on the
postpartum blues
vessel wall
b. Between 30% and 50% of all new
413
mothers report some form of
413
postpartum blues
48. Which of the following assessment findings
c. Between 50% and 80% of all new
would the nurse expect if the client develops
mothers report some form of
DVT?
postpartum blues
a. Midcalf pain, tenderness and redness
d. Between 25% and 70% of all new
along the vein
mothers report some form of
b. Chills, fever, malaise, occurring 2 weeks
postpartum blues
after delivery

c. Muscle pain the presence of Homans

51. For the client who is using oral b. Nulliparous woman
contraceptives,
c. Promiscuous young adult
the nurse informs the client about the need to
d. Postpartum client
take the pill at the same time each day to
55. A client in her third trimester tells the nurse,
accomplish which of the following?
“I’m constipated all the time!” Which of the
a. Decrease the incidence of nausea
following should the nurse recommend?
b. Maintain hormonal levels
a. Daily enemas
c. Reduce side effects
b. Laxatives
d. Prevent drug interactions
c. Increased fiber intake
52. When teaching a client about contraception.
d. Decreased fluid intake
Which of the following would the nurse include
56. Which of the following would the nurse use
as the most effective method for preventing as

sexually transmitted infections? the basis for the teaching plan when caring for a

a. Spermicides pregnant teenager concerned about gaining too

b. Diaphragm much weight during pregnancy?

c. Condoms a. 10 pounds per trimester

d. Vasectomy b. 1 pound per week for 40 weeks

53. When preparing a woman who is 2 days c. ½ pound per week for 40 weeks

postpartum for discharge, recommendations for d. A total gain of 25 to 30 pounds

which of the following contraceptive methods 57. The client tells the nurse that her last
menstrual
would be avoided?
period started on January 14 and ended on
a. Diaphragm
January 20. Using Nagele’s rule, the nurse
b. Female condom
determines her EDD to be which of the
c. Oral contraceptives
following?
d. Rhythm method
a. September 27
54. For which of the following clients would the
b. October 21
nurse expect that an intrauterine device would
c. November 7
not be recommended?
d. December 27
a. Woman over age 35
58. When taking an obstetrical history on a a. Dietary intake
pregnant
b. Medication
client who states, “I had a son born at 38 weeks
c. Exercise
gestation, a daughter born at 30 weeks
d. Glucose monitoring
gestation
61. A client at 24 weeks gestation has gained 6
and I lost a baby at about 8 weeks,” the nurse
pounds in 4 weeks. Which of the following
should record her obstetrical history as which of
would
the following?
be the priority when assessing the client?
a. G2 T2 P0 A0 L2
a. Glucosuria
b. G3 T1 P1 A0 L2
b. Depression
c. G3 T2 P0 A0 L2
c. Hand/face edema
d. G4 T2 P1 A1 L2
d. Dietary intake
59. When preparing to listen to the fetal heart
62. A client 12 weeks’ pregnant come to the
rate
emergency department with abdominal
at 12 weeks’ gestation, the nurse would use
cramping and moderate vaginal bleeding.
which of the following?
Speculum examination reveals 2 to 3 cms
414
cervical dilation. The nurse would document
414
these findings as which of the following?
a. Stethoscope placed midline at the
a. Threatened abortion
umbilicus
b. Imminent abortion
b. Doppler placed midline at the
c. Complete abortion
suprapubic region
d. Missed abortion
c. Fetoscope placed midway between the
63. Which of the following would be the priority
umbilicus and the xiphoid process
nursing diagnosis for a client with an ectopic
d. External electronic fetal monitor placed
pregnancy?
at the umbilicus
a. Risk for infection
60. When developing a plan of care for a client
b. Pain
newly diagnosed with gestational diabetes,
c. Knowledge Deficit
which of the following instructions would be the
d. Anticipatory Grieving
priority?
64. Before assessing the postpartum client’s d. Determine the amount of lochia
uterus
67. The nurse assesses the postpartum vaginal
for firmness and position in relation to the
discharge (lochia) on four clients. Which of the
umbilicus and midline, which of the following
following assessments would warrant
should the nurse do first?
notification of the physician?
a. Assess the vital signs
a. A dark red discharge on a 2-day
b. Administer analgesia
postpartum client
c. Ambulate her in the hall
b. A pink to brownish discharge on a client
d. Assist her to urinate
who is 5 days postpartum
65. Which of the following should the nurse do
c. Almost colorless to creamy discharge on
when a primipara who is lactating tells the nurse
a client 2 weeks after delivery
that she has sore nipples?
d. A bright red discharge 5 days after
a. Tell her to breast feed more frequently
delivery
b. Administer a narcotic before breast
68. A postpartum client has a temperature of
feeding
101.4ºF, with a uterus that is tender when
c. Encourage her to wear a nursing
palpated, remains unusually large, and not
brassiere
descending as normally expected. Which of the
d. Use soap and water to clean the nipples
following should the nurse assess next?
66. The nurse assesses the vital signs of a client,
a. Lochia
4
b. Breasts
hours’ postpartum that are as follows: BP 90/60;
c. Incision
temperature 100.4ºF; pulse 100 weak, thready;
d. Urine
R 20 per minute. Which of the following should
69. Which of the following is the priority focus
the nurse do first?
of
a. Report the temperature to the physician
nursing practice with the current early
b. Recheck the blood pressure with
postpartum discharge?
another cuff
a. Promoting comfort and restoration of
c. Assess the uterus for firmness and
health
position
b. Exploring the emotional status of the
family a. Infection

c. Facilitating safe and effective self-and b. Hemorrhage

newborn care c. Discomfort

d. Teaching about the importance of family d. Dehydration

planning 73. The mother asks the nurse. “What’s wrong

with
70. Which of the following actions would be
least my son’s breasts? Why are they so enlarged?”

effective in maintaining a neutral thermal Whish of the following would be the best

environment for the newborn? response by the nurse?

415 a. “The breast tissue is inflamed from the

415 trauma experienced with birth”

a. Placing infant under radiant warmer b. “A decrease in material hormones

after bathing present before birth causes

b. Covering the scale with a warmed enlargement,”

blanket prior to weighing c. “You should discuss this with your

c. Placing crib close to nursery window for doctor. It could be a malignancy”

family viewing d. “The tissue has hypertrophied while the

d. Covering the infant’s head with a knit baby was in the uterus”

stockinette 74. Immediately after birth the nurse notes the

71. A newborn who has an asymmetrical Moro following on a male newborn: respirations 78;

reflex response should be further assessed for apical hearth rate 160 BPM, nostril flaring; mild

which of the following? intercostal retractions; and grunting at the end

a. Talipes equinovarus of expiration. Which of the following should the

b. Fractured clavicle nurse do?

c. Congenital hypothyroidism a. Call the assessment data to the

d. Increased intracranial pressure physician’s attention

72. During the first 4 hours after a male b. Start oxygen per nasal cannula at 2

circumcision, assessing for which of the L/min.

following is the priority? c. Suction the infant’s mouth and nares

d. Recognize this as normal first period of d. Elimination problems

reactivity 78. When measuring a client’s fundal height,

which
75. The nurse hears a mother telling a friend on
the of the following techniques denotes the correct

telephone about umbilical cord care. Which of method of measurement used by the nurse?

the following statements by the mother a. From the xiphoid process to the

indicates effective teaching? umbilicus

a. “Daily soap and water cleansing is best” b. From the symphysis pubis to the xiphoid

b. ‘Alcohol helps it dry and kills germs” process

c. “An antibiotic ointment applied daily c. From the symphysis pubis to the fundus

prevents infection” d. From the fundus to the umbilicus

d. “He can have a tub bath each day” 79. A client with severe preeclampsia is
admitted
76. A newborn weighing 3000 grams and
feeding with of BP 160/110, proteinuria, and severe

every 4 hours needs 120 calories/kg of body pitting edema. Which of the following would be

weight every 24 hours for proper growth and most important to include in the client’s plan of

development. How many ounces of 20 cal/oz care?

formula should this newborn receive at each a. Daily weights

feeding to meet nutritional needs? b. Seizure precautions

a. 2 ounces c. Right lateral positioning

b. 3 ounces d. Stress reduction

c. 4 ounces 80. A postpartum primipara asks the nurse,

“When
d. 6 ounces
can we have sexual intercourse again?” Which
77. The postterm neonate with meconium-
of
stained
the following would be the nurse’s best
amniotic fluid needs care designed to especially
response?
monitor for which of the following?
a. “Anytime you both want to.”
a. Respiratory problems
b. “As soon as choose a contraceptive
b. Gastrointestinal problems
method.”
c. Integumentary problems
c. “When the discharge has stopped and d. Secretion of estrogen by the fetal gonad

the incision is healed.” 84. A client at 8 weeks’ gestation calls

complaining
d. “After your 6 weeks examination.”
of slight nausea in the morning hours. Which of
81. When preparing to administer the vitamin K
the following client interventions should the
injection to a neonate, the nurse would select
nurse question?
416
a. Taking 1 teaspoon of bicarbonate of
416
soda in an 8-ounce glass of water
which of the following sites as appropriate for
b. Eating a few low-sodium crackers before
the injection?
getting out of bed
a. Deltoid muscle
c. Avoiding the intake of liquids in the
b. Anterior femoris muscle
morning hours
c. Vastus lateralis muscle
d. Eating six small meals a day instead of
d. Gluteus maximus muscle
thee large meals
82. When performing a pelvic examination, the
85. The nurse documents positive ballottement
nurse observes a red swollen area on the right
in
side of the vaginal orifice. The nurse would
the client’s prenatal record. The nurse
document this as enlargement of which of the
understands that this indicates which of the
following?
following?
a. Clitoris
a. Palpable contractions on the abdomen
b. Parotid gland
b. Passive movement of the unengaged
c. Skene’s gland
fetus
d. Bartholin’s gland
c. Fetal kicking felt by the client
83. To differentiate as a female, the hormonal
d. Enlargement and softening of the uterus
stimulation of the embryo that must occur
86. During a pelvic exam the nurse notes a
involves which of the following? purpleblue

a. Increase in maternal estrogen secretion tinge of the cervix. The nurse documents

b. Decrease in maternal androgen this as which of the following?

secretion a. Braxton-Hicks sign

c. Secretion of androgen by the fetal gonad b. Chadwick’s sign

c. Goodell’s sign 89. A multigravida at 38 weeks’ gestation is

d. McDonald’s sign admitted with painless, bright red bleeding and

87. During a prenatal class, the nurse explains mild contractions every 7 to 10 minutes. Which
the
of the following assessments should be
rationale for breathing techniques during avoided?

preparation for labor based on the a. Maternal vital sign

understanding that breathing techniques are b. Fetal heart rate

most important in achieving which of the c. Contraction monitoring

following? d. Cervical dilation

a. Eliminate pain and give the expectant 90. Which of the following would be the nurse’s

parents something to do most appropriate response to a client who asks

b. Reduce the risk of fetal distress by why she must have a cesarean delivery if she
has
increasing uteroplacental perfusion
a complete placenta previa?
c. Facilitate relaxation, possibly reducing
a. “You will have to ask your physician
the perception of pain
when he returns.”
d. Eliminate pain so that less analgesia and
b. “You need a cesarean to prevent
anesthesia are needed
hemorrhage.”
88. After 4 hours of active labor, the nurse notes
c. “The placenta is covering most of your
that the contractions of a primigravida client are
cervix.”
not strong enough to dilate the cervix. Which of
d. “The placenta is covering the opening of
the following would the nurse anticipate doing?
the uterus and blocking your baby.”
a. Obtaining an order to begin IV oxytocin
91. The nurse understands that the fetal head is
infusion
in
b. Administering a light sedative to allow
which of the following positions with a face
the patient to rest for several hour
presentation?
c. Preparing for a cesarean section for
a. Completely flexed
failure to progress
b. Completely extended
d. Increasing the encouragement to the
c. Partially extended
patient when pushing begins
417
417 d. Prolapsed umbilical cord

d. Partially flexed 95. When describing dizygotic twins to a couple,

on
92. With a fetus in the left-anterior breech
which of the following would the nurse base the
presentation, the nurse would expect the fetal
explanation?
heart rate would be most audible in which of
the a. Two ova fertilized by separate sperm

following areas? b. Sharing of a common placenta

a. Above the maternal umbilicus and to the c. Each ova with the same genotype

right of midline d. Sharing of a common chorion

b. In the lower-left maternal abdominal 96. Which of the following refers to the single
cell
quadrant
that reproduces itself after conception?
c. In the lower-right maternal abdominal
a. Chromosome
quadrant
b. Blastocyst
d. Above the maternal umbilicus and to the
c. Zygote
left of midline
d. Trophoblast
93. The amniotic fluid of a client has a greenish
tint. 97. In the late 1950s, consumers and health care

The nurse interprets this to be the result of professionals began challenging the routine use

which of the following? of analgesics and anesthetics during childbirth.

a. Lanugo Which of the following was an outgrowth of this

b. Hydramnio concept?

c. Meconium a. Labor, delivery, recovery, postpartum

d. Vernix (LDRP)

94. A patient is in labor and has just been told b. Nurse-midwifery

she
c. Clinical nurse specialist
has a breech presentation. The nurse should be
d. Prepared childbirth
particularly alert for which of the following?
98. A client has a midpelvic contracture from a
a. Quickening
previous pelvic injury due to a motor vehicle
b. Ophthalmia neonatorum
accident as a teenager. The nurse is aware that
c. Pica
this could prevent a fetus from passing through criterion when assessing male infertility. Sperm

or around which structure during childbirth? count, sperm maturity, and semen volume are

a. Symphysis pubis all significant, but they are not as significant

b. Sacral promontory sperm motility.

c. Ischial spines 2. D. Based on the partner’s statement, the

couple
d. Pubic arch
is verbalizing feelings of inadequacy and
99. When teaching a group of adolescents about
negative feelings about themselves and their
variations in the length of the menstrual cycle,
capabilities. Thus, the nursing diagnosis of
the nurse understands that the underlying
selfesteem
mechanism is due to variations in which of the
disturbance is most appropriate. Fear,
following phases?
pain, and ineffective family coping also may be
a. Menstrual phase
present but as secondary nursing diagnoses.
b. Proliferative phase
3. B. Pressure and irritation of the bladder by
c. Secretory phase the

d. Ischemic phase growing uterus during the first trimester is

100. When teaching a group of adolescents responsible for causing urinary frequency.

about male hormone production, which of the Dysuria, incontinence, and burning are

following would the nurse include as being symptoms associated with urinary tract

produced by the Leydig cells? infections.

a. Follicle-stimulating hormone 4. C. During the second trimester, the reduction

in
b. Testosterone
gastric acidity in conjunction with pressure from
c. Leuteinizing hormone
the growing uterus and smooth muscle
d. Gonadotropin releasing hormone
relaxation, can cause heartburn and flatulence.
418
HCG levels increase in the first, not the second,
418
trimester. Decrease intestinal motility would
ANSWERS and RATIONALES for MATERNITY
most likely be the cause of constipation and
NURSING Part 1
bloating. Estrogen levels decrease in the second
1. B. Although all of the factors listed are
trimester.
important, sperm motility is the most significant
5. D. Chloasma, also called the mask of Thrombophlebitis is an inflammation of the
pregnancy, veins

is an irregular hyperpigmented area found on due to thrombus formation. Pregnancy-induced

the face. It is not seen on the breasts, areola, hypertension is not associated with these

nipples, chest, neck, arms, legs, abdomen, or symptoms. Gravity plays only a minor role with

thighs. these symptoms.

6. C. During pregnancy, hormonal changes cause 9. C. Cervical softening (Goodell sign) and
uterine
relaxation of the pelvic joints, resulting in the
soufflé are two probable signs of pregnancy.
typical “waddling” gait. Changes in posture are
Probable signs are objective findings that
related to the growing fetus. Pressure on the
strongly suggest pregnancy. Other probable
surrounding muscles causing discomfort is due
signs include Hegar sign, which is softening of
to the growing uterus. Weight gain has no effect
the lower uterine segment; Piskacek sign, which
on gait.
is enlargement and softening of the uterus;
7. C. The average amount of weight gained
during serum laboratory tests; changes in skin

pregnancy is 24 to 30 lb. This weight gain pigmentation; and ultrasonic evidence of a

consists of the following: fetus – 7.5 lb; placenta gestational sac. Presumptive signs are subjective

and membrane – 1.5 lb; amniotic fluid – 2 lb; signs and include amenorrhea; nausea and

uterus – 2.5 lb; breasts – 3 lb; and increased vomiting; urinary frequency; breast tenderness

blood volume – 2 to 4 lb; extravascular fluid and and changes; excessive fatigue; uterine

fat – 4 to 9 lb. A gain of 12 to 22 lb is enlargement; and quickening.

insufficient,
10. B. Presumptive signs of pregnancy are
whereas a weight gain of 15 to 25 lb is marginal. subjective

A weight gain of 25 to 40 lb is considered signs. Of the signs listed, only nausea and

excessive. vomiting are presumptive signs. Hegar sign, skin

8. C. Pressure of the growing uterus on blood pigmentation changes, and a positive serum

vessels results in an increased risk for venous pregnancy test are considered probably signs,

stasis in the lower extremities. Subsequently, which are strongly suggestive of pregnancy.

edema and varicose vein formation may occur. 11. D. During the first trimester, common
emotional
reactions include ambivalence, fear, fantasies, thus minimizing blood loss. The presence of
or
maternal antibodies in breast milk helps
anxiety. The second trimester is a period of
decrease the incidence of allergies in the
wellbeing
newborn. A greater chance for error is
accompanied by the increased need to
associated with bottle feeding. No preparation
learn about fetal growth and development.
is
Common emotional reactions during this
required for breast feeding.
trimester include narcissism, passivity, or
14. A. A false-positive reaction can occur if the
introversion. At times the woman may seem
pregnancy test is performed less than 10 days
egocentric and self-centered. During the third
after an abortion. Performing the tests too early
trimester, the woman typically feels awkward,
or too late in the pregnancy, storing the urine
clumsy, and unattractive, often becoming more
sample too long at room temperature, or having
introverted or reflective of her own childhood.
a spontaneous or missed abortion impending
12. B. First-trimester classes commonly focus on
can all produce false-negative results.
such issues as early physiologic changes, fetal
15. D. The FHR can be auscultated with a
development, sexuality during pregnancy, and fetoscope

nutrition. Some early classes may include at about 20 week’s gestation. FHR usually is

pregnant couples. Second and third trimester ausculatated at the midline suprapubic region

classes may focus on preparation for birth, with Doppler ultrasound transducer at 10 to 12

parenting, and newborn care. week’s gestation. FHR, cannot be heard any

13. C. With breast feeding, the father’s body is earlier than 10 weeks’ gestation.
not
16. C. To determine the EDD when the date of
capable of providing the milk for the newborn, the

419 client’s LMP is known use Nagele rule. To the

419 first day of the LMP, add 7 days, subtract 3

which may interfere with feeding the newborn, months, and add 1 year (if applicable) to arrive

providing fewer chances for bonding, or he may at the EDD as follows: 5 + 7 = 12 (July) minus 3 =

be jealous of the infant’s demands on his wife’s 4 (April). Therefore, the client’s EDD is April 12.

time and body. Breast feeding is advantageous 17. A. When the LMP is unknown, the
gestational
because uterine involution occurs more rapidly,
age of the fetus is estimated by uterine size or gradually shortens.

position (fundal height). The presence of the 21. B. Crowing, which occurs when the
newborn’s
uterus in the pelvis indicates less than 12 weeks’
head or presenting part appears at the vaginal
gestation. At approximately 12 to 14 weeks, the
opening, occurs during the second stage of
fundus is out of the pelvis above the symphysis
labor. During the first stage of labor, cervical
pubis. The fundus is at the level of the umbilicus
dilation and effacement occur. During the third
at approximately 20 weeks’ gestation and
stage of labor, the newborn and placenta are
reaches the xiphoid at term or 40 weeks.
delivered. The fourth stage of labor lasts from 1
18. D. Danger signs that require prompt
reporting to 4 hours after birth, during which time the

leaking of amniotic fluid, vaginal bleeding, mother and newborn recover from the physical

blurred vision, rapid weight gain, and elevated process of birth and the mother’s organs

blood pressure. Constipation, breast undergo the initial readjustment to the

tenderness,
nonpregnant state.
and nasal stuffiness are common discomforts
22. C. Barbiturates are rapidly transferred across
associated with pregnancy. the

19. B. A rubella titer should be 1:8 or greater. placental barrier, and lack of an antagonist
Thurs,
makes them generally inappropriate during
a finding of a titer less than 1:8 is significant,
active labor. Neonatal side effects of
indicating that the client may not possess
barbiturates include central nervous system
immunity to rubella. A hematocrit of 33.5% a
depression, prolonged drowsiness, delayed
white blood cell count of 8,000/mm3, and a 1
establishment of feeding (e.g. due to poor
hour glucose challenge test of 110 g/dl are with
sucking reflex or poor sucking pressure).
normal parameters.
Tranquilizers are associated with neonatal
20. D. With true labor, contractions increase in
effects such as hypotonia, hypothermia,
intensity with walking. In addition, true labor
generalized drowsiness, and reluctance to feed
contractions occur at regular intervals, usually
for the first few days. Narcotic analgesic readily
starting in the back and sweeping around to the
cross the placental barrier, causing depressive
abdomen. The interval of true labor
effects in the newborn 2 to 3 hours after
contractions
intramuscular injection. Regional anesthesia is 25. D. Immediately before expulsion or birth of
the
associated with adverse reactions such as
rest of the body, the cardinal movement of
maternal hypotension, allergic or toxic reaction,
external rotation occurs. Descent flexion,
or partial or total respiratory failure.
internal rotation, extension, and restitution (in
23. D. During the third stage of labor, which
begins this order) occur before external rotation.

with the delivery of the newborn, the nurse 26. B. The foramen ovale is an opening between
the
would promote parent-newborn interaction by
right and left auricles (atria) that should close
placing the newborn on the mother’s abdomen
shortly after birth so the newborn will not have
and encouraging the parents to touch the
a
newborn. Collecting a urine specimen and other
murmur or mixed blood traveling through the
laboratory tests is done on admission during the
vascular system. The umbilical vein, ductus
first stage of labor. Assessing uterine
arteriosus, and ductus venosus are obliterated
contractions every 30 minutes is performed at

during the latent phase of the first stage of birth.

labor. Coaching the client to push effectively is 27. B. Uric acid crystals in the urine may
produce the
appropriate during the second stage of labor.
reddish “brick dust” stain on the diaper. Mucus
24. A. The newborn’s ability to regulate body
would not produce a stain. Bilirubin and iron are
temperature is poor. Therefore, placing the
from hepatic adaptation.
newborn under a radiant warmer aids in
28. B. The normal heart rate for a newborn that
maintaining his or her body temperature. is
420 sleeping is approximately 100 beats per minute.
420 If the newborn was awake, the normal heart
Suctioning with a bulb syringe helps maintain a rate

patent airway. Obtaining an Apgar score would range from 120 to 160 beats per minute.

measures the newborn’s immediate adjustment 29. C. The anterior fontanel is larger in size than
the
to extrauterine life. Inspecting the umbilical
cord posterior fontanel. Additionally, the anterior

aids in detecting cord anomalies. fontanel, which is diamond shaped, closes at 18

months, whereas the posterior fontanel, which

is triangular shaped, closes at 8 to 12 weeks. imbalances in the absence of other medical

Neither fontanel should appear bulging, which problems. Hyperemesis is not a form of anemia.

may indicate increased intracranial pressure, or Loss of appetite may occur secondary to the

sunken, which may indicate dehydration. nausea and vomiting of hyperemesis, which, if it

30. B. Blink, cough, sneeze, swallowing and gag continues, can deplete the nutrients
transported
reflexes are all present at birth and remain
to the fetus. Diarrhea does not occur with
unchanged through adulthood. Reflexes such as
hyperemesis.
rooting and stepping subside within the first
33. B. Edema of the hands and face is a classic
year.
sign
31. A. With the babinski reflex, the newborn’s
of PIH. Many healthy pregnant woman
toes
experience foot and ankle edema. A weight gain
hyperextend and fan apart from dorsiflexion of
of 2 lb or more per week indicates a problem.
the big toe when one side of foot is stroked
Early morning headache is not a classic sign of
upward form the heel and across the ball of the
PIH.
foot. With the startle reflex, the newborn
34. C. In a missed abortion, there is early fetal
abducts and flexes all extremities and may begin
intrauterine death, and products of conception
to cry when exposed to sudden movement of
are not expelled. The cervix remains closed;
loud noise. With the rooting and sucking reflex,
there may be a dark brown vaginal discharge,
the newborn turns his head in the direction of
negative pregnancy test, and cessation of
stimulus, opens the mouth, and begins to suck
uterine growth and breast tenderness. A
when the cheeks, lip, or corner of mouth is
threatened abortion is evidenced with cramping
touched. With the crawl reflex, the newborn will
and vaginal bleeding in early pregnancy, with no
attempt to crawl forward with both arms and
cervical dilation. An incomplete abortion
legs when he is placed on his abdomen on a flat
presents with bleeding, cramping, and cervical
surface.
dilation. An incomplete abortion involves only
32. B. The description of hyperemesis
gravidarum expulsion of part of the products of conception

includes severe nausea and vomiting, leading to and bleeding occurs with cervical dilation.

electrolyte, metabolic, and nutritional 35. A. Multiple gestation is one of the

predisposing
factors that may cause placenta previa. Uterine 38. B. Hyperstimulation of the uterus such as
with
anomalies abdominal trauma, and renal or
oxytocin during the induction of labor may
vascular disease may predispose a client to
result
abruptio placentae.
in tetanic contractions prolonged to more than
36. B. A client with abruptio placentae may
90seconds, which could lead to such
exhibit
complications as fetal distress, abruptio
concealed or dark red bleeding, possibly
placentae, amniotic fluid embolism, laceration
reporting sudden intense localized uterine pain.
of
The uterus is typically firm to boardlike, and the
the cervix, and uterine rupture. Weak
fetal presenting part may be engaged. Bright
contractions would not occur. Pain, bright red
red, painless vaginal bleeding, a palpable fetal
vaginal bleeding, and increased restlessness and
outline and a soft nontender abdomen are
anxiety are not associated with
manifestations of placenta previa.
hyperstimulation.
37. D. Abruptio placentae is described as
39. C. A key point to consider when preparing
premature
the
separation of a normally implanted placenta
client for a cesarean delivery is to modify the
during the second half of pregnancy, usually
preoperative teaching to meet the needs of
with
either a planned or emergency cesarean birth,
severe hemorrhage. Placenta previa refers to
the depth and breadth of instruction will
implantation of the placenta in the lower
depend
uterine
on circumstances and time available. Allowing
segment, causing painless bleeding in the third
the mother’s support person to remain with her
trimester of pregnancy. Ectopic pregnancy refers
as much as possible is an important concept,
to the implantation of the products of
although doing so depends on many variables.
421
Arranging for necessary explanations by various
421
staff members to be involved with the client’s
conception in a site other than the
care is a nursing responsibility. The nurse is
endometrium. Incompetent cervix is a
responsible for reinforcing the explanations
conduction characterized by painful dilation of
about the surgery, expected outcome, and type
the cervical os without uterine contractions.
of anesthetic to be used. The obstetrician is 43. A. With uterine rupture, the client is at risk
for
responsible for explaining about the surgery and
hypovolemic shock. Therefore, the priority is to
outcome and the anesthesiology staff is
prevent and limit hypovolemic shock.
responsible for explanations about the type of
Immediate
anesthesia to be used.
steps should include giving oxygen, replacing
40. A. Preterm labor is best described as labor lost
that
fluids, providing drug therapy as needed,
begins after 20 weeks’ gestation and before 37
evaluating fetal responses and preparing for
weeks’ gestation. The other time periods are
surgery. Obtaining blood specimens, instituting
inaccurate.
complete bed rest, and inserting a urinary
41. B. PROM can precipitate many potential and
catheter are necessary in preparation for
actual problems; one of the most serious is the surgery

fetus loss of an effective defense against to remedy the rupture.

infection. This is the client’s most immediate 44. B. The immediate priority is to minimize

need at this time. Typically, PROM occurs about pressure on the cord. Thus the nurse’s initial

1 hour, not 4 hours, before labor begins. Fetal action involves placing the client on bed rest
and
viability and gestational age are less immediate
then placing the client in a knee-chest position
considerations that affect the plan of care.
or lowering the head of the bed, and elevating
Malpresentation and an incompetent cervix
may the maternal hips on a pillow to minimize the

be causes of PROM. pressure on the cord. Monitoring maternal vital

42. B. Dystocia is difficult, painful, prolonged signs and FHR, notifying the physician and
labor
preparing the client for delivery, and wrapping
due to mechanical factors involving the fetus
the cord with sterile saline soaked warm gauze
(passenger), uterus (powers), pelvis (passage),
are important. But these actions have no effect
or
on minimizing the pressure on the cord.
psyche. Nutritional, environment, and medical
45. D. Postpartum hemorrhage is defined as
factors may contribute to the mechanical factors
blood
that cause dystocia.
loss of more than 500 ml following birth. Any

amount less than this not considered

postpartum hemorrhage. 422

46. D. With mastitis, injury to the breast, such as pain occurring 10 to 14 days after delivery

overdistention, stasis, and cracking of the suggest femoral thrombophlebitis.

nipples, is the primary predisposing factor. 49. B. Manifestations of cystitis include,

frequency,
Epidemic and endemic infections are probable
urgency, dysuria, hematuria nocturia, fever, and
sources of infection for mastitis. Temporary
suprapubic pain. Dehydration, hypertension,
urinary retention due to decreased perception
and
of
chills are not typically associated with cystitis.
the urge to void is a contributory factor to the
High fever chills, flank pain, nausea, vomiting,
development of urinary tract infection, not
dysuria, and frequency are associated with
mastitis.
pvelonephritis.
47. D. Thrombophlebitis refers to an
inflammation 50. C. According to statistical reports, between
50%
of the vascular endothelium with clot formation
and 80% of all new mothers report some form
on the wall of the vessel. Blood components
of
combining to form an aggregate body describe a
postpartum blues. The ranges of 10% to 40%,
thrombus or thrombosis. Clots lodging in the
30% to 50%, and 25% to 70% are incorrect.
pulmonary vasculature refers to pulmonary
51. B. Regular timely ingestion of oral
embolism; in the femoral vein, femoral contraceptives

thrombophlebitis. is necessary to maintain hormonal levels of the

48. C. Classic symptoms of DVT include muscle drugs to suppress the action of the
pain,
hypothalamus and anterior pituitary leading to
the presence of Homans sign, and swelling of
inappropriate secretion of FSH and LH.
the
Therefore, follicles do not mature, ovulation is
affected limb. Midcalf pain, tenderness, and
inhibited, and pregnancy is prevented. The
redness, along the vein reflect superficial
estrogen content of the oral site contraceptive
thrombophlebitis. Chills, fever and malaise
may cause the nausea, regardless of when the
occurring 2 weeks after delivery reflect pelvic
pill is taken. Side effects and drug interactions
thrombophlebitis. Chills, fever, stiffness and
may occur with oral contraceptives regardless of
422
the time the pill is taken. vagina until involution is completed at

52. C. Condoms, when used correctly and approximately 6 weeks. Use of a female condom

consistently, are the most effective protects the reproductive system from the

contraceptive method or barrier against introduction of semen or spermicides into the

bacterial and viral sexually transmitted vagina and may be used after childbirth. Oral

infections. Although spermicides kill sperm, contraceptives may be started within the first
they
postpartum week to ensure suppression of
do not provide reliable protection against the
ovulation. For the couple who has determined
spread of sexually transmitted infections,
the female’s fertile period, using the rhythm
especially intracellular organisms such as HIV.
method, avoidance of intercourse during this
Insertion and removal of the diaphragm along
period, is safe and effective.
with the use of the spermicides may cause
54. C. An IUD may increase the risk of pelvic
vaginal irritations, which could place the client
inflammatory disease, especially in women with
at
more than one sexual partner, because of the
risk for infection transmission. Male sterilization
increased risk of sexually transmitted infections.
eliminates spermatozoa from the ejaculate, but
An UID should not be used if the woman has an
it does not eliminate bacterial and/or viral
active or chronic pelvic infection, postpartum
microorganisms that can cause sexually
infection, endometrial hyperplasia or
transmitted infections.
carcinoma,
53. A. The diaphragm must be fitted individually
or uterine abnormalities. Age is not a factor in
to
determining the risks associated with IUD use.
ensure effectiveness. Because of the changes to
Most IUD users are over the age of 30. Although
the reproductive structures during pregnancy
there is a slightly higher risk for infertility in
and following delivery, the diaphragm must be
women who have never been pregnant, the IUD
refitted, usually at the 6 weeks’ examination
is an acceptable option as long as the riskbenefit
following childbirth or after a weight loss of 15
ratio is discussed. IUDs may be inserted
lbs or more. In addition, for maximum
immediately after delivery, but this is not
effectiveness, spermicidal jelly should be placed
recommended because of the increased risk
in the dome and around the rim. However,
and
spermicidal jelly should not be inserted into the
rate of expulsion at this time. weight in the first and second trimester than in

55. C. During the third trimester, the enlarging the third. During the first trimester, the client

uterus places pressure on the intestines. This should only gain 1.5 pounds in the first 10

coupled with the effect of hormones on smooth weeks, not 1 pound per week. A weight gain of
½
muscle relaxation causes decreased intestinal
pound per week would be 20 pounds for the
motility (peristalsis). Increasing fiber in the diet
total pregnancy, less than the recommended
will help fecal matter pass more quickly through
amount.
the intestinal tract, thus decreasing the amount
57. B. To calculate the EDD by Nagele’s rule, add
of water that is absorbed. As a result, stool is
7
softer and easier to pass. Enemas could
days to the first day of the last menstrual period
precipitate preterm labor and/or electrolyte loss
and count back 3 months, changing the year
and should be avoided. Laxatives may cause
appropriately. To obtain a date of September 27,
preterm labor by stimulating peristalsis and may
7 days have been added to the last day of the
interfere with the absorption of nutrients. Use
LMP (rather than the first day of the LMP), plus
for more than 1 week can also lead to laxative 4

dependency. Liquid in the diet helps provide a months (instead of 3 months) were counted

semisolid, soft consistency to the stool. Eight to back. To obtain the date of November 7, 7 days

ten glasses of fluid per day are essential to have been subtracted (instead of added) from

maintain hydration and promote stool the first day of LMP plus November indicates

evacuation. counting back 2 months (instead of 3 months)

56. D. To ensure adequate fetal growth and from January. To obtain the date of December

development during the 40 weeks of a 27, 7 days were added to the last day of the
LMP
pregnancy, a total weight gain 25 to 30 pounds
is (rather than the first day of the LMP) and

recommended: 1.5 pounds in the first 10 weeks; December indicates counting back only 1 month

9 pounds by 30 weeks; and 27.5 pounds by 40 (instead of 3 months) from January.

weeks. The pregnant woman should gain less 58. D. The client has been pregnant four times,

423 including current pregnancy (G). Birth at 38

423 weeks’ gestation is considered full term (T),

while birth form 20 weeks to 38 weeks is women, because it burns up glucose, thus

considered preterm (P). A spontaneous abortion decreasing blood sugar. However, dietary intake,

occurred at 8 weeks (A). She has two living not exercise, is the priority. All pregnant women

children (L). with diabetes should have periodic monitoring

59. B. At 12 weeks gestation, the uterus rises of serum glucose. However, those with
out of
gestational diabetes generally do not need daily
the pelvis and is palpable above the symphysis
glucose monitoring. The standard of care
pubis. The Doppler intensifies the sound of the
recommends a fasting and 2-hour postprandial
fetal pulse rate so it is audible. The uterus has
blood sugar level every 2 weeks.
merely risen out of the pelvis into the
61. C. After 20 weeks’ gestation, when there is a
abdominal
rapid weight gain, preeclampsia should be
cavity and is not at the level of the umbilicus.
suspected, which may be caused by fluid
The fetal heart rate at this age is not audible
retention manifested by edema, especially of
with a stethoscope. The uterus at 12 weeks is
the
just above the symphysis pubis in the abdominal
hands and face. The three classic signs of
cavity, not midway between the umbilicus and
preeclampsia are hypertension, edema, and
the xiphoid process. At 12 weeks the FHR would
proteinuria. Although urine is checked for
be difficult to auscultate with a fetoscope.
glucose at each clinic visit, this is not the
Although the external electronic fetal monitor priority.

would project the FHR, the uterus has not risen Depression may cause either anorexia or

to the umbilicus at 12 weeks. excessive food intake, leading to excessive

60. A. Although all of the choices are important weight gain or loss. This is not, however, the
in
priority consideration at this time. Weight gain
the management of diabetes, diet therapy is the
thought to be caused by excessive food intake
mainstay of the treatment plan and should
would require a 24-hour diet recall. However,
always be the priority. Women diagnosed with
excessive intake would not be the primary
gestational diabetes generally need only diet
consideration for this client at this time.
therapy without medication to control their
62. B. Cramping and vaginal bleeding coupled
blood sugar levels. Exercise, is important for all with

pregnant women and especially for diabetic cervical dilation signifies that termination of the
pregnancy is inevitable and cannot be assessment is not necessary unless an

prevented. Thus, the nurse would document an abnormality in uterine assessment is identified.

imminent abortion. In a threatened abortion, Uterine assessment should not cause acute pain

cramping and vaginal bleeding are present, but that requires administration of analgesia.

there is no cervical dilation. The symptoms may Ambulating the client is an essential component

subside or progress to abortion. In a complete of postpartum care, but is not necessary prior to

abortion all the products of conception are assessment of the uterus.

expelled. A missed abortion is early fetal 65. A. Feeding more frequently, about every 2

intrauterine death without expulsion of the hours, will decrease the infant’s frantic, vigorous

products of conception. sucking from hunger and will decrease breast

63. B. For the client with an ectopic pregnancy, engorgement, soften the breast, and promote

lower abdominal pain, usually unilateral, is the ease of correct latching-on for feeding.
Narcotics
primary symptom. Thus, pain is the priority.
administered prior to breast feeding are passed
Although the potential for infection is always
through the breast milk to the infant, causing
present, the risk is low in ectopic pregnancy
excessive sleepiness. Nipple soreness is not
because pathogenic microorganisms have not
severe enough to warrant narcotic analgesia. All
been introduced from external sources. The
postpartum clients, especially lactating mothers,
client may have a limited knowledge of the
should wear a supportive brassiere with wide
pathology and treatment of the condition and
cotton straps. This does not, however, prevent
will most likely experience grieving, but this is
or reduce nipple soreness. Soaps are drying to
not the priority at this time.
the skin of the nipples and should not be used
64. D. Before uterine assessment is performed,
it is on the breasts of lactating mothers. Dry nipple

essential that the woman empty her bladder. A skin predisposes to cracks and fissures, which

full bladder will interfere with the accuracy of can become sore and painful.

424 66. D. A weak, thready pulse elevated to 100

BPM
424
may indicate impending hemorrhagic shock. An
the assessment by elevating the uterus and
increased pulse is a compensatory mechanism
displacing to the side of the midline. Vital sign
of
the body in response to decreased fluid volume. days after delivery, containing epithelial cells,

Thus, the nurse should check the amount of erythrocyes, leukocytes and decidua. Lochia

lochia present. Temperatures up to 100.48F in serosa is a pink to brownish serosanguineous

the first 24 hours after birth are related to the discharge occurring from 3 to 10 days after

dehydrating effects of labor and are considered delivery that contains decidua, erythrocytes,

normal. Although rechecking the blood pressure leukocytes, cervical mucus, and microorganisms.

may be a correct choice of action, it is not the Lochia alba is an almost colorless to yellowish

first action that should be implemented in light discharge occurring from 10 days to 3 weeks

of the other data. The data indicate a potential after delivery and containing leukocytes,

impending hemorrhage. Assessing the uterus decidua, epithelial cells, fat, cervical mucus,
for
cholesterol crystals, and bacteria.
firmness and position in relation to the
68. A. The data suggests an infection of the
umbilicus
endometrial lining of the uterus. The lochia may
and midline is important, but the nurse should
be decreased or copious, dark brown in
check the extent of vaginal bleeding first. Then
it appearance, and foul smelling, providing further
would be appropriate to check the uterus, evidence of a possible infection. All the client’s
which
data indicate a uterine problem, not a breast
may be a possible cause of the hemorrhage.
problem. Typically, transient fever, usually
67. D. Any bright red vaginal discharge would be
101ºF, may be present with breast
considered abnormal, but especially 5 days after
engorgement. Symptoms of mastitis include
delivery, when the lochia is typically pink to
influenza-like manifestations. Localized infection
brownish. Lochia rubra, a dark red discharge, is
of an episiotomy or C-section incision rarely
present for 2 to 3 days after delivery. Bright red
causes systemic symptoms, and uterine
vaginal bleeding at this time suggests late
involution would not be affected. The client
postpartum hemorrhage, which occurs after the data
first 24 hours following delivery and is generally do not include dysuria, frequency, or urgency,
caused by retained placental fragments or symptoms of urinary tract infections, which
bleeding disorders. Lochia rubra is the normal would necessitate assessing the client’s urine.
dark red discharge occurring in the first 2 to 3
69. C. Because of early postpartum discharge flexion and adduction. In talipes equinovarus
and
(clubfoot) the foot is turned medially, and in
limited time for teaching, the nurse’s priority is
plantar flexion, with the heel elevated. The feet
to facilitate the safe and effective care of the
are not involved with the Moro reflex.
client and newborn. Although promoting
Hypothyroiddism has no effect on the primitive
comfort and restoration of health, exploring the
reflexes. Absence of the Moror reflex is the
family’s emotional status, and teaching about most

family planning are important in significant single indicator of central nervous

postpartum/newborn nursing care, they are not system status, but it is not a sign of increased

the priority focus in the limited time presented intracranial pressure.

by early post-partum discharge. 72. B. Hemorrhage is a potential risk following

any
70. C. Heat loss by radiation occurs when the
surgical procedure. Although the infant has
infant’s crib is placed too near cold walls or
been
windows. Thus placing the newborn’s crib close
given vitamin K to facilitate clotting, the
to the viewing window would be least effective.
prophylactic dose is often not sufficient to
Body heat is lost through evaporation during
prevent bleeding. Although infection is a
bathing. Placing the infant under the radiant
possibility, signs will not appear within 4 hours
warmer after bathing will assist the infant to be
after the surgical procedure. The primary
rewarmed. Covering the scale with a warmed
discomfort of circumcision occurs during the
blanket prior to weighing prevents heat loss
surgical procedure, not afterward. Although
through conduction. A knit cap prevents heat
feedings are withheld prior to the circumcision,
loss from the head a large head, a large body
the chances of dehydration are minimal.
surface area of the newborn’s body.
73. B. The presence of excessive estrogen and
425
progesterone in the maternal-fetal blood
425
followed by prompt withdrawal at birth
71. B. A fractured clavicle would prevent the
precipitates breast engorgement, which will
normal
spontaneously resolve in 4 to 5 days after birth.
Moro response of symmetrical sequential
The trauma of the birth process does not cause
extension and abduction of the arms followed
by inflammation of the newborn’s breast tissue.
Newborns do not have breast malignancy. This do the following mathematical calculation. 3 kg
x
reply by the nurse would cause the mother to
120 cal/kg per day = 360 calories/day feeding q
have undue anxiety. Breast tissue does not
4
hypertrophy in the fetus or newborns.
hours = 6 feedings per day = 60 calories per
74. D. The first 15 minutes to 1 hour after birth
feeding: 60 calories per feeding; 60 calories per
is
feeding with formula 20 cal/oz = 3 ounces per
the first period of reactivity involving respiratory
feeding. Based on the calculation. 2, 4 or 6
and circulatory adaptation to extrauterine life.
ounces are incorrect.
The data given reflect the normal changes
during 77. A. Intrauterine anoxia may cause relaxation
of
this time period. The infant’s assessment data
the anal sphincter and emptying of meconium
reflect normal adaptation. Thus, the physician
into the amniotic fluid. At birth some of the
does not need to be notified and oxygen is not
meconium fluid may be aspirated, causing
needed. The data do not indicate the presence
mechanical obstruction or chemical
of choking, gagging or coughing, which are signs
pneumonitis. The infant is not at increased risk
of excessive secretions. Suctioning is not
for gastrointestinal problems. Even though the
necessary.
skin is stained with meconium, it is
75. B. Application of 70% isopropyl alcohol to
noninfectious
the
(sterile) and nonirritating. The postterm
cord minimizes microorganisms (germicidal) and
meconium-stained infant is not at additional risk
promotes drying. The cord should be kept dry
for bowel or urinary problems.
until it falls off and the stump has healed.
78. C. The nurse should use a nonelastic,
Antibiotic ointment should only be used to treat
flexible,
an infection, not as a prophylaxis. Infants should
paper measuring tape, placing the zero point on
not be submerged in a tub of water until the
the superior border of the symphysis pubis and
cord falls off and the stump has completely
stretching the tape across the abdomen at the
healed.
midline to the top of the fundus. The xiphoid
76. B. To determine the amount of formula and
needed,
umbilicus are not appropriate landmarks to use

when measuring the height of the fundus

(McDonald’s measurement). been used as the time frame for resuming
sexual
79. B. Women hospitalized with severe
activity, but it may be resumed earlier.
preeclampsia need decreased CNS stimulation
to 81. C. The middle third of the vastus lateralis is
the
prevent a seizure. Seizure precautions provide
preferred injection site for vitamin K
environmental safety should a seizure occur.
administration because it is free of blood vessels
Because of edema, daily weight is important but
and nerves and is large enough to absorb the
not the priority. Preclampsia causes vasospasm
medication. The deltoid muscle of a newborn is
and therefore can reduce utero-placental
not large enough for a newborn IM injection.
perfusion. The client should be placed on her
left Injections into this muscle in a small child might

side to maximize blood flow, reduce blood cause damage to the radial nerve. The anterior

pressure, and promote diuresis. Interventions to femoris muscle is the next safest muscle to use

reduce stress and anxiety are very important to in a newborn but is not the safest. Because of

facilitate coping and a sense of control, but the proximity of the sciatic nerve, the gluteus

seizure precautions are the priority. maximus muscle should not be until the child

80. C. Cessation of the lochial discharge signifies has been walking 2 years.

healing of the endometrium. Risk of 82. D. Bartholin’s glands are the glands on either
hemorrhage
side of the vaginal orifice. The clitoris is female
and infection are minimal 3 weeks after a
erectile tissue found in the perineal area above
normal vaginal delivery. Telling the client
the urethra. The parotid glands are open into
anytime is inappropriate because this response the

does not provide the client with the specific mouth. Skene’s glands open into the posterior

information she is requesting. Choice of a wall of the female urinary meatus.

contraceptive method is important, but not the 83. D. The fetal gonad must secrete estrogen for
the
specific criteria for safe resumption of sexual
embryo to differentiate as a female. An increase
activity. Culturally, the 6-weeks’ examination has
in maternal estrogen secretion does not effect
426
differentiation of the embryo, and maternal
426
estrogen secretion occurs in every pregnancy.
Maternal androgen secretion remains the same They also promote relaxation. Breathing

as before pregnancy and does not effect techniques do not eliminate pain, but they can

differentiation. Secretion of androgen by the reduce it. Positioning, not breathing, increases

fetal gonad would produce a male fetus. uteroplacental perfusion.

84. A. Using bicarbonate would increase the 88. A. The client’s labor is hypotonic. The nurse
amount
should call the physical and obtain an order for
of sodium ingested, which can cause
an infusion of oxytocin, which will assist the
complications. Eating low-sodium crackers
uterus to contact more forcefully in an attempt
would be appropriate. Since liquids can increase
to dilate the cervix. Administering light sedative
nausea avoiding them in the morning hours
would be done for hypertonic uterine
when nausea is usually the strongest is
contractions. Preparing for cesarean section is
appropriate. Eating six small meals a day would
unnecessary at this time. Oxytocin would
keep the stomach full, which often decrease
increase the uterine contractions and hopefully
nausea.
progress labor before a cesarean would be
85. B. Ballottement indicates passive movement
necessary. It is too early to anticipate client
of
pushing with contractions.
the unengaged fetus. Ballottement is not a
89. D. The signs indicate placenta previa and
contraction. Fetal kicking felt by the client
vaginal
represents quickening. Enlargement and
exam to determine cervical dilation would not
softening of the uterus is known as Piskacek’s
be done because it could cause hemorrhage.
sign.
Assessing maternal vital signs can help
86. B. Chadwick’s sign refers to the purple-blue
determine maternal physiologic status. Fetal
tinge
heart rate is important to assess fetal well-being
of the cervix. Braxton Hicks contractions are
and should be done. Monitoring the
painless contractions beginning around the 4th
contractions
month. Goodell’s sign indicates softening of the
will help evaluate the progress of labor.
cervix. Flexibility of the uterus against the cervix
90. D. A complete placenta previa occurs when
is known as McDonald’s sign. the

87. C. Breathing techniques can raise the pain placenta covers the opening of the uterus, thus

threshold and reduce the perception of pain. blocking the passageway for the baby. This
response explains what a complete previa is and represents excessive amniotic fluid. Vernix is the

the reason the baby cannot come out except by white, cheesy substance covering the fetus.

cesarean delivery. Telling the client to ask the 94. D. In a breech position, because of the space

physician is a poor response and would increase between the presenting part and the cervix,

the patient’s anxiety. Although a cesarean prolapse of the umbilical cord is common.
would
Quickening is the woman’s first perception of
help to prevent hemorrhage, the statement
fetal movement. Ophthalmia neonatorum
does
usually results from maternal gonorrhea and is
not explain why the hemorrhage could occur.
conjunctivitis. Pica refers to the oral intake of
With a complete previa, the placenta is covering
nonfood substances.
all the cervix, not just most of it.
95. A. Dizygotic (fraternal) twins involve two ova
91. B. With a face presentation, the head is
fertilized by separate sperm. Monozygotic
completely extended. With a vertex
(identical) twins involve a common placenta,
presentation, the head is completely or partially
same genotype, and common chorion.
flexed. With a brow (forehead) presentation, the
96. C. The zygote is the single cell that
head would be partially extended.
reproduces
92. D. With this presentation, the fetal upper
itself after conception. The chromosome is the
torso
material that makes up the cell and is gained
and back face the left upper maternal
abdominal from each parent. Blastocyst and trophoblast
are
wall. The fetal heart rate would be most audible
later terms for the embryo after zygote.
above the maternal umbilicus and to the left of
97. D. Prepared childbirth was the direct result
the middle. The other positions would be
of
incorrect.
the 1950’s challenging of the routine use of
93. C. The greenish tint is due to the presence of
analgesic and anesthetics during childbirth. The
meconium. Lanugo is the soft, downy hair on
LDRP was a much later concept and was not a
the
direct result of the challenging of routine use of
shoulders and back of the fetus. Hydramnios
analgesics and anesthetics during childbirth.
427
Roles for nurse midwives and clinical nurse
427
specialists did not develop from this challenge.
98. C. The ischial spines are located in the mid- that is occurring in nursing because of social
pelvic
change?
region and could be narrowed due to the
a. So many children are treated in ambulatory
previous pelvic injury. The symphysis pubis,
units that nurses are hardly needed
sacral promontory, and pubic arch are not part
b. Immunizations are no longer needed for
of the mid-pelvis.
infectious diseases
99. B. Variations in the length of the menstrual
c. The use of skilled technology has made
cycle
nursing care more complex
are due to variations in the proliferative phase.
d. Pregnant women are so healthy today that
The menstrual, secretory and ischemic phases
they rarely need prenatal care
do not contribute to this variation.
3. The best description if the family nurse
100. B. Testosterone is produced by the
practitioner role is
Leyding cells in the seminiferous tubules.
a. To give bedside care to critically ill family
Follicle-stimulating hormone and leuteinzing
members
hormone are released by the anterior pituitary
b. To supervise the health of children up to age
gland. The hypothalamus is responsible for
18 years
releasing gonadotropin-releasing hormone.
c. To provide health supervision for families
428
d. To supervise women during pregnancy
428
4. The Delos Reyes family was a single-parent
MATERNITY NURSING Part 2
one
1. Suppose Melissa Chung asks you whether
before Mrs. Delos Reyes remarried. What is a
maternal child health nursing is a profession.
common concern of single-parent families?
What qualifies an activity as a profession?
a. Too many people give advice
a. Members supervise other people
b. Finances are inadequate
b. Members use a distinct body of knowledge
c. Children miss many days of school
c. Members enjoy good working conditions
d. Children don’t know any other family like
d. Members receive relatively high pay theirs

2. Nursing is changing because social change 5. Mrs. Delos Reyes serves many roles in her

affects care. Which of the following is a trend family. If, when you talk to Veronica, her
daughter, she interrupts to say, “Don’t tell our 8. Monet Rivera tells you she used to wrry
because
family secrets,” she is fulfilling what family role?
she developed breasts later than most of her
a. Decision-maker
friends. Breast development is termed:
b. Gatekeeper
a. Adrenarche
c. Problem-solver
b. Mamarche
d. Bread-earner
c. Thelarche
6. The Delos Reyes family consists of two
parents; d. Menarche

Veronica, 12; and Paolo, 2. Mrs. Delos Reyes is 5 9. Suppose Jaypee Manalo tells you that he is

months pregnant. Which of Duvall’s family life considering a vasectomy after the birth of his

stages is the family currently experiencing? new child. Vasectomy is the incision of which

a. Pregnancy stage organ?

b. Preschool stage a. Testes

c. School-age stage b. Vas deferens

d. Launching stage c. Fallopian tube

7. While she is in the hospital, Carmela makes d. Epididymis

the
10. On physical examination, Monet Rivera is
following statements. Which is the best example found

of stereotyping? to have cystocele. A cystocele is:

a. My doctor is funny; he tells jokes and makes a. A sebaceous cyst arising from a vulvar fold
me
b. Protrusion of the intestine into the vagina
laugh.
c. Prolapse of the uterus and cervix into the
b. I’m glad I’m Batangueño because all vagina

Batangueños are smart. d. Herniation of the bladder into the vaginal wall

c. I’m sure my leg will heal quickly; I’m overall 11. Monet Rivera typically has a menstrual cycle
of
healthy.
34 days. She tells you she had coitus on days 8,
d. I like foods in Batangas, although not if it
tastes 10, 15, and 20 of her last cycle. Which is the day

too spicy. on which she most likely conceived?

a. The 8th day

b. The 10th day combination oral contraceptive (COC) as her

c. Day 15 family planning method. What is a danger sign

of
d. Day 20
COCs you would ask her to report?
429
a. A stuffy or runny nose
429
b. Arthritis-like symptoms
12. The Manalo’s neighbor Cahrell is a woman
who c. Slight weight gain

has sex with women. Another term for this d. Migraine headache

sexual orientation is 15. Suppose Roseann, 17 years old, chooses

a. Lesbian subcutaneous implants (Norplant) as her

b. Celibate method of reproductive life planning. How long

c. Gay will these implants be effective?

d. Voyeur a. One month

13. Suppose Roseann, 17 years old, tells you b. 12 months

that
c. Five years
she wants to use fertility awareness method of
d. 10 years
contraception. How will she determine her
16. Roseann, 17 years old, wants to try female
fertile days?
condoms as her reproductive life planning
a. She will notice that she feels hot, as if she has
method. Which instruction would you give her?
an
a. The hormone the condom releases may cause
elevated temperature
mild weight gain.
b. She should assess whether her cervical
mucus is b. She should insert the condom before any
penile
thin and watery
penetration
c. She should monitor her emotions for sudden
c. She should coat the condom with a
anger or crying
spermicide
d. She should assess whether her breasts feels
before use
sensitive to cool air
d. Female condoms, unlike male condoms, can
14. Suppose Roseann, 17 years old, chooses to be
use a
reused.
17. Roseann, 17 years old, asks you how a tubal d. Endometrial implants can block the fallopian

ligation prevents pregnancy. Which would be tubes

the
20. Guadalupe Atienza is scheduled to have a
best answer?
hysterosalpingogram. Which of the following
a. Sperm can no longer reach the ova because
instructions would you give her regarding this
fallopian tubes are blocked
procedure?
b. Sperm can not enter the uterus because the
a. She may feel some mild cramping when the
cervical entrance is blocked dye

c. Prostaglandins released from the cut fallopian is inserted

tubes can kill sperm b. The sonogram of the uterus will reveal any

d. The ovary no longer releases ova as there is tumors present

no
c. She will not be able to conceive for three
where for them to go
months after the procedure
18. The Atienzas are a couple undergoing testing
d. May women experience mild bleeding as an
for
aftereffect
infertility. Infertility is said to exist when:
21. Ruel Marasigan asks you what artificial
a. A couple has been trying to conceive for 1
year insemination by donor entails. Which would be
b. A woman has no children your best answer?
c. A woman has no uterus a. Artificial sperm are injected vaginally to test
d. A couple has wanted a child for 6 months tubal patency
19. Guadalupe Atienza is diagnosed as having b. Donor sperm are introduced vaginally into
the
endometriosis. This condition interferes with
uterus of the cervix
fertility because:
c. The husband’s sperm is administered
a. The ovaries stop producing adequate
estrogen intravenously weekly
b. The uterine cervix becomes inflamed and 430
swollen 430
c. Pressure on the pituitary leads to decreased d. Donor sperm are injected intraabdominally
FSH into
levels each ovary
22. Guadalupe Atienza is having a gamete d. It is impossible for any of her children to be
born
intrafallopian transfer (GIFT) procedure. What
with Down syndrome
makes her a good candidate for this procedure?
25. Jean Suarez was told at a genetic counseling
a. She has patent fallopian tubes, so fertilized
ova session tat she is a balanced translocation
carrier
can be implanted into them
for Down syndrome. What would be your best
b. She is Rh negative, a necessary stipulation to
action regarding this information?
rule out Rh incompatibility
a. Be certain all of her family understand what
c. She has a normal uterus, so sperm can be
this
injected through the cervix into it
means
d. Her husband is taking sildenafil (Viagra), so all
b. Discuss the cost of various abortion
his perm will be motile techniques

23. Jean Suarez is pregnant with her first child. with Jean
Her
c. Be sure Jean knows she should not have any
phenotype refers to:
more children
a. Her concept of herself as male or female
d. Ask Jean is she has any questions that you
b. Whether she has 46 chromosomes or not could

c. Her actual genetic composition answer for her

d. Her outward appearance 26. Jean Suarez’s child is born with Down
Syndrome.
24. Jean Suarez is a balanced translocation
carrier What is a common physical feature of newborn

for Down syndrome. This term means that: with this disorder?

a. All of her children will be born with some a. Spastic and stiff muscles

aspects of Down syndrome b. Loose skin at back of neck

b. All of her female and none of her male c. A white lock of forehead hair
children
d. Wrinkles on soles of the feet
will have Down syndrome
27. Rizalyn asks how much longer her doctor
c. She has a greater than average chance a child will

will have Down syndrome refer to the baby inside her as an embryo. What

would be your best explanation?

a. This term is used during the time before b. Surfactant is produced by the fetal liver, so its

fertilization precursor reveals liver maturity

b. Her baby will be a fetus as soon as the c. Surfactant is the precursor to IgM antibody
placenta
production, so it prevents infection
forms
d. Surfactant reveals mature kidney function, as
c. After the 20th week of pregnancy, the baby is it

called zygote is produced by kidney glomeruli

d. From the time of implantation until 5 to 8 30. Rizalyn is scheduled to have an ultrasound

weeks, the baby is an embryo examination. What instruction would you give

28. Rizalyn is worried that her baby will be born her before her examination?
with
a. Void immediately before the procedure to
congenital heart disease. What assessment of a
reduce your bladder size
fetus at birth is important to help detect
b. The intravenous fluid infused to dilate your
congenital heart defects?
uterus does not hurt the fetus
a. Assessing whether the Wharton’s jelly if the
c. You will need to drink at least 3 glasses of
cord
fluid
has a pH higher than 7.2
before the procedure
b. Assessing whether the umbilical cord has two
d. You can have medicine for pain for any
arteries and one vein
contractions caused by the test
c. Measuring the length of the cord to be certain
431
that it is longer than three feet
431
d. Determining that the color of the umbilical
31. Rizalyn is scheduled to have an
cord
amniocentesis to
is not green
test for fetal maturity. What instruction would
29. Rizalyn asks you why her doctor is
you give her before this procedure?
concerned
a. Void immediately before the procedure to
about whether her fetus us producing
surfactant reduce your bladder size
or not. Your best answer would be: b. The x-ray used to reveal your fetus’ position
has
a. Surfactant keeps lungs from collapsing on
no long-term effects
expiration, and thus aids newborn breathing
c. The intravenous fluid infused to dilate your b. She can feel the fetus move inside her

uterus does not hurt the fetus c. hCG can be found in her bloodstream

d. No more amniotic fluid forms afterward, d. The fetal heart can be seen on ultrasound
which
35. Bernadette’s doctor told her she had a
is why only a small amount is removed positive

32. Bernadette sometimes feels ambivalent Chadwick’s sign. She asks you what this means,
about
and you tell her that:
being pregnant. What is the psychological task
a. Her abdomen is soft and tender
you’d like to see her complete during the first
b. Her uterus has tipped forward
trimester of pregnancy?
c. Cervical mucus is clear and sticky
a. View morning sickness as tolerable
d. Her vagina has darkened in color
b. Accept the fact that she’s pregnant
36. Bernadette overheard her doctor say that
c. Accept the fact that a baby is growing inside insulin
her
is not as effective during pregnancy as usual.
d. Choose a name for the baby
That made her worry that she is developing
33. Bernadette is aware that she’s been showing
diabetes, like her aunt. How would you explain
some narcissism since becoming pregnant.
how decreased insulin effectiveness safeguards
Which of her actions best describes narcissism?
the fetus?
a. Her skin feels “pulled thin” across her
a. Decreased effectiveness prevents the fetus
abdomen
from
b. Her thoughts tend to be mainly about herself
being hypoglycemic
c. She feels a need to sleep a lot more than
b. If insulin is ineffective it cannot cross the
usual
placenta and harm the fetus
d. She often feels “numb” or as if she’s taken a
c. The lessened action prevents the fetus from
narcotic
gaining too much weight
34. Bernadette did a urine pregnancy test but
was d. The mother, not the fetus, is guarded by this
surprised to learn that a positive result is not a decreased insulin action
sure sign if pregnancy. She asks you what would 37. Riza Cua feels well. She asks you why she
needs
be a positive sign. You tell her would be if:
to come for prenatal care The best reason for
a. She is having consistent uterine growth
her to receive regular care is: c. Her weight gain has stretched the skin over
her
a. Discovering allergies can help eliminate early
hands
birth
d. This is a common reaction to increasing
b. It helps document how many pregnancies
estrogen
occur
levels.
each year
40. Riza has not had a pelvic exam since she was
c. It provides time for education about
in
pregnancy
highschool. What advice would you give her to
and birth
help her relax during her first prenatal pelvic
d. It determines whether pregnancies today are
exam?
planned or not
a. Have her take a deep breath and hold it
38. Why is it important to ask Riza about past
during
surgery on a pregnancy health history?
the exam
a. To test her recent and long-term memory
432
b. Adhesions from surgery could limit uterine
432
growth
b. Tell her to bear down slightly as the speculum
c. To assess she could be allergic to any is
medication
inserted
d. To determine if she has effective heath
c. Singing out loud helps, because this pushes
insurance
down the diaphragm
39. Riza reports that the palms of her hands are
d. She should breathe slowly and evenly during
always itchy. You notice scratches on them when the

you do a physical exam. What is the most likely exam

cause of this finding during pregnancy? 41. Riza has pelvic measurements taken. What
size
a. She must have become allergic to
dishwashing should the ischial tuberosity diameter be to be

soap considered adequate?

b. She has an allergy to her fetus and will a. 6 cm

probably
b. Twice the width of the conjugate diameter
abort
c. 11 cm
d. Half the width of the symphysis pubis varicosities.”

Situation: One of the nursing roles in caring for 44. Vanna tells you that she is developing
the painful

pregnant family is promoting fetal and maternal hemorrhoids. Advice you would give her would
health
be:
42. Which statement by Vanna Delgado would
a. Take a tablespoon of mineral oil with each of
alert
your meals
you that she needs more teaching about safe
b. Omit fiber from your diet. This will prevent
practices during pregnancy?
constipation
a. “I take either a shower or tub bath, because I
c. Lie on your stomach daily to drain blood from
know both are safe.”
the rectal veins
b. “I wash my breasts with clear water, not with
d. Witch hazel pads feel cool against swollen
soap daily.”
hemorrhoids
c. “I’m glad I don’t have to ask my boyfriend to
use 45. Vanna has ankle edema by the end of each
day.
condoms anymore.”
Which statement by her would reveal that she
d. “I’m wearing low-heeled shoes to try and
avoid understands what causes this?
backache.” a. “I know this is a beginning complication; I’ll
call
43. Vanna describes her typical day to you.
What my doctor tonight.”
would alert you that she may need further b. “I understand this is from eating too much
salt;
pregnancy advice?
I’ll restrict that more.”
a. “I jog rather than walk every time I can for
c. “I’ll rest in a Sims’ position to take pressure
exercise.”
off
b. “I always go to sleep on my side, not on my
lower extremity veins.”
back.”
d. “I’ll walk for half an hour every day to relieve
c. “I pack my lunch in the morning when I’m not
this; I’ll try walking more.”
so
433
tired.”
433
d. “I walk around my desk every hour to prevent
Answer for maternity part 2 indicates the earliest age at which this should be

BCCBB done?

CBCBD a. 1 month

DABDC b. 2 months

BAADA c. 3 months

BADCD d. 4 months

BDBAC 3. The infant of a substance-abusing mother is

at
ABBDD
risk for developing a sense of which of the
ACBDD
following?
CCADC
a. Mistrust
434
b. Shame
434
c. Guilt
PEDIATRIC NURSING
d. Inferiority
1. While performing physical assessment of a 12
4. Which of the following toys should the nurse
month-old, the nurse notes that the infant’s
recommend for a 5-month-old?
anterior fontanelle is still slightly open. Which of
a. A big red balloon
the following is the nurse’s most appropriate
b. A teddy bear with button eyes
action?
c. A push-pull wooden truck
a. Notify the physician immediately
d. A colorful busy box
because there is a problem.
5. The mother of a 2-month-old is concerned
b. Perform an intensive neurologic
that
examination.
she may be spoiling her baby by picking her up
c. Perform an intensive developmental
when she cries. Which of the following would
examination. be

d. Do nothing because this is a normal the nurse’s best response?

finding for the age. a. “ Let her cry for a while before picking

2. When teaching a mother about introducing her up, so you don’t spoil her”
solid
b. “Babies need to be held and cuddled;
foods to her child, which of the following
you won’t spoil her this way”
c. “Crying at this age means the baby is following signs should the nurse instruct them
to
hungry; give her a bottle”
watch for in the toddler?
d. “If you leave her alone she will learn
a. Demonstrates dryness for 4 hours
how to cry herself to sleep”
b. Demonstrates ability to sit and walk
6. When assessing an 18-month-old, the nurse
c. Has a new sibling for stimulation
notes a characteristic protruding abdomen.
d. Verbalizes desire to go to the bathroom
Which of the following would explain the
10. When teaching parents about typical toddler
rationale for this finding?
eating patterns, which of the following should
a. Increased food intake owing to age
be
b. Underdeveloped abdominal muscles
included?
c. Bowlegged posture
a. Food “jags”
d. Linear growth curve
b. Preference to eat alone
7. If parents keep a toddler dependent in areas
c. Consistent table manners
where he is capable of using skills, the toddle
d. Increase in appetite
will develop a sense of which of the following?
11. Which of the following suggestions should
a. Mistrust the

b. Shame nurse offer the parents of a 4-year-old boy who

c. Guilt resists going to bed at night?

d. Inferiority a. “Allow him to fall asleep in your room,

8. Which of the following is an appropriate toy then move him to his own bed.”
for
b. “Tell him that you will lock him in his
an 18-month-old?
room if he gets out of bed one more
a. Multiple-piece puzzle
time.”
b. Miniature cars
c. “Encourage active play at bedtime to tire
c. Finger paints
him out so he will fall asleep faster.”
d. Comic book
d. “Read him a story and allow him to play
9. When teaching parents about the child’s
quietly in his bed until he falls asleep.”
readiness for toilet training, which of the
12. When providing therapeutic play, which of
the
following toys would best promote imaginative prevention for schoolagers, which of the

play in a 4-year-old? following statements by the group would

a. Large blocks indicate the need for more teaching?

b. Dress-up clothes a. “Schoolagers are more active and

c. Wooden puzzle adventurous than are younger children.”

d. Big wheels b. “Schoolagers are more susceptible to

435 home hazards than are younger

435 children.”

13. Which of the following activities, when c. “Schoolagers are unable to understand
voiced by
potential dangers around them.”
the parents following a teaching session about
d. “Schoolargers are less subject to
the characteristics of school-age cognitive
parental control than are younger
development would indicate the need for
children.”
additional teaching?
16. Which of the following skills is the most
a. Collecting baseball cards and marbles
significant one learned during the schoolage
b. Ordering dolls according to size
period?
c. Considering simple problem-solving
a. Collecting
options
b. Ordering
d. Developing plans for the future
c. Reading
14. A hospitalized schoolager states: “I’m not
d. Sorting
afraid
17. A child age 7 was unable to receive the
of this place, I’m not afraid of anything.” This
measles,
statement is most likely an example of which of
mumps, and rubella (MMR) vaccine at the
the following?
recommended scheduled time. When would the
a. Regression
nurse expect to administer MMR vaccine?
b. Repression
a. In a month from now
c. Reaction formation
b. In a year from now
d. Rationalization
c. At age 10
15. After teaching a group of parents about
d. At age 13
accident
18. The adolescent’s inability to develop a sense peers perceive them. So they spend a lot
of
of time grooming.”
who he is and what he can become results in a
c. “A teen may develop a poor self-image
sense of which of the following?
when experiencing acne. Do you feel this
a. Shame
way sometimes?”
b. Guilt
d. “You appear to be keeping your face
c. Inferiority
well washed. Would you feel
d. Role diffusion
comfortable discussing your cleansing
19. Which of the following would be most
method?”
appropriate for a nurse to use when describing
21. Which of the following should the nurse
menarche to a 13-year-old? suspect

a. A female’s first menstruation or when noting that a 3-year-old is engaging in

menstrual “periods” explicit sexual behavior during doll play?

b. The first year of menstruation or a. The child is exhibiting normal pre-school

“period” curiosity

c. The entire menstrual cycle or from one b. The child is acting out personal

“period” to another experiences

d. The onset of uterine maturation or peak c. The child does not know how to play

growth with dolls

20. A 14-year-old boy has acne and according to d. The child is probably developmentally
his
delayed.
parents, dominates the bathroom by using the
22. Which of the following statements by the
mirror all the time. Which of the following
parents of a child with school phobia would
remarks by the nurse would be least helpful in
indicate the need for further teaching?
talking to the boy and his parents?
a. “We’ll keep him at home until phobia
a. “This is probably the only concern he has
subsides.”
about his body. So don’t worry about it
b. “We’ll work with his teachers and
or the time he spends on it.”
counselors at school.”
b. “Teenagers are anxious about how their
c. “We’ll try to encourage him to talk
about his problem.” 25. While performing a neurodevelopmental

436 assessment on a 3-month-old infant, which of

436 the following characteristics would be

expected?
d. “We’ll discuss possible solutions with
a. A strong Moro reflex
him and his counselor.”
b. A strong parachute reflex
23. When developing a teaching plan for a
group of c. Rolling from front to back

high school students about teenage pregnancy, d. Lifting of head and chest when prone

the nurse would keep in mind which of the 26. By the end of which of the following would
the
following?
nurse most commonly expect a child’s birth
a. The incidence of teenage pregnancies is
weight to triple?
increasing.
a. 4 months
b. Most teenage pregnancies are planned.
b. 7 months
c. Denial of the pregnancy is common early
c. 9 months
on.
d. 12 months
d. The risk for complications during
27. Which of the following best describes
pregnancy is rare.
parallel
24. When assessing a child with a cleft palate,
play between two toddlers?
the
a. Sharing crayons to color separate
nurse is aware that the child is at risk for more
pictures
frequent episodes of otitis media due to which
b. Playing a board game with a nurse
of the following?
c. Sitting near each other while playing
a. Lowered resistance from malnutrition
with separate dolls
b. Ineffective functioning of the Eustachian
d. Sharing their dolls with two different
tubes
nurses
c. Plugging of the Eustachian tubes with
28. Which of the following would the nurse
food particles
identify
d. Associated congenital defects of the
as the initial priority for a child with acute
middle ear.
lymphocytic leukemia?
a. Instituting infection control precautions finding in a toddler.

b. Encouraging adequate intake of iron-rich 31. Which of the following is being used when
the
foods
mother of a hospitalized child calls the student
c. Assisting with coping with chronic illness
nurse and states, “You idiot, you have no idea
d. Administering medications via IM
how to care for my sick child”?
injections
a. Displacement
29. Which of the following information, when
voiced b. Projection

by the mother, would indicate to the nurse that c. Repression

she understands home care instructions d. Psychosis

following the administration of a diphtheria, 32. Which of the following should the nurse
expect
tetanus, and pertussis injection?
to note as a frequent complication for a child
a. Measures to reduce fever
with congenital heart disease?
b. Need for dietary restrictions
a. Susceptibility to respiratory infection
c. Reasons for subsequent rash
b. Bleeding tendencies
d. Measures to control subsequent
c. Frequent vomiting and diarrhea
diarrhea
d. Seizure disorder
30. Which of the following actions by a
community 33. Which of the following would the nurse do
first
health nurse is most appropriate when noting
for a 3-year-old boy who arrives in the
multiple bruises and burns on the posterior
emergency room with a temperature of 105
trunk of an 18-month-old child during a home
degrees, inspiratory stridor, and restlessness,
visit?
who is learning forward and drooling?
a. Report the child’s condition to
a. Auscultate his lungs and place him in a
Protective Services immediately.
mist tent.
b. Schedule a follow-up visit to check for
b. Have him lie down and rest after
more bruises.
encouraging fluids.
c. Notify the child’s physician immediately.
437
d. Don nothing because this is a normal
437
c. Examine his throat and perform a throat d. 12 months

culture 37. When discussing normal infant growth and

d. Notify the physician immediately and development with parents, which of the

prepare for intubation. following toys would the nurse suggest as most

34. Which of the following would the nurse appropriate for an 8-month-old?
need to
a. Push-pull toys
keep in mind as a predisposing factor when
b. Rattle
formulating a teaching plan for child with a
c. Large blocks
urinary tract infection?
d. Mobile
a. A shorter urethra in females
38. Which of the following aspects of
b. Frequent emptying of the bladder psychosocial

c. Increased fluid intake development is necessary for the nurse to keep

d. Ingestion of acidic juices in mind when providing care for the preschool

35. Which of the following should the nurse do child?

first
a. The child can use complex reasoning to
for a 15-year-old boy with a full leg cast who is
think out situations.
screaming in unrelenting pain and exhibiting
b. Fear of body mutilation is a common
right foot pallor signifying compartment
preschool fear
syndrome?
c. The child engages in competitive types
a. Medicate him with acetaminophen.
of play
b. Notify the physician immediately
d. Immediate gratification is necessary to
c. Release the traction
develop initiative.
d. Monitor him every 5 minutes
39. Which of the following is characteristic of a
36. At which of the following ages would the
preschooler with mid mental retardation?
nurse
a. Slow to feed self
expect to administer the varicella zoster vaccine
b. Lack of speech
to child?
c. Marked motor delays
a. At birth
d. Gait disability
b. 2 months
40. Which of the following assessment findings
c. 6 months
would lead the nurse to suspect Down 44. Which of the following nursing diagnoses
syndrome would

in an infant? be inappropriate for the infant with

a. Small tongue gastroesophageal reflux (GER)?

b. Transverse palmar crease a. Fluid volume deficit

c. Large nose b. Risk for aspiration

d. Restricted joint movement c. Altered nutrition: less than body

41. While assessing a newborn with cleft lip, the requirements

nurse would be alert that which of the following d. Altered oral mucous membranes

will most likely be compromised? 45. Which of the following parameters would
the
a. Sucking ability
nurse monitor to evaluate the effectiveness of
b. Respiratory status
thickened feedings for an infant with
c. Locomotion
gastroesophageal reflux (GER)?
d. GI function
a. Vomiting
42. When providing postoperative care for the
child b. Stools

with a cleft palate, the nurse should position the c. Uterine

child in which of the following positions? d. Weight

a. Supine 46. Discharge teaching for a child with celiac

disease
b. Prone
would include instructions about avoiding which
c. In an infant seat
of the following?
d. On the side
a. Rice
43. While assessing a child with pyloric stenosis,
the b. Milk

nurse is likely to note which of the following? c. Wheat

a. Regurgitation d. Chicken

b. Steatorrhea 438

c. Projectile vomiting 438

d. “Currant jelly” stools 47. Which of the following would the nurse
expect
to assess in a child with celiac disease having a b. Pain pattern

celiac crisis secondary to an upper respiratory c. Family history

infection? d. Abdominal palpation

a. Respiratory distress 439

b. Lethargy 439

c. Watery diarrhea ANSWERS and RATIONALES for PEDIATRIC

NURSING
d. Weight gain
1. D. The anterior fontanelle typically closes
48. Which of the following should the nurse do
first anywhere between 12 to 18 months of age.

after noting that a child with Hirschsprung Thus, assessing the anterior fontanelle as still

disease has a fever and watery explosive being slightly open is a normal finding requiring

diarrhea? no further action. Because it is normal finding

for
a. Notify the physician immediately
this age, notifying he physician or performing
b. Administer antidiarrheal medications
additional examinations are inappropriate.
c. Monitor child ever 30 minutes
2. D. Solid foods are not recommended before
d. Nothing, this is characteristic of
age
Hirschsprung disease
4 to 6 months because of the sucking reflex and
49. A newborn’s failure to pass meconium
the immaturity of the gastrointestinal tract and
within
immune system. Therefore, the earliest age at
the first 24 hours after birth may indicate which
which to introduce foods is 4 months. Any time
of the following?
earlier would be inappropriate.
a. Hirschsprung disease
3. A. According to Erikson, infants need to have
b. Celiac disease
their needs met consistently and effectively to
c. Intussusception
develop a sense of trust. An infant whose needs
d. Abdominal wall defect
are consistently unmet or who experiences
50. When assessing a child for possible
significant delays in having them met, such as in
intussusception, which of the following would
be the case of the infant of a substance-abusing

least likely to provide valuable information? mother, will develop a sense of uncertainty,

a. Stool inspection leading to mistrust of caregivers and the

environment. Toddlers develop a sense of abdomen. During toddlerhood, food intake

shame when their autonomy needs are not met decreases, not increases. Toddlers are

consistently. Preschoolers develop a sense of characteristically bowlegged because the leg

guilt when their sense of initiative is thwarted. muscles must bear the weight of the relatively

Schoolagers develop a sense of inferiority when large trunk. Toddler growth patterns occur in a

they do not develop a sense of industry. steplike, not linear pattern.

4. D. A busy box facilitates the fine motor 7. B. According to Erikson, toddlers experience a

development that occurs between 4 and 6 sense of shame when they are not allowed to

months. Balloons are contraindicated because develop appropriate independence and

small children may aspirate balloons. Because autonomy. Infants develop mistrust when their

the button eyes of a teddy bear may detach and needs are not consistently gratified.

be aspirated, this toy is unsafe for children Preschoolers develop guilt when their initiative

younger than 3 years. A 5-month-old is too needs are not met while schoolagers develop a

young to use a push-pull toy. sense of inferiority when their industry needs

5. B. Infants need to have their security needs are not met.

met
8. C. Young toddlers are still sensorimotor
by being held and cuddled. At 2 months of age, learners

they are unable to make the connection and they enjoy the experience of feeling

between crying and attention. This association different textures. Thus, finger paints would be

does not occur until late infancy or early an appropriate toy choice. Multiple-piece toys,

toddlerhood. Letting the infant cry for a time such as puzzle, are too difficult to manipulate

before picking up the infant or leaving the infant and may be hazardous if the pieces are small

alone to cry herself to sleep interferes with enough to be aspirated. Miniature cars also
have
meeting the infant’s need for security at this
a high potential for aspiration. Comic books are
very young age. Infants cry for many reasons.
on too high a level for toddlers. Although they
Assuming that the child s hungry may cause
may enjoy looking at some of the pictures,
overfeeding problems such as obesity.
toddlers are more likely to rip a comic book
6. B. Underdeveloped abdominal musculature
apart.
gives the toddler a characteristically protruding
9. D. The child must be able to sate the need to 440
go
440
to the bathroom to initiate toilet training.
frightening and potentially hazardous. Vigorous
Usually, a child needs to be dry for only 2 hours,
activity at bedtime stirs up the child and makes
not 4 hours. The child also must be able to sit,
more difficult to fall asleep.
walk, and squat. A new sibling would most likely
12. B. Dress-up clothes enhance imaginative
hinder toilet training. play

10. A. Toddlers become picky eaters, and imagination, allowing preschoolers to

experiencing
engage in rich fantasy play. Building blocks and
food jags and eating large amounts one day and
wooden puzzles are appropriate for encouraging
very little the next. A toddler’s food gags express
fine motor development. Big wheels and
a preference for the ritualism of eating one type
tricycles encourage gross motor development.
of food for several days at a time. Toddlers
13. D. The school-aged child is in the stage of
typically enjoy socialization and limiting others
concrete operations, marked by inductive
at meal time. Toddlers prefer to feed themselves
reasoning, logical operations, and reversible
and thus are too young to have table manners.
concrete thought. The ability to consider the
A
future requires formal thought operations,
toddler’s appetite and need for calories,
protein, which are not developed until adolescence.
and fluid decrease due to the dramatic slowing Collecting baseball cards and marbles, ordering
of growth rate. dolls by size, and simple problem-solving
options
11. D. Preschoolers commonly have fears of the
are examples of the concrete operational
dark, being left alone especially at bedtime, and
thinking of the schoolager.
ghosts, which may affect the child’s going to bed
14. C. Reaction formation is the schoolager’s
at night. Quiet play and time with parents is a
typical
positive bedtime routine that provides security
defensive response when hospitalized. In
and also readies the child for sleep. The child
reaction formation, expression of unacceptable
should sleep in his own bed. Telling the child
thoughts or behaviors is prevented (or
about locking him in his room will viewed by the
overridden) by the exaggerated expression of
child as a threat. Additionally, a locked door is
opposite thoughts or types of behaviors.
Regression is seen in toddlers and preshcoolers 16. C. The most significant skill learned during
the
when they retreat or return to an earlier level of
school-age period is reading. During this time
development. Repression refers to the
the child develops formal adult articulation
involuntary blocking of unpleasant feelings and
patterns and learns that words can be arranged
experiences from one’s awareness.
in structure. Collective, ordering, and sorting,
Rationalization is the attempt to make excuses
although important, are not most significant
to justify unacceptable feelings or behaviors.
skills learned.
15. C. The schoolager’s cognitive level is
sufficiently 17. C. Based on the recommendations of the

developed to enable good understanding of and American Academy of Family Physicians and the

adherence to rules. Thus, schoolagers should be American Academy of Pediatrics, the MMR

able to understand the potential dangers vaccine should be given at the age of 10 if the
around
child did not receive it between the ages of 4 to
them. With growth comes greater freedom and
6 years as recommended. Immunization for
children become more adventurous and daring.
diphtheria and tetanus is required at age 13.
The school-aged child is also still prone to
18. D. According to Erikson, role diffusion
accidents and home hazards, especially because develops

of increased motor abilities and independence. when the adolescent does not develop a sense

Plus the home hazards differ from other age of identity and a sense or where he fits in.

groups. These hazards, which are potentially Toddlers develop a sense of shame when they

lethal but tempting, may include firearms, do not achieve autonomy. Preschoolers develop

alcohol, and medications. School-age children a sense of guilt when they do not develop a

begin to internalize their own controls and need sense of initiative. School-age children develop
a
less outside direction. Plus the child is away
from sense of inferiority when they do not develop a

home more often. Some parental or caregiver sense of industry.

assistance is still needed to answer questions 19. A. Menarche refers to the onset of the first

and provide guidance for decisions and menstruation or menstrual period and refers

responsibilities. only to the first cycle. Uterine growth and

broadening of the pelvic girdle occurs before

menarche. developmental delay. Whether or nor the child

20. A. Stating that this is probably the only knows how to play with dolls is irrelevant.
concern
22. A. The parents need more teaching if they
the adolescent has and telling the parents not state
to
that they will keep the child home until the
worry about it or the time her spends on it
phobia subsides. Doing so reinforces the child’s
shuts
feelings of worthlessness and dependency. The
off further investigation and is likely to make the
child should attend school even during
adolescent and his parents feel defensive. The
resolution of the problem. Allowing the child to
statement about peer acceptance and time
verbalize helps the child to ventilate feelings
spent in front of the mirror for the development
and
of self image provides information about the
may help to uncover causes and solutions.
adolescent’s needs to the parents and may help
Collaboration with the teachers and counselors
to gain trust with the adolescent. Asking the
at school may lead to uncovering the cause of
adolescent how he feels about the acne will
the phobia and to the development of solutions.
encourage the adolescent to share his feelings.
The child should participate and play an active
Discussing the cleansing method shows interest
role in developing possible solutions.
and concern for the adolescent and also can
23. C. The adolescent who becomes pregnant
help
typically denies the pregnancy early on. Early
to identify any patient-teaching needs for the
recognition by a parent or health care provider
adolescent regarding cleansing.
may be crucial to timely initiation of prenatal
21. B. Preschoolers should be developmentally
care. The incidence of adolescent pregnancy has
incapable of demonstrating explicit sexual
declined since 1991, yet morbidity remains high.
behavior. If a child does so, the child has been
Most teenage pregnancies are unplanned and
exposed to such behavior, and sexual abuse
occur out of wedlock. The pregnant adolescent
should be suspected. Explicit sexual behavior
is
during doll play is not a characteristic of
at high risk for physical complications including
preschool development nor symptomatic of
premature labor and low-birth-weight infants,
441
high neonatal mortality, iron deficiency anemia,
441
prolonged labor, and fetopelvic disproportion as
well as numerous psychological crises. nurses are all examples of cooperative play.

24. B. Because of the structural defect, children 28. A. Acute lymphocytic leukemia (ALL) causes
with
leukopenia, resulting in immunosuppression
cleft palate may have ineffective functioning of and

their Eustachian tubes creating frequent bouts increasing the risk of infection, a leading cause

of otitis media. Most children with cleft palate of death in children with ALL. Therefore, the

remain well-nourished and maintain adequate initial priority nursing intervention would be to

nutrition through the use of proper feeding institute infection control precautions to

techniques. Food particles do not pass through decrease the risk of infection. Iron-rich foods

the cleft and into the Eustachian tubes. There is help with anemia, but dietary iron is not an

no association between cleft palate and initial intervention. The prognosis of ALL usually

congenial ear deformities. is good. However, later on, the nurse may need

25. D. A 3-month-old infant should be able to lift to assist the child and family with coping since
the
death and dying may still be an issue in need of
head and chest when prone. The Moro reflex
discussion. Injections should be discouraged,
typically diminishes or subsides by 3 months.
owing to increased risk from bleeding due to
The parachute reflex appears at 9 months.
thrombocytopenia.
Rolling from front to back usually is
29. A. The pertusis component may result in
accomplished at about 5 months. fever

26. D. A child’s birth weight usually triples by 12 and the tetanus component may result in

months and doubles by 4 months. No specific injection soreness. Therefore, the mother’s

birth weight parameters are established for 7 or verbalization of information about measures to

9 months. reduce fever indicates understanding. No

dietary
27. C. Toddlers engaging in parallel play will play
restrictions are necessary after this injection is
near each other, but not with each other. Thus,
given. A subsequent rash is more likely to be
when two toddlers sit near each other but play
seen 5 to 10 days after receiving the MMR
with separate dolls, they are exhibiting parallel
vaccine, not the diphtheria, pertussis, and
play. Sharing crayons, playing a board game with
tetanus vaccine. Diarrhea is not associated with
a nurse, or sharing dolls with two different
this vaccine.
30. A. Multiple bruises and burns on a toddler more prone to respiratory infections. Bleeding
are
tendencies, frequent vomiting, and diarrhea and
signs child abuse. Therefore, the nurse is
seizure disorders are not associated with
responsible for reporting the case to Protective
congenital heart disease.
Services immediately to protect the child from
33. D. The child is exhibiting classic signs of
further harm. Scheduling a follow-up visit is
epiglottitis, always a pediatric emergency. The
inappropriate because additional harm may
physician must be notified immediately and the
come to the child if the nurse waits for further
nurse must be prepared for an emergency
assessment data. Although the nurse should
intubation or tracheostomy. Further assessment
notify the physician, the goal is to initiate
with auscultating lungs and placing the child in a
measures to protect the child’s safety. Notifying
mist tent wastes valuable time. The situation is
the physician immediately does not initiate the a

removal of the child from harm nor does it possible life-threatening emergency. Having the

absolve the nurse from responsibility. Multiple child lie down would cause additional distress

bruises and burns are not normal toddler and may result in respiratory arrest. Throat

injuries. examination may result in laryngospasm that

31. B. The mother is using projection, the could be fatal.

defense
34. A. In females, the urethra is shorter than in
mechanism used when a person attributes his
males. This decreases the distance for
or
organisms
her own undesirable traits to another.
to travel, thereby increasing the chance of the
Displacement is the transfer of emotion onto an
child developing a urinary tract infection.
unrelated object, such as when the mother
Frequent emptying of the bladder would help to
would kick a chair or bang the door shut.
decrease urinary tract infections by avoiding
Repression is the submerging of painful ideas
sphincter stress. Increased fluid intake enables
442
the bladder to be cleared more frequently, thus
442
helping to prevent urinary tract infections. The
into the unconscious. Psychosis is a state of
intake of acidic juices helps to keep the urine pH
being out of touch with reality.
acidic and thus decrease the chance of flora
32. A. Children with congenital heart disease are
development. she begins to cruise the environment. Rattles

35. B. Compartment syndrome is an emergent and mobiles are more appropriate for infants in

situation and the physician needs to be notified the 1 to 3 month age range. Mobiles pose a

immediately so that interventions can be danger to older infants because of possible

initiated to relieve the increasing pressure and strangulation.

restore circulation. Acetaminophen (Tylenol) will 38. B. During the preschool period, the child has

be ineffective since the pain is related to the mastered a sense of autonomy and goes on to

increasing pressure and tissue ischemia. The master a sense of initiative. During this period,

cast, not traction, is being used in this situation the child commonly experiences more fears
than
for immobilization, so releasing the traction
at any other time. One common fear is fear of
would be inappropriate. In this situation,
specific the body mutilation, especially associated with

action not continued monitoring is indicated. painful experiences. The preschool child uses

36. D. The varicella zoster vaccine (VZV) is a live simple, not complex, reasoning, engages in

vaccine given after age 12 months. The first associative, not competitive, play (interactive
dose
and cooperative play with sharing), and is able
of hepatitis B vaccine is given at birth to 2 to

months, then at 1 to 4 months, and then again tolerate longer periods of delayed gratification.
at
39. A. Mild mental retardation refers to
6 to 18 months. DtaP is routinely given at 2, 4, 6,
development disability involving an IQ 50 to 70.
and 15 to 18 months and a booster at 4 to 6
Typically, the child is not noted as being
years.
retarded, but exhibits slowness in performing
37. C. Because the 8-month-old is refining his
tasks, such as self-feeding, walking, and taking.
gross
Little or no speech, marked motor delays, and
motor skills, being able to sit unsupported and
gait disabilities would be seen in more severe
also improving his fine motor skills, probably
forms mental retardation.
capable of making hand-to-hand transfers, large
40. B. Down syndrome is characterized by the
blocks would be the most appropriate toy
following a transverse palmar crease (simian
selection. Push-pull toys would be more
crease), separated sagittal suture, oblique
appropriate for the 10 to 12-month-old as he or
palpebral fissures, small nose, depressed nasal with GER. Steatorrhea occurs in malabsorption

bridge, high-arched palate, excess and lax skin, disorders such as celiac disease. “Currant jelly”

wide spacing and plantar crease between the stools are characteristic of intussusception.

second and big toes, hyperextensible and lax 44. D. GER is the backflow of gastric contents
into
joints, large protruding tongue, and muscle
the esophagus resulting from relaxation or
weakness.
incompetence of the lower esophageal (cardiac)
41. A. Because of the defect, the child will be
unable sphincter. No alteration in the oral mucous

to from the mouth adequately around nipple, membranes occurs with this disorder. Fluid

thereby requiring special devices to allow for volume deficit, risk for aspiration, and altered

feeding and sucking gratification. Respiratory nutrition are appropriate nursing diagnoses.

status may be compromised if the child is fed 45. A. Thickened feedings are used with GER to
stop
improperly or during postoperative period,
the vomiting. Therefore, the nurse would
Locomotion would be a problem for the older
monitor the child’s vomiting to evaluate the
infant because of the use of restraints. GI
effectiveness of using the thickened feedings.
functioning is not compromised in the child with
No
a cleft lip.
relationship exists between feedings and
42. B. Postoperatively children with cleft palate
characteristics of stools and uterine. If feedings
should be placed on their abdomens to facilitate
are ineffective, this should be noted before
drainage. If the child is placed in the supine
there is any change in the child’s weight.
position, he or she may aspirate. Using an infant
46. C. Children with celiac disease cannot
seat does not facilitate drainage. Side-lying does tolerate or

443 digest gluten. Therefore, because of its gluten

443 content, wheat and wheat-containing products

not facilitate drainage as well as the prone must be avoided. Rice, milk, and chicken do not

position. contain gluten and need not be avoided.

43. C. Projectile vomiting is a key symptom of 47. C. Episodes of celiac crises are precipitated
pyloric by

stenosis. Regurgitation is seen more commonly infections, ingestion of gluten, prolonged

fasting,
or exposure to anticholinergic drugs. Celiac wall defect.
crisis
50. C. Because intussusception is not believed to
is typically characterized by severe watery
have a familial tendency, obtaining a family
diarrhea. Respiratory distress is unlikely in a
history would provide the least amount of
routine upper respiratory infection. Irritability,
information. Stool inspection, pain pattern, and
rather than lethargy, is more likely. Because of
abdominal palpation would reveal possible
the fluid loss associated with the severe watery
indicators of intussusception. Current, jelly-like
diarrhea, the child’s weight is more likely to be
stools containing blood and mucus are an
decreased.
indication of intussusception. Acute, episodic
48. A. For the child with Hirschsprung disease,
abdominal pain is characteristics of
fever
intussusception. A sausage-shaped mass may be
and explosive diarrhea indicate enterocolitis, a
palpated in the right upper quadrant.
life-threatening situation. Therefore, the
444
physician should be notified immediately.
444
Generally, because of the intestinal obstruction
COMMUNITY HEALTH NURSING Part 1
and inadequate propulsive intestinal movement,
SITUATION : Epidemiology and Vital statistics is a
antidiarrheals are not used to treat
very
Hirschsprung
important tool that a nurse could use in
disease. The child is acutely ill and requires
controlling the
intervention, with monitoring more frequently
spread of disease in the community and at the
than every 30 minutes. Hirschsprung disease same

typically presents with chronic constipation. time, surveying the impact of the disease on the

49. A. Failure to pass meconium within the first population and prevent it’s future occurrence.
24
1. It is concerned with the study of factors that
hours after birth may be an indication of influence

Hirschsprung disease, a congenital anomaly the occurrence and distribution of diseases,

defects,
resulting in mechanical obstruction due to
disability or death which occurs in groups or
inadequate motility in an intestinal segment.
aggregation
Failure to pass meconium is not associated with
of individuals.
celiac disease, intussusception, or abdominal
A. Epidemiology
B. Demographics 5. After the epidemiological investigation
produced final
C. Vital Statistics
conclusions, which of the following is your initial
D. Health Statistics
step in
2. Which of the following is the backbone in
your operational procedure during disease
disease
outbreak?
prevention?
A. Coordinate personnel from Municipal to the
A. Epidemiology National

B. Demographics level

C. Vital Statistics B. Collect pertinent laboratory specimen to

confirm
D. Health Statistics
disease causation
3. Which of the following type of research could
show C. Immunize nearby communities with Measles

how community expectations can result in the D. Educate the community in future prevention
actual of similar

provision of services? outbreaks

A. Basic Research 6. The main concern of a public health nurse is

the
B. Operational Research
prevention of disease, prolonging of life and
C. Action Research promoting
D. Applied Research physical health and efficiency through which of
4. An outbreak of measles has been reported in the

Community A. As a nurse, which of the following?

following is your A. Use of epidemiological tools and vital health
first action for an Epidemiological investigation? statistics

A. Classify if the outbreak of measles is B. Determine the spread and occurrence of the
epidemic or just disease

sporadic C. Political empowerment and Socio Economic

B. Report the incidence into the RHU Assistance

C. Determine the first day when the outbreak D. Organized Community Efforts
occurred 7. In order to control a disease effectively, which
D. Identify if it is the disease which it is reported of the
to be following must first be known?
1. The conditions surrounding its occurrence demonstrates hemorrhagic type of fever. You
are
2. Factors that do not favor its development
designated now to plan for epidemiological
3. The condition that do not surround its
occurrence investigation. Arrange the sequence of events in

4. Factors that favors its development 445

A. 1 and 3 445

B. 1 and 4 accordance with the correct outline plan for

C. 2 and 3 epidemiological investigation.

D. 2 and 4 1. Report the presence of dengue

8. All of the following are uses of epidemiology 2. Summarize data and conclude the final
except: picture of

A. To study the history of health population and epidemic

the rise
3. Relate the occurrence to the population
and fall of disease group,

B. To diagnose the health of the community and facilities, food supply and carriers
the
4. Determine if the disease is factual or real
condition of the people
5. Determine any unusual prevalence of the
C. To provide summary data on health service disease and
delivery
its nature; is it epidemic, sporadic, endemic or
D. To identify groups needing special attention
pandemic?
9. Before reporting the fact of presence of an
6. Determine onset and the geographical
epidemic,
limitation of
which of the following is of most importance to
the disease.
determine?
A. 4,1,3,5,2,6
A. Are the facts complete?
B. 4,1,5,6,3,2
B. Is the disease real?
C. 5,4,6,2,1,3
C. Is the disease tangible?
D. 5,4,6,1,2,3
D. Is it epidemic or endemic?
E. 1,2,3,4,5,6
10. An unknown epidemic has just been
11. In the occurrence of SARS and other
reported in
pandemics,
Barangay Dekbudekbu. People said that affected
person
which of the following is the most vital role of a B. 6,5,4,3,2,1
nurse in
C. 5,6,4,2,3,1
epidemiology?
D. 5,2,3,4,6,1
A. Health promotion
13. All of the following are function of Nurse
B. Disease prevention Budek in

C. Surveillance epidemiology except

D. Casefinding A. Laboratory Diagnosis

12. Measles outbreak has been reported in B. Surveillance of disease occurrence

Barangay
C. Follow up cases and contacts
Bahay Toro, After conducting an epidemiological
D. Refer cases to hospitals if necessary
investigation you have confirmed that the
E. Isolate cases of communicable disease
outbreak is
14. All of the following are performed in team
factual. You are tasked to lead a team of medical
organization except
workers for operational procedure in disease
outbreak. A. Orientation and demonstration of
methodology to be
Arrange the correct sequence of events that you
must employed
do to effectively contain the disease B. Area assignments of team members
1. Create a final report and recommendation C. Check team’s equipments and paraphernalia
2. Perform nasopharyngeal swabbing to infected D. Active case finding and Surveillance
individuals 15. Which of the following is the final output of
data
3. Perform mass measles immunization to
vulnerable reporting in epidemiological operational
procedure?
groups
A. Recommendation
4. Perform an environmental sanitation survey
on the B. Evaluation
immediate environment C. Final Report
5. Organize your team and Coordinate the D. Preliminary report
personnels
16. The office in charge with registering vital
6. Educate the community on disease facts in the
transmission
Philippines is none other than the
A. 1,2,3,4,5,6
A. PCSO A. Nurse

B PAGCOR B. Midwife

C. DOH C. OB Gyne

D. NSO D. Birth Attendant

17. The following are possible sources of Data 21. In reporting the birth of Baby Lestat, where
except: will he be

A. Experience registered?

B. Census A. At the Local Civil Registrar

C. Surveys B. In the National Statistics Office

D. Research C. In the City Health Department

18. This refers to systematic study of vital events D. In the Field Health Services and Information
such as System

births, illnesses, marriages, divorces and deaths Main Office

A. Epidemiology 22. Deejay, The birth attendant noticed that

Lestat has
B. Demographics
low set of ears, Micrognathia, Microcephaly and
C. Vital Statistics
a typical
D. Health Statistics
cat like cry. What should Deejay do?
19. In case of clerical errors in your birth
A. Bring Lestat immediately to the nearest
certificate,
hospital
Where should you go to have it corrected?
B. Ask his assistant to call the nearby
446 pediatrician

446 C. Bring Lestat to the nearest pediatric clinic

A. NSO D. Call a Taxi and together with Acasia, Bring

Lestat to
B. Court of Appeals
the nearest hospital
C. Municipal Trial Court
23. Deejay would suspect which disorder?
D. Local Civil Registrar
A. Trisomy 21
20. Acasia just gave birth to Lestat, A healthy
baby boy. B. Turners Syndrome

Who are going to report the birth of Baby C. Cri Du Chat

Lestat?
D. Klinefelters Syndrome
24. Deejay could expect which of the following B. Ratios

congenital anomaly that would accompany this C. Crude/General Rate

disorder? D. Specific Rate

A. AVSD 27. This is the most sensitive index in

determining the
B. PDA
general health condition of a community since it
C. TOF
reflects
D. TOGV
the changes in the environment and medical
26. Which presidential decree orders reporting conditions
of births
of a community
within 30 days after its occurrence?
A. Crude death rate
A. 651
B. Infant mortality rate
B. 541
C. Maternal mortality rate
C. 996
D. Fetal death rate
D. 825
28. According to the WHO, which of the
25. These rates are referred to the total living following is the

population, It must be presumed that the total most frequent cause of death in children
underfive
population was exposed to the risk of
occurrence of the worldwide in the 2003 WHO Survey?

event. A. Neonatal

A. Rate B. Pneumonia

B. Ratio C. Diarrhea

C. Crude/General Rates D. HIV/AIDS

D. Specific Rate 29. In the Philippines, what is the most common

cause of
26. These are used to describe the relationship
between death of infants according to the latest survey?

two numerical quantities or measures of events A. Pneumonia

without
B. Diarrhea
taking particular considerations to the time or
C. Other perinatal condition
place.
D. Respiratory condition of fetus and newborn
A. Rate
30. The major cause of mortality from 1999 up 33. Working in the community as a PHN for
to 2002 almost 10

447 years, Aida knew the fluctuation in vital

statistics. She
447
knew that the most common cause of morbidity
in the Philippines are
among
A. Diseases of the heart
the Filipinos is
B. Diseases of the vascular system
A. Diseases of the heart
C. Pneumonias
B. Diarrhea
D. Tuberculosis
C. Pneumonia
31. Alicia, a 9 year old child asked you “ What is
D. Vascular system diseases
the
34. Nurse Aida also knew that most maternal
common cause of death in my age group here in
deaths are
the
caused by
Philippines? “ The nurse is correct if he will
answer A. Hemorrhage

A. Pneumonia is the top leading cause of death B. Other Complications related to pregnancy
in occurring

children age 5 to 9 in the course of labor, delivery and puerperium

B. Malignant neoplasm if common in your age C. Hypertension complicating pregnancy,

group childbirth and

C. Probability wise, You might die due to puerperium

accidents
D. Abortion
D. Diseases of the respiratory system is the most
SITUATION : Barangay PinoyBSN has the
common cause of death in children following data

32. In children 1 to 4 years old, which is the in year 2006

most
1. July 1 population : 254,316
common cause of death?
2. Livebirths : 2,289
A. Diarrhea
3. Deaths from maternal cause : 15
B. Accidents
4. Death from CVD : 3,029
C. Pneumonia
5. Deaths under 1 year of age : 23
D. Diseases of the heart
6. Fetal deaths : 8
7. Deaths under 28 days : 8 C. 3.14/1000

8. Death due to rabies : 45 D. 3.14/100,000

9. Registered cases of rabies : 45 39. What is the attack rate of pneumonia?

10. People with pneumonia : 79 A. 3.04/1000

11. People exposed with pneumonia : 2,593 B. 7.18/1000

12. Total number of deaths from all causes : C. 32.82/100

10,998
D. 3.04/100
The following questions refer to these data
40. Determine the Case fatality ratio of rabies in
35. What is the crude birth rate of Barangay this
PinoyBSN?
Barangay
A. 90/100,000
448
B. 9/100
448
C. 90/1000
A. 1/100
D. 9/1000
B. 100%
36. What is the cause specific death rate from
C. 1%
cardiovascular diseases?
D. 100/1000
A. 27/100
41. The following are all functions of the nurse
B. 1191/100,000 in vital

C. 27/100,000 statistics, which of the following is not?

D. 1.1/1000 A. Consolidate Data

37. What is the Maternal Mortality rate of this B. Collects Data

barangay? C. Analyze Data

A. 6.55/1000 D. Tabulate Data

B. 5.89/1000 42. The following are Notifiable diseases that

needs to
C. 1.36/1000
have a tally sheet in data reporting, Which one
D. 3.67/1000
is not?
38. What is the fetal death rate?
A. Hypertension
A. 3.49/1000
B. Bronchiolitis
B. 10.04/1000
C. Chemical Poisoning
D. Accidents D. Determining the source and nature of the
epidemic
43. Which of the following requires reporting
within 24 47. Which of the following is a POINT SOURCE
epidemic?
hours?
A. Dengue H.F
A. Neonatal tetanus
B. Malaria
B. Measles
C. Contaminated Water Source
C. Hypertension
D. Tuberculosis
D. Tetanus
48. All but one is a characteristic of a point
44. Which Act declared that all communicable
source
disease be
epidemic, which one is not?
reported to the nearest health station?
A. The spread of the disease is caused by a
A. 1082
common
B. 1891
vehicle
C. 3573
B. The disease is usually caused by
D. 6675 contaminated food

45. In the RHU Team, Which professional is C. There is a gradual increase of cases
directly
D. Epidemic is usually sudden
responsible in caring a sick person who is
49. The only Microorganism monitored in cases
homebound?
of
A. Midwife
contaminated water is
B. Nurse
A. Vibrio Cholera
C. BHW
B. Escherichia Coli
D. Physician
C. Entamoeba Histolytica
46. During epidemics, which of the following
D. Coliform Test
epidemiological function will you have to
50. Dengue increase in number during June, July
perform first?
and
A. Teaching the community on disease
August. This pattern is called
prevention
A. Epidemic
B. Assessment on suspected cases
B. Endemic
C. Monitor the condition of people affected
C. Cyclical
D. Secular A. Family treatment record

SITUATION : Field health services and B. Target Client list

information
C. Reporting forms
system provides summary data on health
D. Output record
service
53. What is the primary advantage of having a
delivery and selected program from the
target
barangay level
client list?
up to the national level. As a nurse, you should
know the A. Nurses need not to go back to FTR to monitor
process on how these information became treatment and services to beneficiaries thus
processed saving time
and consolidated. and effort
51. All of the following are objectives of FHSIS B. Help monitor service rendered to clients in
Except general
A. To complete the clinical picture of chronic C. Facilitate monitoring and supervision of
disease services
and describe their natural history D. Facilitates easier reporting
B. To provide standardized, facility level data 54. Which of the following is used to monitor
base which particular
can be accessed for more in depth studies groups that are qualified as eligible to a certain
program
C. To minimize recording and reporting burden
allowing of the DOH?
more time for patient care and promotive A. Family treatment record
activities
B. Target Client list
D. To ensure that data reported are useful and
accurate C. Reporting forms

and are disseminated in a timely and easy to use D. Output record

fashion 55. In using the tally sheet, what is the
52. What is the fundamental block or recommended
foundation of the frequency in tallying activities and services?
449 A. Daily
449 B. Weekly
field health service information system? C. Monthly
D. Quarterly activities is prepared how frequently?

56. When is the counting of the tally sheet A. Daily

done?
B. Weekly
A. At the end of the day
C. Quarterly
B. At the end of the week
D. Yearly
C. At the end of the month
61. Nurse Budek is preparing the reporting form
D. At the end of the year for

57. Target client list will be transmitted to the weekly notifiable diseases. He knew that he will
next code the

facility in the form of report form as

A. Family treatment record A. FHSIS/E-1

B. Target Client list B. FHSIS/E-2

C. Reporting forms C. FHSIS/E-3

D. Output record D. FHSIS/M-1

58. All but one of the following are eligible 62. In preparing the maternal death report,
target client which of the

list following correctly codes this occurrence?

A. Leprosy cases A. FHSIS/E-1

B. TB cases B. FHSIS/E-2

C. Prenatal care C. FHSIS/E-3

D. Diarrhea cases D. FHSIS/M-1

59. This is the only mechanism through which 63. Where should Nurse Budek bring the
data are reporting forms

routinely transmitted from once facility to if he is in the BHU Facility?

another
A. Rural health office
A. Family treatment record
B. FHSIS Main office
B. Target Client list
C. Provincial health office
C. Reporting forms
D. Regional health office
D. Output record
64. After bringing the reporting forms in the
60. FHSIS/Q-3 Or the report for environmental right facility
health
for processing, Nurse Budek knew that the he is in the target client’s list, In what TCL
output should Mang

reports are solely produced by what office? Raul’s entry be documented?

A. Rural health office A. TCL Eligible Population

B. FHSIS Main office B. TCL Family Planning

450 C. TCL Nutrition

450 D. TCL Pre Natal

C. Provincial health office 68. The nurse uses the FHSIS Record system
incorrectly
D. Regional health office
when she found out that
65. Mang Raul entered the health center
complaining of A. She go to the individual or FTR for entry
confirmation
fatigue and frequent syncope. You assessed
Mang Raul in the Tally/Report Summary

and found out that he is severely malnourished B. She refer to other sources for completing
and monthly

anemic. What record should you get first to and quarterly reports
document
C. She records diarrhea in the Tally sheet/Report
these findings? form

A. Family treatment record with a code FHSIS/M-1

B. Target Client list D. She records a Child who have frequent

diarrhea in TCL
C. Reporting forms
: Under Five
D. Output record
69. The BHS Is the lowest level of reporting unit
66. The information about Mang Raul’s address,
in FHSIS.
full
A BHS can be considered a reporting unit if all of
name, age, symptoms and diagnosis is recorded
the
in
following are met except
A. Family treatment record
A. It renders service to 3 barangays
B. Target Client list
B. There is a midwife the regularly renders
C. Reporting forms
service to the
D. Output record
area
67. Another entry is to be made for Mang Raul
C. The BHS Have no mother BHS
because
D. It should be a satellite BHS D. Make a courtesy call to the Municipal Mayor

70. Data submitted to the PHO is processed 73. Preparatory phase is the first phase in
using what organizing the

type of technology? community. Which of the following is the initial

step in
A. Internet
the preparatory phase?
B. Microcomputer
A. Area selection
C. Supercomputer
B. Community profiling
D. Server Interlink Connections
C. Entry in the community
SITUATION : Community organizing is a process
by which D. Integration with the people

people, health services and agencies of the 74. the most important factor in determining
community the proper

are brought together to act and solve their own area for community organizing is that this area
should
problems.
A. Be already adopted by another organization
71. Mang Ambo approaches you for counseling.
You are B. Be able to finance the projects

an effective counselor if you C. Have problems and needs assistance

A. Give good advice to Mang Ambo D. Have people with expertise to be developed
as
B. Identify Mang Ambo’s problems
leaders
C. Convince Mang Ambo to follow your advice
75. Which of the following dwelling place should
D. Help Mang Ambo identify his problems
the
72. As a newly appointed PHN instructed to
Nurse choose when integrating with the
organize
people?
Barangay Baritan, Which of the following is your
451
initial
451
step in organizing the community for initial
action? A. A simple house in the border of Barangay
Baritan and
A. Study the Barangay Health statistics and
records San Pablo

B. Make a courtesy call to the Barangay Captain B. A simple house with fencing and gate located
in the
C. Meet with the Barangay Captain to make
plans center of Barangay Baritan
C. A modest dwelling place where people will C. Education and Training
not
D. Intersectoral Collaboration
hesitate to enter
E. Phase out
D. A modest dwelling place where people will
79. Community diagnosis is done to come up
not
with a
hesitate to enter located in the center of the
profile of local health situation that will serve as
community basis of

76. In choosing a leader in the community health programs and services. This is done in
during the what phase

Organizational phase, Which among these of COPAR?

people will
A. Preparatory
you choose?
B. Organizational
A. Miguel Zobel, 50 years old, Rich and Famous
C. Education and Training
B. Rustom, 27 years old, Actor
D. Intersectoral Collaboration
C. Mang Ambo, 70, Willing to work for the
E. Phase out
desired
80. The people named the community health
change
workers
D. Ricky, 30 years old, Influential and Willing to
based on the collective decision in accordance
work
with the
for the desired change
set criteria. Before they can be trained by the
77. Which type of leadership style should the Nurse, The
leaders of
Nurse must first
the community practice?
A. Make a lesson plan
A. Autocratic
B. Set learning goals and objective
B. Democratic
C. Assess their learning needs
C. Laissez Faire
D. Review materials needed for training
D. Consultative
81. Nurse Budek wrote a letter to PCSO asking
78. Setting up Committee on Education and them for
Training is in
assistance in their feeding programs for the
what phase of COPAR? community’s

A. Preparatory nutrition and health projects. PCSO then

approved the
B. Organizational
request and gave Budek 50,000 Pesos and a 3. It is incompatible with their personal beliefs
truckload of
4. It is compatible with their personal beliefs
rice, fruits and vegetables. Which phase of
A. 1 and 3
COPAR did
B. 2 and 4
Budek utilized?
C. 1 and 2
A. Preparatory
D. 1 and 4
B. Organizational
85. Nurse Budek made a proposal that people
C. Education and Training
should
D. Intersectoral Collaboration
turn their backyard into small farming lots to
E. Phase out plant

82. Ideally, How many years should the Nurse 452

stay in the
452
community before he can phase out and be
vegetables and fruits. He specified that the
assured of a
objective is
Self Reliant community?
to save money in buying vegetables and fruits
A. 5 years that tend

B. 10 years to have a fluctuating and cyclical price. Which

step in
C. 1 year
Community organizing process did he utilized?
D. 6 months
A. Fact finding
83. Major discussion in community organization
are B. Determination of needs

made by C. Program formation

A. The nurse D. Education and Interpretation

B. The leaders of each committee 86. One of the critical steps in COPAR is
becoming one
C. The entire group
with the people and understanding their culture
D. Collaborating Agencies
and
84. The nurse should know that Organizational
lifestyle. Which critical step in COPAR will the
plan best
Nurse try
succeeds when
to immerse himself in the community?
1. People sees its values
A. Integration
2. People think its antagonistic professionally
B. Social Mobilization
C. Ground Work 90. This is considered the first act of integrating
with the
D. Mobilization
people. This gives an in depth participation in
87. The Actual exercise of people power occurs
during community health problems and needs.

when? A. Residing in the area of assignment

A. Integration B. Listing down the name of person to contact

for
B. Social Mobilization
courtesy call
C. Ground Work
C. Gathering initial information about the
D. Mobilization
community
88. Which steps in COPAR trains indigenous and
D. Preparing Agenda for the first meeting
informal
SITUATION : Health education is the process
leaders?
whereby
A. Ground Work
knowledge, attitude and practice of people are
B. Mobilization changed

C. Core Group formation to improve individual, family and community

health.
D. Integration
91. Which of the following is the correct
89. As a PHN, One of your role is to organize the sequence in
community. Nurse Budek knows that the health education?
purposes of
1. Information
community organizing are
2. Communication
1. Move the community to act on their own
problems 3. Education

2. Make people aware of their own problems A. 1,2,3

3. Enable the nurse to solve the community B. 3,2,1

problems
C. 1,3,2
4. Offer people means of solving their own
D. 3,1,2
problems
92. The health status of the people is greatly
A. 1,2,3
affected
B. 1,2,3,4
and determined by which of the following?
C. 1,2
A. Behavioral factors
D. 1,2,4
B. Socioeconomic factors
C. Political factors learning readiness of an adult learner?

D. Psychological factors A. The individuals stage of development

93. Nurse Budek is conducting a health teaching B. Ability to concentrate on information to be

to learned

Agnesia, 50 year old breast cancer survivor C. The individual’s psychosocial adaptation to
needing his illness

rehabilitative measures. He knows that health D. The internal impulses that drive the person to
education take

is effective when action

A. Agnesia recites the procedure and 96. Which of the following is the most
instructions important

perfectly condition for diabetic patients to learn how to

control
B. Agnesia’s behavior and outlook in life was
changed their diet?

positively A. Use of pamphlets and other materials during

C. Agnesia gave feedback to Budek saying that instructions

she
B. Motivation to be symptom free
understood the instruction
C. Ability of the patient to understand teaching
D. Agnesia requested a written instruction from
instruction
Budek
D. Language used by the nurse
94. Which of the following is true about health
97. An important skill that a primigravida has to
education?
acquire
A. It helps people attain their health through the
is the ability to bathe her newborn baby and
nurse’s
clean her
sole efforts
breast if she decides to breastfeed her baby,
B. It should not be flexible Which of

C. It is a fast and mushroom like process the following learning domain will you classify
the above
453
goals?
453
A. Psychomotor
D. It is a slow and continuous process
B. Cognitive
95. Which of the following factors least
influence the C. Affective
D. Attitudinal D. Actual Physical examination

98. When you prepare your teaching plan for a 454

group of
454
hypertensive patients, you first formulate your
COMMUNITY HEALTH NURSING Part 2
learning
1. Which is the primary goal of community
objectives. Which of the following steps in the
health
nursing
nursing?
process corresponds to the writing of the
learning A. To support and supplement the efforts of the
medical
objectives?
profession in the promotion of health and
A. Planning
prevention of
B. Implementing
illness
C. Evaluation
B. To enhance the capacity of individuals,
C. Assessment families and

99. Rose, 50 years old and newly diagnosed communities to cope with their health needs
diabetic
C. To increase the productivity of the people by
patient must learn how to inject insulin. Which
providing them with services that will increase
of the
their level
following physical attribute is not in anyway
of health
related to
D. To contribute to national development
her ability to administer insulin?
through
A. Strength
promotion of family welfare, focusing
B. Coordination particularly on

C. Dexterity mothers and children.

D. Muscle Built Answer: (B) To enhance the capacity of

individuals,
100. Appearance and disposition of clients are
best families and communities to cope with their
health
observed initially during which of the following
needs
situation?
To contribute to national development through
A. Taking V/S
promotion of family welfare, focusing
B. Interview
particularly on
C. Implementation of the initial care
mothers and children. Population-focused nursing care means
providing care
2. CHN is a community-based practice. Which
best based on the greater need of the majority of the

explains this statement? population. The greater need is identified

through
A. The service is provided in the natural
environment of community diagnosis.

people. 4. R.A. 1054 is also known as the Occupational

Health
B. The nurse has to conduct community
diagnosis to Act. Aside from number of employees, what
other factor
determine nursing needs and problems.
must be considered in determining the
C. The services are based on the available
occupational
resources
health privileges to which the workers will be
within the community.
entitled?
D. Priority setting is based on the magnitude of
A. Type of occupation: agricultural, commercial,
the
industrial
health problems identified.
B. Location of the workplace in relation to
Answer: A. The service is provided in the natural
health
environment of people.
facilities
Community-based practice means providing
C. Classification of the business enterprise
care to
based on net
people in their own natural environments: the
profit
home,
D. Sex and age composition of employees
school and workplace, for example.
Answer: (B) Location of the workplace in
3. Population-focused nursing practice requires
relation to
which of
health facilities
the following processes?
Based on R.A. 1054, an occupational nurse must
A. Community organizing
be
B. Nursing process
employed when there are 30 to 100 employees
C. Community diagnosis and the

D. Epidemiologic process workplace is more than 1 km. away from the

nearest
Answer: (C) Community diagnosis
health center.
5. A business firm must employ an occupational C. Public health nurse of the RHU of their
health municipality

nurse when it has at least how many D. Rural sanitary inspector of the RHU of their
employees?
municipality
A. 21
455
B. 101
455
C. 201
Answer: (C) Public health nurse of the RHU of
D. 301 their

Answer: (B) 101 municipality

Again, this is based on R.A. 1054. You’re right! This question is based on R.A.1054.

6. When the occupational health nurse employs 8. “Public health services are given free of
charge.” Is this
ergonomic principles, she is performing which
of her statement true or false?

roles? A. The statement is true; it is the responsibility

of
A. Health care provider
government to provide basic services.
B. Health educator
B. The statement is false; people pay indirectly
C. Health care coordinator
for public
D. Environmental manager
health services.
Answer: (D) Environmental manager
C. The statement may be true or false,
Ergonomics is improving efficiency of workers by depending on the

improving the worker’s environment through specific service required.

appropriately designed furniture, for example. D. The statement may be true or false,
depending on
7. A garment factory does not have an
occupational policies of the government concerned.

nurse. Who shall provide the occupational Answer: (B) The statement is false; people pay
health needs
indirectly for public health services.
of the factory workers?
Community health services, including public
A. Occupational health nurse at the Provincial health
Health
services, are pre-paid services, though taxation,
Office for

B. Physician employed by the factory example.

9. According to C.E.Winslow, which of the years or older. Its inverse represents the
following is percentage of

the goal of Public Health? untimely deaths (those who died younger than
50 years).
A. For people to attain their birthrights of health
and 11. Which of the following is the most
prominent feature
longevity
of public health nursing?
B. For promotion of health and prevention of
disease A. It involves providing home care to sick people
who are
C. For people to have access to basic health
services not confined in the hospital.

D. For people to be organized in their health B. Services are provided free of charge to
efforts people within

Answer: (A) For people to attain their birthrights the catchment area.
of
C. The public health nurse functions as part of a
health and longevity team

According to Winslow, all public health efforts providing a public health nursing services.
are for
D. Public health nursing focuses on preventive,
people to realize their birthrights of health and not

longevity. curative, services.

10. We say that a Filipino has attained longevity Answer: (D) Public health nursing focuses on
when he
preventive, not curative, services.
is able to reach the average lifespan of Filipinos.
The catchment area in PHN consists of a
What
residential
other statistic may be used to determine
community, many of whom are well individuals
attainment of
who
longevity?
have greater need for preventive rather than
A. Age-specific mortality rate curative

B. Proportionate mortality rate services.

C. Swaroop’s index 12. According to Margaret Shetland, the

philosophy of
D. Case fatality rate
public health nursing is based on which of the
Answer: (C) Swaroop’s index
following?
Swaroop’s index is the percentage of the deaths
A. Health and longevity as birthrights
aged 50
B. The mandate of the state to protect the Regional hospitals are tertiary facilities because
birthrights of they

its citizens serve as training hospitals for the region.

C. Public health nursing as a specialized field of 456

nursing
456
D. The worth and dignity of man
15. Which is true of primary facilities?
Answer: (D) The worth and dignity of man
A. They are usually government-run.
This is a direct quote from Dr. Margaret
B. Their services are provided on an out-patient
Shetland’s
basis.
statements on Public Health Nursing.
C. They are training facilities for health
13. Which of the following is the mission of the professionals.

Department of Health? D. A community hospital is an example of this

level of
A. Health for all Filipinos
health facilities.
B. Ensure the accessibility and quality of health
care Answer: (B) Their services are provided on an
outpatient
C. Improve the general health status of the
population basis.

D. Health in the hands of the Filipino people by Primary facilities government and non-
the year government

2020 facilities that provide basic out-patient services.

Answer: (B) Ensure the accessibility and quality 16. Which is an example of the school nurse’s
of health

health care care provider functions?

(none) A. Requesting for BCG from the RHU for school

entrant
14. Region IV Hospital is classified as what level
of immunization

facility? B. Conducting random classroom inspection

during a
A. Primary
measles epidemic
B. Secondary
C. Taking remedial action on an accident hazard
C. Intermediate
in the
D. Tertiary
school playground
Answer: (D) Tertiary
D. Observing places in the school where pupils government units (LGU’s ). The public health
spend nurse is an

their free time employee of the LGU.

Answer: (B) Conducting random classroom 19. R.A. 7160 mandates devolution of basic
inspection services from

during a measles epidemic the national government to local government

units.
Random classroom inspection is assessment of
Which of the following is the major goal of
pupils/students and teachers for signs of a
devolution?
health
A. To strengthen local government units
problem prevalent in the community.
B. To allow greater autonomy to local
17. When the nurse determines whether
government units
resources were
C. To empower the people and promote their
maximized in implementing Ligtas Tigdas, she is
selfreliance
evaluating
D. To make basic services more accessible to the
A. Effectiveness people

B. Efficiency Answer: (C) To empower the people and

promote their
C. Adequacy
self-reliance
D. Appropriateness
People empowerment is the basic motivation
Answer: (B) Efficiency behind
Efficiency is determining whether the goals devolution of basic services to LGU’s.
were
20. Who is the Chairman of the Municipal
attained at the least possible cost. Health Board?
18. You are a new B.S.N. graduate. You want to A. Mayor
become
B. Municipal Health Officer
a Public Health Nurse. Where will you apply?
C. Public Health Nurse
A. Department of Health
D. Any qualified physician
B. Provincial Health Office
Answer: (A) Mayor
C. Regional Health Office
The local executive serves as the chairman of
D. Rural Health Unit the
Answer: (D) Rural Health Unit Municipal Health Board.
R.A. 7160 devolved basic health services to local
21. Which level of health facility is the usual the care of clients, particularly in the
point of implementation of

entry of a client into the health care delivery 457

system?
457
A. Primary
management guidelines, as in Integrated
B. Secondary Management

C. Intermediate of Childhood Illness.

D. Tertiary 23. One of the participants in a hilot training

class asked
Answer: (A) Primary
you to whom she should refer a patient in labor
The entry of a person into the health care
who
delivery
develops a complication. You will answer, to the
system is usually through a consultation in out-
patient A. Public Health Nurse

services. B. Rural Health Midwife

22. The public health nurse is the supervisor of C. Municipal Health Officer
rural
D. Any of these health professionals
health midwives. Which of the following is a
Answer: (C) Municipal Health Officer
supervisory
A public health nurse and rural health midwife
function of the public health nurse?
can
A. Referring cases or patients to the midwife
provide care during normal childbirth. A
B. Providing technical guidance to the midwife physician should

C. Providing nursing care to cases referred by attend to a woman with a complication during
the labor.

midwife 24. You are the public health nurse in a

municipality with
D. Formulating and implementing training
programs for a total population of about 20,000. There are 3
rural
midwives
health midwives among the RHU personnel.
Answer: (B) Providing technical guidance to the
How many
midwife
more midwife items will the RHU need?
The nurse provides technical guidance to the
A. 1
midwife in
B. 2
C. 3 Act 3573, the Law on Reporting of
Communicable
D. The RHU does not need any more midwife
item. Diseases, enacted in 1929, mandated the
reporting of
Answer: (A) 1
diseases listed in the law to the nearest health
Each rural health midwife is given a population
station.
assignment of about 5,000.
27. According to Freeman and Heinrich,
25. If the RHU needs additional midwife items, community
you will
health nursing is a developmental service.
submit the request for additional midwife items Which of the
for
following best illustrates this statement?
approval to the
A. The community health nurse continuously
A. Rural Health Unit develops

B. District Health Office himself personally and professionally.

C. Provincial Health Office B. Health education and community organizing

are
D. Municipal Health Board
necessary in providing community health
Answer: (D) Municipal Health Board services.
As mandated by R.A. 7160, basic health services C. Community health nursing is intended
have primarily for
been devolved from the national government to health promotion and prevention and treatment
local of
government units. disease.
26. As an epidemiologist, the nurse is D. The goal of community health nursing is to
responsible for provide
reporting cases of notifiable diseases. What law nursing services to people in their own places of
mandates reporting of cases of notifiable residence.
diseases?
Answer: (B) Health education and community
A. Act 3573
organizing are necessary in providing
B. R.A. 3753 community health
C. R.A. 1054 services.
D. R.A. 1082 The community health nurse develops the
Answer: (A) Act 3573 health
capability of people through health education line graph for trends over time or age, a pie
and graph for

community organizing activities. population composition or distribution, and a

scatter
28. Which disease was declared through
Presidential diagram for correlation of two variables.

Proclamation No. 4 as a target for eradication in 458

the
458
Philippines?
30. Which step in community organizing
A. Poliomyelitis involves training

B. Measles of potential leaders in the community?

C. Rabies A. Integration

D. Neonatal tetanus B. Community organization

Answer: (B) Measles C. Community study

Presidential Proclamation No. 4 is on the Ligtas D. Core group formation

Tigdas
Answer: (D) Core group formation
Program.
In core group formation, the nurse is able to
29. The public health nurse is responsible for transfer the
presenting
technology of community organizing to the
the municipal health statistics using graphs and potential or
tables.
informal community leaders through a training
To compare the frequency of the leading causes program.
of
31. In which step are plans formulated for
mortality in the municipality, which graph will solving
you
community problems?
prepare?
A. Mobilization
A. Line
B. Community organization
B. Bar
C. Follow-up/extension
C. Pie
D. Core group formation
D. Scatter diagram
Answer: (B) Community organization
Answer: (B) Bar
Community organization is the step when
A bar graph is used to present comparison of community
values, a
assemblies take place. During the community objectives of contributory objectives to this
assembly, goal.

the people may opt to formalize the community 33. An indicator of success in community
organizing is
organization and make plans for community
action to when people are able to

resolve a community health problem. A. Participate in community activities for the

solution of
32. The public health nurse takes an active role
in a community problem

community participation. What is the primary B. Implement activities for the solution of the
goal of
community problem
community organizing?
C. Plan activities for the solution of the
A. To educate the people regarding community community
health
problem
problems
D. Identify the health problem as a common
B. To mobilize the people to resolve community concern
health
Answer: (A) Participate in community activities
problems for the

C. To maximize the community’s resources in solution of a community problem

dealing
Participation in community activities in resolving
with health problems a

D. To maximize the community’s resources in community problem may be in any of the

dealing processes

with health problems mentioned in the other choices.

Answer: (D) To maximize the community’s 34. Tertiary prevention is needed in which stage
resources in of the

dealing with health problems natural history of disease?

Community organizing is a developmental A. Pre-pathogenesis

service, with
B. Pathogenesis
the goal of developing the people’s self-reliance
C. Prodromal
in
D. Terminal
dealing with community health problems. A, B
and C are Answer: (D) Terminal
Tertiary prevention involves rehabilitation, susceptible population who are malnourished.
prevention of Its

permanent disability and disability limitation purpose is early diagnosis and, subsequently,
appropriate prompt

for convalescents, the disabled, complicated treatment.

cases and
37. Which type of family-nurse contact will
the terminally ill (those in the terminal stage of provide you
a
with the best opportunity to observe family
disease) dynamics?

35. Isolation of a child with measles belongs to A. Clinic consultation

what
B. Group conference
level of prevention?
459
A. Primary
459
B. Secondary
C. Home visit
C. Intermediate
D. Written communication
D. Tertiary
Answer: (C) Home visit
Answer: (A) Primary
Dynamics of family relationships can best be
The purpose of isolating a client with a observed in
communicable
the family’s natural environment, which is the
disease is to protect those who are not sick home.
(specific
38. The typology of family nursing problems is
disease prevention). used in

36. On the other hand, Operation Timbang is the statement of nursing diagnosis in the care of
_____
families. The youngest child of the de los Reyes
prevention. family

A. Primary has been diagnosed as mentally retarded. This is

B. Secondary classified as a

C. Intermediate A. Health threat

D. Tertiary B. Health deficit

Answer: (B) Secondary C. Foreseeable crisis

Operation Timbang is done to identify members D. Stress point

of the
Answer: (B) Health deficit
Failure of a family member to develop according Answer: (B) It provides an opportunity to do
to what first hand

is expected, as in mental retardation, is a health appraisal of the home situation.

deficit.
Choice A is not correct since a home visit
39. The de los Reyes couple have a 6-year old requires that
child
the nurse spend so much time with the family.
entering school for the first time. The de los Choice C
Reyes family
is an advantage of a group conference, while
has a choice D is

A. Health threat true of a clinic consultation.

B. Health deficit 41. Which is CONTRARY to the principles in

planning a
C. Foreseeable crisis
home visit?
D. Stress point
A. A home visit should have a purpose or
Answer: (C) Foreseeable crisis
objective.
Entry of the 6-year old into school is an
B. The plan should revolve around family health
anticipated
needs.
period of unusual demand on the family.
C. A home visit should be conducted in the
40. Which of the following is an advantage of a manner
home
prescribed by the RHU.
visit?
D. Planning of continuing care should involve a
A. It allows the nurse to provide nursing care to
responsible family member.
a greater
Answer: (C) A home visit should be conducted in
number of people.
the
B. It provides an opportunity to do first hand
manner prescribed by the RHU.
appraisal of
The home visit plan should be flexible and
the home situation.
practical,
C. It allows sharing of experiences among
depending on factors, such as the family’s needs
people with
and the
similar health problems.
resources available to the nurse and the family.
D. It develops the family’s initiative in providing
42. The PHN bag is an important tool in
for
providing
health needs of its members.
nursing care during a home visit. The most with the right side out before putting it back
important into the

principle of bag technique states that it bag.

A. Should save time and effort. D. At the end of the visit, fold the lining on
which the bag
B. Should minimize if not totally prevent the
spread of was placed, ensuring that the contaminated
side is on
infection.
the outside.
C. Should not overshadow concern for the
patient and Answer: (A) Wash his/her hands before and
after
his family.
providing nursing care to the family members.
D. May be done in a variety of ways depending
on the Choice B goes against the idea of utilizing the
family’s
home situation, etc.
resources, which is encouraged in CHN. Choices
Answer: (B) Should minimize if not totally
C and D
prevent the
goes against the principle of asepsis of confining
spread of infection.
the
Bag technique is performed before and after
contaminated surface of objects.
handling a
460
client in the home to prevent transmission of
infection 460

to and from the client. 44. The public health nurse conducts a study on
the
43. To maintain the cleanliness of the bag and
its factors contributing to the high mortality rate
due to
contents, which of the following must the nurse
do? heart disease in the municipality where she
works.
A. Wash his/her hands before and after
providing Which branch of epidemiology does the nurse
practice in
nursing care to the family members.
this situation?
B. In the care of family members, as much as
possible, A. Descriptive

use only articles taken from the bag. B. Analytical

C. Put on an apron to protect her uniform and C. Therapeutic

fold it
D. Evaluation
Answer: (B) Analytical the communicable disease

Analytical epidemiology is the study of factors B. Monitoring the condition of the cases
or affected by the

determinants affecting the patterns of communicable disease

occurrence and
C. Participating in the investigation to determine
distribution of disease in a community. the

45. Which of the following is a function of source of the epidemic

epidemiology?
D. Teaching the community on preventive
A. Identifying the disease condition based on measures

manifestations presented by a client against the disease

B. Determining factors that contributed to the Answer: (C) Participating in the investigation to

occurrence of pneumonia in a 3 year old determine the source of the epidemic

C. Determining the efficacy of the antibiotic Epidemiology is the study of patterns of

used in the occurrence and

treatment of the 3 year old client with distribution of disease in the community, as well
pneumonia as the

D. Evaluating the effectiveness of the factors that affect disease patterns. The purpose
implementation of of an

the Integrated Management of Childhood Illness epidemiologic investigation is to identify the

source of
Answer: (D) Evaluating the effectiveness of the
an epidemic, i.e., what brought about the
implementation of the Integrated Management
epidemic.
of
47. The primary purpose of conducting an
Childhood Illness
epidemiologic
Epidemiology is used in the assessment of a
investigation is to
community
A. Delineate the etiology of the epidemic
or evaluation of interventions in community
health B. Encourage cooperation and support of the
community
practice.
C. Identify groups who are at risk of contracting
46. Which of the following is an epidemiologic
the
function
disease
of the nurse during an epidemic?
D. Identify geographical location of cases of the
A. Conducting assessment of suspected cases to
disease
detect
in the community B. Testing the hypothesis

Answer: (A) Delineate the etiology of the C. Formulation of the hypothesis

epidemic
D. Appraisal of facts
Delineating the etiology of an epidemic is
Answer: (A) Establishing the epidemic
identifying its
Establishing the epidemic is determining
source.
whether there
48. Which is a characteristic of person-to-person
is an epidemic or not. This is done by comparing
propagated epidemics? the

A. There are more cases of the disease than present number of cases with the usual number
expected. of cases

B. The disease must necessarily be transmitted of the disease at the same time of the year, as
through a well as

vector. establishing the relatedness of the cases of the

disease.
C. The spread of the disease can be attributed to
a 50. The number of cases of Dengue fever
usually
common vehicle.
increases towards the end of the rainy season.
D. There is a gradual build up of cases before
This
the
pattern of occurrence of Dengue fever is best
epidemic becomes easily noticeable.
described
Answer: (D) There is a gradual build up of cases
as
before
A. Epidemic occurrence
the epidemic becomes easily noticeable.
B. Cyclical variation
A gradual or insidious onset of the epidemic is
usually C. Sporadic occurrence

observable in person-to-person propagated D. Secular variation

epidemics.
461
49. In the investigation of an epidemic, you
461
compare the
Answer: (B) Cyclical variation
present frequency of the disease with the usual
A cyclical variation is a periodic fluctuation in
frequency at this time of the year in this
the
community. This
number of cases of a disease in the community.
is done during which stage of the investigation?

A. Establishing the epidemic

51. In the year 1980, the World Health success in the use of the primary health care
Organization approach?

declared the Philippines, together with some A. Health services are provided free of charge to
other
individuals and families.
countries in the Western Pacific Region, “free”
B. Local officials are empowered as the major
of which
decision
disease?
makers in matters of health.
A. Pneumonic plague
C. Health workers are able to provide care based
B. Poliomyelitis on

C. Small pox identified health needs of the people.

D. Anthrax D. Health programs are sustained according to

the level
Answer: (C) Small pox
of development of the community.
The last documented case of Small pox was in
1977 at Answer: (D) Health programs are sustained
according to
Somalia.
the level of development of the community.
52. In the census of the Philippines in 1995,
there were Primary health care is essential health care that
can be
about 35,299,000 males and about 34,968,000
females. sustained in all stages of development of the

What is the sex ratio? community.

A. 99.06:100 54. Sputum examination is the major screening

tool for
B. 100.94:100
pulmonary tuberculosis. Clients would
C. 50.23%
sometimes get
D. 49.76%
false negative results in this exam. This means
Answer: (B) 100.94:100 that the

Sex ratio is the number of males for every 100 test is not perfect in terms of which
females in characteristic of a

the population. diagnostic examination?

53. Primary health care is a total approach to A. Effectiveness

community
B. Efficacy
development. Which of the following is an
C. Specificity
indicator of
D. Sensitivity (none)

Answer: (D) Sensitivity 57. In traditional Chinese medicine, the yielding,

Sensitivity is the capacity of a diagnostic negative and feminine force is termed

examination to
A. Yin
detect cases of the disease. If a test is 100%
B. Yang
sensitive, all
C. Qi
the cases tested will have a positive result, i.e.,
there will D. Chai
be no false negative results. Answer: (A) Yin
55. Use of appropriate technology requires Yang is the male dominating, positive and
knowledge of masculine
indigenous technology. Which medicinal herb is force.
given for
58. What is the legal basis for Primary Health
fever, headache and cough? Care
A. Sambong approach in the Philippines?
B. Tsaang gubat A. Alma Ata Declaration on PHC
C. Akapulko B. Letter of Instruction No. 949
D. Lagundi C. Presidential Decree No. 147
Answer: (D) Lagundi D. Presidential Decree 996
Sambong is used as a diuretic. Tsaang gubat is 462
used to
462
relieve diarrhea. Akapulko is used for its
antifungal Answer: (B) Letter of Instruction No. 949

property. Letter of Instruction 949 was issued by then

President
56. What law created the Philippine Institute of
Ferdinand Marcos, directing the formerly called
Traditional and Alternative Health Care? Ministry
A. R.A. 8423 of Health, now the Department of Health, to
utilize
B. R.A. 4823
Primary Health Care approach in planning and
C. R.A. 2483
implementing health programs.
D. R.A. 3482
59. Which of the following demonstrates
Answer: (A) R.A. 8423
intersectoral
linkages? total population by 11.5%.

A. Two-way referral system 61. Estimate the number of pregnant women

who will be
B. Team approach
given tetanus toxoid during an immunization
C. Endorsement done by a midwife to another
outreach
midwife
activity in a barangay with a population of about
D. Cooperation between the PHN and public
1,500.
school
A. 265
teacher
B. 300
Answer: (D) Cooperation between the PHN and
public C. 375

school teacher D. 400

Intersectoral linkages refer to working Answer: (A) 265

relationships
To estimate the number of pregnant women,
between the health sector and other sectors multiply
involved in
the total population by 3.5%.
community development.
62. To describe the sex composition of the
60. The municipality assigned to you has a population,
population of
which demographic tool may be used?
about 20,000. Estimate the number of 1-4 year
A. Sex ratio
old
B. Sex proportion
children who will be given Retinol capsule
200,000 I.U. C. Population pyramid
every 6 months. D. Any of these may be used.
A. 1,500 Answer: (D) Any of these may be used.
B. 1,800 Sex ratio and sex proportion are used to
determine the
C. 2,000
sex composition of a population. A population
D. 2,300
pyramid is
Answer: (D) 2,300
used to present the composition of a population
Based on the Philippine population by age
composition, to
and sex.
estimate the number of 1-4 year old children,
63. Which of the following is a natality rate?
multiply
A. Crude birth rate
B. Neonatal mortality rate A. Pregnant women and the elderly

C. Infant mortality rate B. Under-5 year old children

D. General fertility rate C. 1-4 year old children

Answer: (A) Crude birth rate D. School age children

Natality means birth. A natality rate is a birth Answer: (C) 1-4 year old children
rate.
Preschoolers are the most susceptible to PEM
64. You are computing the crude death rate of because
your
they have generally been weaned. Also, this is
municipality, with a total population of about the
18,000, for
population who, unable to feed themselves, are
last year. There were 94 deaths. Among those often
who died,
the victims of poor intrafamilial food
20 died because of diseases of the heart and 32 distribution.
were
66. Which statistic can give the most accurate
aged 50 years or older. What is the crude death reflection
rate?
of the health status of a community?
A. 4.2/1,000
A. 1-4 year old age-specific mortality rate
B. 5.2/1,000
B. Infant mortality rate
C. 6.3/1,000
463
D. 7.3/1,000
463
Answer: (B) 5.2/1,000
C. Swaroop’s index
To compute crude death rate divide total
D. Crude death rate
number of
Answer: (C) Swaroop’s index
deaths (94) by total population (18,000) and
multiply by Swaroop’s index is the proportion of deaths
aged 50
1,000.
years and above. The higher the Swaroop’s
65. Knowing that malnutrition is a frequent
index of a
community
population, the greater the proportion of the
health problem, you decided to conduct
deaths
nutritional
who were able to reach the age of at least 50
assessment. What population is particularly
years, i.e.,
susceptible
more people grew old before they died.
to protein energy malnutrition (PEM)?
67. In the past year, Barangay A had an average nutritional status will most likely have a high 1-4
year old
population of 1655. 46 babies were born in that
year, 2 age-specific mortality rate, also known as child
mortality
of whom died less than 4 weeks after they were
born. rate.

There were 4 recorded stillbirths. What is the 69. What numerator is used in computing
neonatal general

mortality rate? fertility rate?

A. 27.8/1,000 A. Estimated midyear population

B. 43.5/1,000 B. Number of registered live births

C. 86.9/1,000 C. Number of pregnancies in the year

D. 130.4/1,000 D. Number of females of reproductive age

Answer: (B) 43.5/1,000 Answer: (B) Number of registered live births

To compute for neonatal mortality rate, divide To compute for general or total fertility rate,
the divide the

number of babies who died before reaching the number of registered live births by the number
age of of

28 days by the total number of live births, then females of reproductive age (15-45 years), then
multiply multiply

by 1,000. by 1,000.

68. Which statistic best reflects the nutritional 70. You will gather data for nutritional
status of a assessment of a

population? purok. You will gather information only from

families
A. 1-4 year old age-specific mortality rate
with members who belong to the target
B. Proportionate mortality rate
population for
C. Infant mortality rate
PEM. What method of data gathering is best for
D. Swaroop’s index this

Answer: (A) 1-4 year old age-specific mortality purpose?

rate
A. Census
Since preschoolers are the most susceptible to
B. Survey
the
C. Record review
effects of malnutrition, a population with poor
D. Review of civil registry Answer: (A) Tally report

Answer: (B) Survey A tally report is prepared monthly or quarterly

by the
A survey, also called sample survey, is data
gathering RHU personnel and transmitted to the Provincial
Health
about a sample of the population.
Office.
71. In the conduct of a census, the method of
population 73. To monitor clients registered in long-term
regimens,
assignment based on the actual physical
location of the such as the Multi-Drug Therapy, which
component will
people is termed
be most useful?
A. De jure
A. Tally report
B. De locus
B. Output report
C. De facto
C. Target/client list
D. De novo
D. Individual health record
Answer: (C) De facto
Answer: (C) Target/client list
The other method of population assignment, de
jure, is The MDT Client List is a record of clients
enrolled in MDT
based on the usual place of residence of the
people. 464

72. The Field Health Services and Information 464

System
and other relevant data, such as dates when
(FHSIS) is the recording and reporting system in clients
public
collected their monthly supply of drugs.
health care in the Philippines. The Monthly Field
74. Civil registries are important sources of data.
Health
Which
Service Activity Report is a form used in which
law requires registration of births within 30 days
of the
from
components of the FHSIS?
the occurrence of the birth?
A. Tally report
A. P.D. 651
B. Output report
B. Act 3573
C. Target/client list
C. R.A. 3753
D. Individual health record
D. R.A. 3375
Answer: (A) P.D. 651 improve health service delivery. Which of the
following
P.D. 651 amended R.A. 3753, requiring the
registry of is/are true of this movement?

births within 30 days from their occurrence. A. This is a project spearheaded by local
government
75. Which of the following professionals can
sign the units.

birth certificate? B. It is a basis for increasing funding from local

A. Public health nurse government units.

B. Rural health midwife C. It encourages health centers to focus on

disease
C. Municipal health officer
prevention and control.
D. Any of these health professionals
D. Its main strategy is certification of health
Answer: (D) Any of these health professionals
centers able
D. R.A. 3753 states that any birth attendant may
to comply with standards.
sign the
Answer: (D) Its main strategy is certification of
certificate of live birth.
health
76. Which criterion in priority setting of health
centers able to comply with standards.
problems
Sentrong Sigla Movement is a joint project of
is used only in community health care?
the DOH
A. Modifiability of the problem
and local government units. Its main strategy is
B. Nature of the problem presented
certification of health centers that are able to
C. Magnitude of the health problem comply

D. Preventive potential of the health problem with standards set by the DOH.

Answer: (C) Magnitude of the health problem 78. Which of the following women should be
considered
Magnitude of the problem refers to the
percentage of as special targets for family planning?

the population affected by a health problem. A. Those who have two children or more
The other
B. Those with medical conditions such as
choices are criteria considered in both family anemia
and
C. Those younger than 20 years and older than
community health care. 35 years

77. The Sentrong Sigla Movement has been D. Those who just had a delivery within the past
launched to 15
months available to them, considering the availability of
quality
Answer: (D) Those who just had a delivery
within the services that can support their choice.

past 15 months 80. A woman, 6 months pregnant, came to the

center for
The ideal birth spacing is at least two years. 15
months consultation. Which of the following substances
is
plus 9 months of pregnancy = 2 years.
contraindicated?
79. Freedom of choice is one of the policies of
the Family A. Tetanus toxoid

Planning Program of the Philippines. Which of B. Retinol 200,000 IU

the
C. Ferrous sulfate 200 mg
following illustrates this principle?
D. Potassium iodate 200 mg. capsule
A. Information dissemination about the need for
Answer: (B) Retinol 200,000 IU
family
Retinol 200,000 IU is a form of megadose
planning
Vitamin A. This
B. Support of research and development in
may have a teratogenic effect.
family
465
planning methods
465
C. Adequate information for couples regarding
the 81. During prenatal consultation, a client asked
you if
different methods
she can have her delivery at home. After history
D. Encouragement of couples to take family
taking
planning as
and physical examination, you advised her
a joint responsibility
against a
Answer: (C) Adequate information for couples
home delivery. Which of the following findings
regarding the different methods
disqualifies her for a home delivery?
To enable the couple to choose freely among
A. Her OB score is G5P3.
different
B. She has some palmar pallor.
methods of family planning, they must be given
full C. Her blood pressure is 130/80.
information regarding the different methods D. Her baby is in cephalic presentation.
that are
Answer: (A) Her OB score is G5P3.
Only women with less than 5 pregnancies are Assessment of the woman should be done first
qualified to

for a home delivery. It is also advisable for a determine whether she is having true labor and,
primigravida if so,

to have delivery at a childbirth facility. what stage of labor she is in.

82. Inadequate intake by the pregnant woman 84. In preparing a primigravida for
of which breastfeeding, which

vitamin may cause neural tube defects? of the following will you do?

A. Niacin A. Tell her that lactation begins within a day

after
B. Riboflavin
delivery.
C. Folic acid
B. Teach her nipple stretching exercises if her
D. Thiamine
nipples are
Answer: (C) Folic acid
everted.
It is estimated that the incidence of neural tube
C. Instruct her to wash her nipples before and
defects
after each
can be reduced drastically if pregnant women
breastfeeding.
have an
D. Explain to her that putting the baby to breast
adequate intake of folic acid.
will
83. You are in a client’s home to attend to a
lessen blood loss after delivery.
delivery.
Answer: (D) Explain to her that putting the baby
Which of the following will you do first?
to
A. Set up the sterile area.
breast will lessen blood loss after delivery.
B. Put on a clean gown or apron.
Suckling of the nipple stimulates the release of
C. Cleanse the client’s vulva with soap and oxytocin
water.
by the posterior pituitary gland, which causes
D. Note the interval, duration and intensity of uterine
labor
contraction. Lactation begins 1 to 3 days after
contractions. delivery.

Answer: (D) Note the interval, duration and Nipple stretching exercises are done when the
intensity of nipples

labor contractions. are flat or inverted. Frequent washing dries up

the
nipples, making them prone to the formation of Answer: (B) The mother does not feel nipple
fissures. pain.

85. A primigravida is instructed to offer her When the baby has properly latched on to the
breast to the breast, he

baby for the first time within 30 minutes after takes deep, slow sucks; his mouth is wide open;
delivery. and

What is the purpose of offering the breast this much of the areola is inside his mouth. And,
early? you’re right!

A. To initiate the occurrence of milk letdown The mother does not feel nipple pain.

B. To stimulate milk production by the 87. You explain to a breastfeeding mother that
mammary acini breast

C. To make sure that the baby is able to get the milk is sufficient for all of the baby’s nutrient
needs only
colostrum
up to ____.
D. To allow the woman to practice breastfeeding
in the A. 3 months

presence of the health worker B. 6 months

Answer: (B) To stimulate milk production by the C. 1 year

mammary acini D. 2 years

Suckling of the nipple stimulates prolactin reflex Answer: (B) 6 months

(the
After 6 months, the baby’s nutrient needs,
release of prolactin by the anterior pituitary especially the
gland),
baby’s iron requirement, can no longer be
which initiates lactation. provided by

86. In a mothers’ class, you discuss proper mother’s milk alone.

breastfeeding
466
technique. Which is of these is a sign that the
466
baby has
88. What is given to a woman within a month
“latched on” to the breast properly?
after the
A. The baby takes shallow, rapid sucks.
delivery of a baby?
B. The mother does not feel nipple pain.
A. Malunggay capsule
C. The baby’s mouth is only partly open.
B. Ferrous sulfate 100 mg. OD
D. Only the mother’s nipple is inside the baby’s
C. Retinol 200,000 I.U., 1 capsule
mouth.
D. Potassium iodate 200 mg, 1 capsule While the unused portion of other biologicals in
EPI may
Answer: (C) Retinol 200,000 I.U., 1 capsule
be given until the end of the day, only BCG is
A capsule of Retinol 200,000 IU is given within 1
discarded 4
month
hours after reconstitution. This is why BCG
after delivery. Potassium iodate is given during
immunization
pregnancy; malunggay capsule is not routinely
is scheduled only in the morning.
administered after delivery; and ferrous sulfate
91. In immunizing school entrants with BCG, you
is taken
are not
for two months after delivery.
obliged to secure parental consent. This is
89. Which biological used in Expanded Program because of
on
which legal document?
Immunization (EPI) is stored in the freezer?
A. P.D. 996
A. DPT
B. R.A. 7846
B. Tetanus toxoid
C. Presidential Proclamation No. 6
C. Measles vaccine
D. Presidential Proclamation No. 46
D. Hepatitis B vaccine
Answer: (A) P.D. 996
Answer: (C) Measles vaccine
Presidential Decree 996, enacted in 1976, made
Among the biologicals used in the Expanded
immunization in the EPI compulsory for children
Program on
under 8
Immunization, measles vaccine and OPV are
years of age. Hepatitis B vaccination was made
highly
compulsory for the same age group by R.A.
sensitive to heat, requiring storage in the
7846.
freezer.
92. Which immunization produces a permanent
90. Unused BCG should be discarded how many
scar?
hours
A. DPT
after reconstitution?
B. BCG
A. 2
C. Measles vaccination
B. 4
D. Hepatitis B vaccination
C. 6
Answer: (B) BCG
D. At the end of the day
BCG causes the formation of a superficial
Answer: (B) 4
abscess, which
begins 2 weeks after immunization. The abscess 95. A 2-month old infant was brought to the
heals health

without treatment, with the formation of a center for immunization. During assessment,
permanent the infant’s

scar. temperature registered at 38.1°C. Which is the

best
93. A 4-week old baby was brought to the
health center course of action that you will take?

for his first immunization. Which can be given to A. Go on with the infant’s immunizations.
him?
B. Give Paracetamol and wait for his fever to
A. DPT1 subside.

B. OPV1 C. Refer the infant to the physician for further

C. Infant BCG assessment.

D. Hepatitis B vaccine 1 D. Advise the infant’s mother to bring him back

for
Answer: (C) Infant BCG
immunization when he is well.
Infant BCG may be given at birth. All the other
Answer: (A) Go on with the infant’s
immunizations mentioned can be given at 6
immunizations.
weeks of
In the EPI, fever up to 38.5°C is not a
age.
contraindication to
94. You will not give DPT 2 if the mother says
immunization. Mild acute respiratory tract
that the
infection,
infant had
467
A. Seizures a day after DPT 1.
467
B. Fever for 3 days after DPT 1.
simple diarrhea and malnutrition are not
C. Abscess formation after DPT 1.
contraindications either.
D. Local tenderness for 3 days after DPT 1.
96. A pregnant woman had just received her 4th
Answer: (A) Seizures a day after DPT 1. dose of

Seizures within 3 days after administration of tetanus toxoid. Subsequently, her baby will have
DPT is an
protection against tetanus for how long?
indication of hypersensitivity to pertussis
A. 1 year
vaccine, a
B. 3 years
component of DPT. This is considered a specific
C. 10 years
contraindication to subsequent doses of DPT.
D. Lifetime Answer: (D) Chest indrawing

Answer: (A) 1 year In IMCI, chest indrawing is used as the positive

sign of
The baby will have passive natural immunity by
placental dyspnea, indicating severe pneumonia.

transfer of antibodies. The mother will have 99. Using IMCI guidelines, you classify a child as
active having

artificial immunity lasting for about 10 years. 5 severe pneumonia. What is the best
doses will management for

give the mother lifetime protection. the child?

97. A 4-month old infant was brought to the A. Prescribe an antibiotic.

health
B. Refer him urgently to the hospital.
center because of cough. Her respiratory rate is
C. Instruct the mother to increase fluid intake.
42/minute. Using the Integrated Management
D. Instruct the mother to continue
of Child
breastfeeding.
Illness (IMCI) guidelines of assessment, her
Answer: (B) Refer him urgently to the hospital.
breathing is
Severe pneumonia requires urgent referral to a
considered
hospital.
A. Fast
Answers A, C and D are done for a client
B. Slow classified as

C. Normal having pneumonia.

D. Insignificant 100. A 5-month old infant was brought by his

mother to
Answer: (C) Normal
the health center because of diarrhea occurring
In IMCI, a respiratory rate of 50/minute or more
4 to 5
is fast
times a day. His skin goes back slowly after a
breathing for an infant aged 2 to 12 months.
skin pinch
98. Which of the following signs will indicate
and his eyes are sunken. Using the IMCI
that a
guidelines, you
young child is suffering from severe pneumonia?
will classify this infant in which category?
A. Dyspnea
A. No signs of dehydration
B. Wheezing
B. Some dehydration
C. Fast breathing
C. Severe dehydration
D. Chest indrawing
D. The data is insufficient. ml. of Oresol in 4 hours.

Answer: (B) Some dehydration In the IMCI management guidelines, SOME

Using the assessment guidelines of IMCI, a child DEHYDRATION is treated with the
(2 administration of

months to 5 years old) with diarrhea is classified Oresol within a period of 4 hours. The amount
as of Oresol

having SOME DEHYDRATION if he shows 2 or is best computed on the basis of the child’s
more of weight (75

the following signs: restless or irritable, sunken ml/kg body weight). If the weight is unknown,
eyes, the the

skin goes back slow after a skin pinch. amount of Oresol is based on the child’s age.

101. Based on assessment, you classified a 3- 102. A mother is using Oresol in the
month old management of

infant with the chief complaint of diarrhea in diarrhea of her 3-year old child. She asked you
the what to

category of SOME DEHYDRATION. Based on do if her child vomits. You will tell her to
IMCI
A. Bring the child to the nearest hospital for
management guidelines, which of the following further
will you
assessment.
do?
B. Bring the child to the health center for
A. Bring the infant to the nearest facility where intravenous
IV fluids
fluid therapy.
can be given.
C. Bring the child to the health center for
B. Supervise the mother in giving 200 to 400 ml. assessment by
of
the physician.
Oresol in 4 hours.
D. Let the child rest for 10 minutes then
C. Give the infant’s mother instructions on continue giving
home
468
management.
468
D. Keep the infant in your health center for close
Oresol more slowly.
observation.
Answer: (D) Let the child rest for 10 minutes
Answer: (B) Supervise the mother in giving 200 then
to 400
continue giving Oresol more slowly.
If the child vomits persistently, that is, he vomits A. Refer the child urgently to a hospital for
confinement.
everything that he takes in, he has to be
referred B. Coordinate with the social worker to enroll
the child in
urgently to a hospital. Otherwise, vomiting is
managed a feeding program.

by letting the child rest for 10 minutes and then C. Make a teaching plan for the mother, focusing
on
continuing with Oresol administration. Teach
the mother menu planning for her child.

to give Oresol more slowly. D. Assess and treat the child for health
problems like
103. A 1 ½ year old child was classified as having
3rd infections and intestinal parasitism.

degree protein energy malnutrition, Answer: (A) Refer the child urgently to a hospital
kwashiorkor. Which for

of the following signs will be most apparent in confinement.

this child?
“Baggy pants” is a sign of severe marasmus. The
A. Voracious appetite best

B. Wasting management is urgent referral to a hospital.

C. Apathy 105. During the physical examination of a young

child,
D. Edema
what is the earliest sign of xerophthalmia that
Answer: (D) Edema
you may
Edema, a major sign of kwashiorkor, is caused
observe?
by
A. Keratomalacia
decreased colloidal osmotic pressure of the
blood B. Corneal opacity

brought about by hypoalbuminemia. Decreased C. Night blindness

blood
D. Conjunctival xerosis
albumin level is due a protein-deficient diet.
Answer: (D) Conjunctival xerosis
104. Assessment of a 2-year old child revealed
The earliest sign of Vitamin A deficiency
“baggy
(xerophthalmia)
pants”. Using the IMCI guidelines, how will you
is night blindness. However, this is a functional
manage
change,
this child?
which is not observable during physical
examination.The
earliest visible lesion is conjunctival xerosis or 108. Food fortification is one of the strategies to
dullness of prevent

the conjunctiva due to inadequate tear micronutrient deficiency conditions. R.A. 8976
production. mandates

106. To prevent xerophthalmia, young children fortification of certain food items. Which of the
are given following

Retinol capsule every 6 months. What is the is among these food items?
dose given
A. Sugar
to preschoolers?
B. Bread
A. 10,000 IU
C. Margarine
B. 20,000 IU
D. Filled milk
C. 100,000 IU
Answer: (A) Sugar
D. 200,000 IU
R.A. 8976 mandates fortification of rice, wheat
Answer: (D) 200,000 IU flour,

Preschoolers are given Retinol 200,000 IU every sugar and cooking oil with Vitamin A, iron
6 and/or iodine.

months. 100,000 IU is given once to infants 109. What is the best course of action when
aged 6 to 12 there is a

months. The dose for pregnant women is measles epidemic in a nearby municipality?
10,000 IU.
A. Give measles vaccine to babies aged 6 to 8
107. The major sign of iron deficiency anemia is months.
pallor.
B. Give babies aged 6 to 11 months one dose of
What part is best examined for pallor? 100,000

A. Palms I.U. of Retinol

B. Nailbeds C. Instruct mothers to keep their babies at home

to
C. Around the lips
prevent disease transmission.
D. Lower conjunctival sac
D. Instruct mothers to feed their babies
Answer: (A) Palms
adequately to
The anatomic characteristics of the palms allow
enhance their babies’ resistance.
a
Answer: (A) Give measles vaccine to babies aged
reliable and convenient basis for examination
6 to 8
for pallor.
months.
469 111. Management of a child with measles
includes the
469
administration of which of the following?
Ordinarily, measles vaccine is given at 9 months
of age. A. Gentian violet on mouth lesions

During an impending epidemic, however, one B. Antibiotics to prevent pneumonia

dose may
C. Tetracycline eye ointment for corneal opacity
be given to babies aged 6 to 8 months. The
D. Retinol capsule regardless of when the last
mother is
dose was
instructed that the baby needs another dose
given
when the
Answer: (D) Retinol capsule regardless of when
baby is 9 months old.
the last
110. A mother brought her daughter, 4 years
dose was given
old, to the
An infant 6 to 12 months classified as a case of
RHU because of cough and colds. Following the
measles
IMCI
is given Retinol 100,000 IU; a child is given
assessment guide, which of the following is a
200,000 IU
danger sign
regardless of when the last dose was given.
that indicates the need for urgent referral to a
hospital? 112. A mother brought her 10 month old infant
for
A. Inability to drink
consultation because of fever, which started 4
B. High grade fever
days prior
C. Signs of severe dehydration
to consultation. To determine malaria risk, what
D. Cough for more than 30 days will you

Answer: (A) Inability to drink do?

A sick child aged 2 months to 5 years must be A. Do a tourniquet test.

referred
B. Ask where the family resides.
urgently to a hospital if he/she has one or more
C. Get a specimen for blood smear.
of the
D. Ask if the fever is present everyday.
following signs: not able to feed or drink, vomits
Answer: (B) Ask where the family resides.
everything, convulsions, abnormally sleepy or
difficult to Because malaria is endemic, the first question
to
awaken.
determine malaria risk is where the client’s country.
family
114. Secondary prevention for malaria includes
resides. If the area of residence is not a known
A. Planting of neem or eucalyptus trees
endemic
B. Residual spraying of insecticides at night
area, ask if the child had traveled within the
past 6 C. Determining whether a place is endemic or
not
months, where he/she was brought and
whether he/she D. Growing larva-eating fish in mosquito
breeding places
stayed overnight in that area.
Answer: (C) Determining whether a place is
113. The following are strategies implemented
endemic or
by the
not
Department of Health to prevent mosquito-
borne This is diagnostic and therefore secondary level
diseases. Which of these is most effective in the prevention. The other choices are for primary
control
prevention.
of Dengue fever?
115. Scotch tape swab is done to check for
A. Stream seeding with larva-eating fish which
B. Destroying breeding places of mosquitoes intestinal parasite?
C. Chemoprophylaxis of non-immune persons A. Ascaris
going to
B. Pinworm
endemic areas
C. Hookworm
D. Teaching people in endemic areas to use
chemically D. Schistosoma

treated mosquito nets Answer: (B) Pinworm

Answer: (B) Destroying breeding places of Pinworm ova are deposited around the anal
mosquitoes orifice.

Aedes aegypti, the vector of Dengue fever, 116. Which of the following signs indicates the
breeds in need for

stagnant, clear water. Its feeding time is usually sputum examination for AFB?
during A. Hematemesis
the daytime. It has a cyclical pattern of B. Fever for 1 week
occurrence,
C. Cough for 3 weeks
unlike malaria which is endemic in certain parts
of the D. Chest pain for 1 week
Answer: (C) Cough for 3 weeks osteomyelitis.

A client is considered a PTB suspect when he 118. To improve compliance to treatment, what
has cough
innovation is being implemented in DOTS?
for 2 weeks or more, plus one or more of the
A. Having the health worker follow up the client
following
at home
signs: fever for 1 month or more; chest pain
B. Having the health worker or a responsible
lasting for 2
family
470
member monitor drug intake
470
C. Having the patient come to the health center
weeks or more not attributed to other every
conditions;
month to get his medications
progressive, unexplained weight loss; night
D. Having a target list to check on whether the
sweats; and
patient
hemoptysis.
has collected his monthly supply of drugs
117. Which clients are considered targets for
Answer: (B) Having the health worker or a
DOTS
responsible
Category I?
family member monitor drug intake
A. Sputum negative cavitary cases
Directly Observed Treatment Short Course is so-
B. Clients returning after a default called

C. Relapses and failures of previous PTB because a treatment partner, preferably a

treatment health worker

regimens accessible to the client, monitors the client’s

compliance
D. Clients diagnosed for the first time through a
positive to the treatment.

sputum exam 119. Diagnosis of leprosy is highly dependent on

Answer: (D) Clients diagnosed for the first time recognition of symptoms. Which of the
through following is an

a positive sputum exam early sign of leprosy?

Category I is for new clients diagnosed by A. Macular lesions

sputum
B. Inability to close eyelids
examination and clients diagnosed to have a
C. Thickened painful nerves
serious
D. Sinking of the nosebridge
form of extrapulmonary tuberculosis, such as TB
Answer: (C) Thickened painful nerves The etiologic agent of schistosomiasis in the
Philippines
The lesion of leprosy is not macular. It is
characterized by is Schistosoma japonicum, which affects the
small
a change in skin color (either reddish or whitish)
and loss intestine and the liver. Liver damage is a
consequence of
of sensation, sweating and hair growth over the
lesion. fibrotic reactions to schistosoma eggs in the
liver.
Inability to close the eyelids (lagophthalmos)
and sinking 122. What is the most effective way of
controlling
of the nosebridge are late symptoms.
schistosomiasis in an endemic area?
120. Which of the following clients should be
classified A. Use of molluscicides

as a case of multibacillary leprosy? B. Building of foot bridges

A. 3 skin lesions, negative slit skin smear C. Proper use of sanitary toilets

B. 3 skin lesions, positive slit skin smear D. Use of protective footwear, such as rubber
boots
C. 5 skin lesions, negative slit skin smear
Answer: (C) Proper use of sanitary toilets
D. 5 skin lesions, positive slit skin smear
The ova of the parasite get out of the human
Answer: (D) 5 skin lesions, positive slit skin
body
smear
together with feces. Cutting the cycle at this
A multibacillary leprosy case is one who has a
stage is the
positive
most effective way of preventing the spread of
slit skin smear and at least 5 skin lesions.
the
121. In the Philippines, which condition is the
disease to susceptible hosts.
most
123. When residents obtain water from an
frequent cause of death associated with
artesian well
schistosomiasis?
in the neighborhood, the level of this approved
A. Liver cancer
type of
B. Liver cirrhosis
water facility is
C. Bladder cancer
A. I
D. Intestinal perforation
B. II
Answer: (B) Liver cirrhosis
C. III

D. IV
Answer: (B) II D. MMR

A communal faucet or water standpost is Answer: (A) DPT

classified as
DPT is sensitive to freezing. The appropriate
Level II. storage

124. For prevention of hepatitis A, you decided temperature of DPT is 2 to 8° C only. OPV and
to measles

conduct health education activities. Which of vaccine are highly sensitive to heat and require
the freezing.

following is IRRELEVANT? MMR is not an immunization in the Expanded

Program
471
on Immunization.
471
127. You will conduct outreach immunization in
A. Use of sterile syringes and needles
a
B. Safe food preparation and food handling by
barangay with a population of about 1500.
vendors
Estimate the
C. Proper disposal of human excreta and
number of infants in the barangay.
personal
A. 45
hygiene
B. 50
D. Immediate reporting of water pipe leaks and
illegal C. 55

water connections D. 60

Answer: (A) Use of sterile syringes and needles Answer: (A) 45

Hepatitis A is transmitted through the fecal oral To estimate the number of infants, multiply total
route.
population by 3%.
Hepatitis B is transmitted through infected body
128. In Integrated Management of Childhood
secretions like blood and semen. Illness,

126. Which biological used in Expanded severe conditions generally require urgent
Program on referral to a

Immunization (EPI) should NOT be stored in the hospital. Which of the following severe
freezer? conditions DOES

A. DPT NOT always require urgent referral to a

hospital?
B. Oral polio vaccine
A. Mastoiditis
C. Measles vaccine
B. Severe dehydration 130. A 3-year old child was brought by his
mother to the
C. Severe pneumonia
health center because of fever of 4-day
D. Severe febrile disease
duration. The
Answer: (B) Severe dehydration
child had a positive tourniquet test result. In the
The order of priority in the management of absence
severe
of other signs, which is the most appropriate
dehydration is as follows: intravenous fluid measure
therapy,
that the PHN may carry out to prevent Dengue
referral to a facility where IV fluids can be shock
initiated
syndrome?
within 30 minutes, Oresol/nasogastric tube,
A. Insert an NGT and give fluids per NGT.
Oresol/orem. When the foregoing measures are
B. Instruct the mother to give the child Oresol.
not
C. Start the patient on intravenous fluids STAT.
possible or effective, tehn urgent referral to the
hospital D. Refer the client to the physician for
appropriate
is done.
management.
129. A client was diagnosed as having Dengue
fever. You Answer: (B) Instruct the mother to give the child

will say that there is slow capillary refill when Oresol.

the color
Since the child does not manifest any other
of the nailbed that you pressed does not return danger sign,
within
maintenance of fluid balance and replacement
how many seconds? of fluid

A. 3 loss may be done by giving the client Oresol.

B. 5 131. The pathognomonic sign of measles is

Koplik’s spot.
C. 8
You may see Koplik’s spot by inspecting the
D. 10
_____.
Answer: (A) 3
A. Nasal mucosa
Adequate blood supply to the area allows the
B. Buccal mucosa
return of
C. Skin on the abdomen
the color of the nailbed within 3 seconds.
D. Skin on the antecubital surface
Answer: (B) Buccal mucosa Answer: (A) Hemophilus influenzae

Koplik’s spot may be seen on the mucosa of the Hemophilus meningitis is unusual over the age
mouth of 5

or the throat. years. In developing countries, the peak

incidence is in
132. Among the following diseases, which is
airborne? children less than 6 months of age. Morbillivirus
is the
A. Viral conjunctivitis
etiology of measles. Streptococcus pneumoniae
B. Acute poliomyelitis
and
C. Diphtheria
Neisseria meningitidis may cause meningitis,
D. Measles but age

472 distribution is not specific in young children.

472 134. Human beings are the major reservoir of

malaria.
Answer: (D) Measles
Which of the following strategies in malaria
Viral conjunctivitis is transmitted by direct or control is
indirect
based on this fact?
contact with discharges from infected eyes.
Acute A. Stream seeding

poliomyelitis is spread through the fecal-oral B. Stream clearing

route and
C. Destruction of breeding places
contact with throat secretions, whereas
D. Zooprophylaxis
diphtheria is
Answer: (D) Zooprophylaxis
through direct and indirect contact with
respiratory Zooprophylaxis is done by putting animals like
cattle or
secretions.
dogs close to windows or doorways just before
133. Among children aged 2 months to 3 years,
nightfall.
the most
The Anopheles mosquito takes his blood meal
prevalent form of meningitis is caused by which
from the
microorganism?
animal and goes back to its breeding place,
A. Hemophilus influenzae thereby

B. Morbillivirus preventing infection of humans.

C. Steptococcus pneumoniae 135. The use of larvivorous fish in malaria

control is the
D. Neisseria meningitidis
basis for which strategy of malaria control? with the chief complaint of severe diarrhea and
the
A. Stream seeding
passage of “rice water” stools. The client is most
B. Stream clearing
probably suffering from which condition?
C. Destruction of breeding places
A. Giardiasis
D. Zooprophylaxis
B. Cholera
Answer: (A) Stream seeding
C. Amebiasis
Stream seeding is done by putting tilapia fry in
streams D. Dysentery

or other bodies of water identified as breeding Answer: (B) Cholera

places of
Passage of profuse watery stools is the major
the Anopheles mosquito symptom

136. Mosquito-borne diseases are prevented of cholera. Both amebic and bacillary dysentery
mostly are

with the use of mosquito control measures. characterized by the presence of blood and/or
Which of the mucus in

following is NOT appropriate for malaria the stools. Giardiasis is characterized by fat
control?
malabsorption and, therefore, steatorrhea.
A. Use of chemically treated mosquito nets
138. In the Philippines, which specie of
B. Seeding of breeding places with larva-eating schistosoma is
fish
endemic in certain regions?
C. Destruction of breeding places of the
A. S. mansoni
mosquito vector
B. S. japonicum
D. Use of mosquito-repelling soaps, such as
those with C. S. malayensis
basil or citronella D. S. haematobium
Answer: (C) Destruction of breeding places of Answer: (B) S. japonicum
the
S. mansoni is found mostly in Africa and South
mosquito vector America;
Anopheles mosquitoes breed in slow-moving, S. haematobium in Africa and the Middle East;
clear and S.
water, such as mountain streams. malayensis only in peninsular Malaysia.
137. A 4-year old client was brought to the 139. A 32-year old client came for consultation
health center at the
health center with the chief complaint of fever C. III
for a
D. IV
week. Accompanying symptoms were muscle
Answer: (C) III
pains and
Waterworks systems, such as MWSS, are
body malaise. A week after the start of fever,
classified as
the client
level III.
noted yellowish discoloration of his sclera.
History 141. You are the PHN in the city health center. A
client
showed that he waded in flood waters about 2
weeks underwent screening for AIDS using ELISA. His
result was
before the onset of symptoms. Based on his
history, positive. What is the best course of action that
you may
which disease condition will you suspect?
take?
A. Hepatitis A
A. Get a thorough history of the client, focusing
B. Hepatitis B
on the
473
practice of high risk behaviors.
473
B. Ask the client to be accompanied by a
C. Tetanus significant

D. Leptospirosis person before revealing the result.

Answer: (D) Leptospirosis C. Refer the client to the physician since he is

the best
Leptospirosis is transmitted through contact
with the person to reveal the result to the client.

skin or mucous membrane with water or moist D. Refer the client for a supplementary test,
soil such as

contaminated with urine of infected animals, Western blot, since the ELISA result may be
like rats. false.

140. MWSS provides water to Manila and other Answer: (D) Refer the client for a supplementary
cities in test,

Metro Manila. This is an example of which level such as Western blot, since the ELISA result may
of water be

facility? false.

A. I A client having a reactive ELISA result must

undergo a
B. II
more specific test, such as Western blot. A B. Infectious mononucleosis
negative
C. Cytomegalovirus disease
supplementary test result means that the ELISA
D. Pneumocystis carinii pneumonia
result
Answer: (B) Infectious mononucleosis
was false and that, most probably, the client is
not Cytomegalovirus disease is an acute viral
disease
infected.
characterized by fever, sore throat and
142. Which is the BEST control measure for
AIDS? lymphadenopathy.
A. Being faithful to a single sexual partner 144. To determine possible sources of sexually
B. Using a condom during each sexual contact transmitted infections, which is the BEST
method that
C. Avoiding sexual contact with commercial sex
workers may be undertaken by the public health nurse?
D. Making sure that one’s sexual partner does A. Contact tracing
not have
B. Community survey
signs of AIDS
C. Mass screening tests
Answer: (A) Being faithful to a single sexual
partner D. Interview of suspects

Sexual fidelity rules out the possibility of getting Answer: (A) Contact tracing
the Contact tracing is the most practical and reliable
disease by sexual contact with another infected method
person. of finding possible sources of person-to-person
Transmission occurs mostly through sexual transmitted infections, such as sexually
intercourse transmitted
and exposure to blood or tissues. diseases.
143. The most frequent causes of death among 145. Antiretroviral agents, such as AZT, are used
clients in the
with AIDS are opportunistic diseases. Which of management of AIDS. Which of the following is
the NOT an
following opportunistic infections is action expected of these drugs.
characterized by
A. They prolong the life of the client with AIDS.
tonsillopharyngitis?
B. They reduce the risk of opportunistic
A. Respiratory candidiasis infections
C. They shorten the period of communicability Answer: (D) Consult a physician who may give
of the them

disease. rubella immunoglobulin.

D. They are able to bring about a cure of the Rubella vaccine is made up of attenuated
disease German

condition. measles viruses. This is contraindicated in

pregnancy.
Answer: (D) They are able to bring about a cure
of the Immune globulin, a specific prophylactic against
German
disease condition.
measles, may be given to pregnant women.
There is no known treatment for AIDS.
Antiretroviral 147. You were invited to be the resource person
in a
agents reduce the risk of opportunistic
infections and training class for food handlers. Which of the
following
prolong life, but does not cure the underlying
would you emphasize regarding prevention of
immunodeficiency.
staphylococcal food poisoning?
146. A barangay had an outbreak of German
measles. To A. All cooking and eating utensils must be
thoroughly
prevent congenital rubella, what is the BEST
advice that washed.

you can give to women in the first trimester of B. Food must be cooked properly to destroy

pregnancy in the barangay? staphylococcal microorganisms.

474 C. Food handlers and food servers must have a

negative
474
stool examination result.
A. Advice them on the signs of German measles.
D. Proper handwashing during food preparation
B. Avoid crowded places, such as markets and
is the
moviehouses.
best way of preventing the condition.
C. Consult at the health center where rubella
Answer: (D) Proper handwashing during food
vaccine
preparation is the best way of preventing the
may be given.
condition.
D. Consult a physician who may give them
rubella Symptoms of this food poisoning are due to

immunoglobulin.
staphylococcal enterotoxin, not the be serious in which type of clients?
microorganisms
A. Pregnant women
themselves. Contamination is by food handling
B. Elderly clients
by
C. Young adult males
persons with staphylococcal skin or eye
infections. D. Young infants
148. In a mothers’ class, you discussed Answer: (C) Young adult males
childhood
Epididymitis and orchitis are possible
diseases such as chicken pox. Which of the complications of
following
mumps. In post-adolescent males, bilateral
statements about chicken pox is correct? inflammation
A. The older one gets, the more susceptible he of the testes and epididymis may cause sterility.
becomes
475
to the complications of chicken pox.
475
B. A single attack of chicken pox will prevent
future MEDICAL SURGICAL NURSING Part 1

episodes, including conditions such as shingles. 1. Mrs. Chua a 78 year old client is admitted
with the
C. To prevent an outbreak in the community,
quarantine diagnosis of mild chronic heart failure. The
nurse expects
may be imposed by health authorities.
to hear when listening to client’s lungs
D. Chicken pox vaccine is best given when there indicative of
is an
chronic heart failure would be:
impending outbreak in the community.
a. Stridor
Answer: (A) The older one gets, the more
susceptible b. Crackles

he becomes to the complications of chicken c. Wheezes

pox. d. Friction rubs
Chicken pox is usually more severe in adults 2. Patrick who is hospitalized following a
than in myocardial
children. Complications, such as pneumonia, are infarction asks the nurse why he is taking
higher morphine. The
in incidence in adults. nurse explains that morphine:
149. Complications to infectious parotitis a. Decrease anxiety and restlessness
(mumps) may
b. Prevents shock and relieves pain of the following is a characteristic of this type of

c. Dilates coronary blood vessels posturing?

d. Helps prevent fibrillation of the heart a. Upper extremity flexion with lower extremity
flexion
3. Which of the following should the nurse
teach the b. Upper extremity flexion with lower extremity

client about the signs of digitalis toxicity? extension

a. Increased appetite c. Extension of the extremities after a stimulus

b. Elevated blood pressure d. Flexion of the extremities after stimulus

c. Skin rash over the chest and back 7. A female client is taking Cascara Sagrada.
Nurse Betty
d. Visual disturbances such as seeing yellow
spots informs the client that the following maybe
experienced
4. Nurse Trisha teaches a client with heart
failure to take as side effects of this medication:

oral Furosemide in the morning. The reason for a. GI bleeding

this is to
b. Peptic ulcer disease
help…
c. Abdominal cramps
a. Retard rapid drug absorption
d. Partial bowel obstruction
b. Excrete excessive fluids accumulated at night
8. Dr. Marquez orders a continuous intravenous
c. Prevents sleep disturbances during night
nitroglycerin infusion for the client suffering
d. Prevention of electrolyte imbalance from

5. What would be the primary goal of therapy myocardial infarction. Which of the following is
for a client the most

with pulmonary edema and heart failure? essential nursing action?

a. Enhance comfort a. Monitoring urine output frequently

b. Increase cardiac output b. Monitoring blood pressure every 4 hours

c. Improve respiratory status c. Obtaining serum potassium levels daily

d. Peripheral edema decreased d. Obtaining infusion pump for the medication

6. Nurse Linda is caring for a client with head 9. During the second day of hospitalization of
injury and the client

monitoring the client with decerebrate after a Myocardial Infarction. Which of the
posturing. Which following is
an expected outcome? 12. A 64 year old male client with a long history
of
a. Able to perform self-care activities without
pain cardiovascular problem including hypertension
and
b. Severe chest pain
angina is to be scheduled for cardiac
c. Can recognize the risk factors of Myocardial
catheterization.
Infarction
During pre cardiac catheterization teaching,
d. Can Participate in cardiac rehabilitation
Nurse
walking
Cherry should inform the client that the primary
program
purpose
10. A 68 year old client is diagnosed with a right-
of the procedure is…..
sided
a. To determine the existence of CHD
brain attack and is admitted to the hospital. In
caring for b. To visualize the disease process in the
coronary
this client, the nurse should plan to:
arteries
a. Application of elastic stockings to prevent
flaccid by c. To obtain the heart chambers pressure

muscle d. To measure oxygen content of different heart

b. Use hand roll and extend the left upper chambers

extremity on a
13. During the first several hours after a cardiac
pillow to prevent contractions
catheterization, it would be most essential for
c. Use a bed cradle to prevent dorsiflexion of nurse
feet
Cherry to…
d. Do passive range of motion exercise
a. Elevate clients bed at 45°
11. Nurse Liza is assigned to care for a client
b. Instruct the client to cough and deep breathe
who has
every 2
returned to the nursing unit after left
hours
nephrectomy.
c. Frequently monitor client’s apical pulse and
Nurse Liza’s highest priority would be…
blood
a. Hourly urine output
pressure
b. Temperature
476
c. Able to turn side to side
476
d. Able to sips clear liquid
d. Monitor clients temperature every hour
14. Kate who has undergone mitral valve c. Increase creatine phospholinase
replacement concentration

suddenly experiences continuous bleeding from d. Chest pain

the
17. Kris with a history of chronic infection of the
surgical incision during postoperative period. urinary
Which of
system complains of urinary frequency and
the following pharmaceutical agents should burning
Nurse Aiza
sensation. To figure out whether the current
prepare to administer to Kate? problem is

a. Protamine Sulfate in renal origin, the nurse should assess whether

the
b. Quinidine Sulfate
client has discomfort or pain in the…
c. Vitamin C
a. Urinary meatus
d. Coumadin
b. Pain in the Labium
15. In reducing the risk of endocarditis, good
dental care c. Suprapubic area

is an important measure. To promote good d. Right or left costovertebral angle

dental care
18. Nurse Perry is evaluating the renal function
in client with mitral stenosis in teaching plan of a male
should
client. After documenting urine volume and
include proper use of…
characteristics, Nurse Perry assesses which signs
a. Dental floss as the

b. Electric toothbrush best indicator of renal function.

c. Manual toothbrush a. Blood pressure

d. Irrigation device b. Consciousness

16. Among the following signs and symptoms, c. Distension of the bladder
which
d. Pulse rate
would most likely be present in a client with
19. John suddenly experiences a seizure, and
mitral
Nurse Gina
gurgitation?
notice that John exhibits uncontrollable jerking
a. Altered level of consciousness
movements. Nurse Gina documents that John
b. Exceptional Dyspnea
experienced which type of seizure?

a. Tonic seizure
b. Absence seizure d. It is not influenced by drugs

c. Myoclonic seizure 23. Jessie weighed 210 pounds on admission to

the
d. Clonic seizure
hospital. After 2 days of diuretic therapy, Jessie
20. Smoking cessation is critical strategy for the
weighs
client
205.5 pounds. The nurse could estimate the
with Burgher’s disease, Nurse Jasmin anticipates
amount of
that the
fluid Jessie has lost…
male client will go home with a prescription for
which a. 0.3 L

medication? b. 1.5 L

a. Paracetamol c. 2.0 L

b. Ibuprofen d. 3.5 L

c. Nitroglycerin 24. Nurse Donna is aware that the shift of body

fluids
d. Nicotine (Nicotrol)
associated with Intravenous administration of
21. Nurse Lilly has been assigned to a client with
albumin
Raynaud’s disease. Nurse Lilly realizes that the
occurs in the process of:
etiology
a. Osmosis
of the disease is unknown but it is characterized
by: b. Diffusion

a. Episodic vasospastic disorder of capillaries c. Active transport

b. Episodic vasospastic disorder of small veins d. Filtration

c. Episodic vasospastic disorder of the aorta 25. Myrna a 52 year old client with a fractured
left tibia
d. Episodic vasospastic disorder of the small
arteries has a long leg cast and she is using crutches to
ambulate.
22. Nurse Jamie should explain to male client
with Nurse Joy assesses for which sign and symptom
that
diabetes that self-monitoring of blood glucose is
indicates complication associated with crutch
preferred to urine glucose testing because…
walking?
a. More accurate
a. Left leg discomfort
b. Can be done by the client
b. Weak biceps brachii
c. It is easy to perform
c. Triceps muscle spasm
d. Forearm weakness c. Position client laterally with the neck
extended
26. Which of the following statements should
the nurse d. Maintain humidified oxygen via nasal canula

teach the neutropenic client and his family to 29. George who has undergone thoracic surgery
avoid? has

a. Performing oral hygiene after every meal chest tube connected to a water-seal drainage
system
b. Using suppositories or enemas
attached to suction. Presence of excessive
c. Performing perineal hygiene after each bowel
bubbling is
movement
identified in water-seal chamber, the nurse
d. Using a filter mask should…

27. A female client is experiencing painful and a. “Strip” the chest tube catheter
rigid
b. Check the system for air leaks
abdomen and is diagnosed with perforated
c. Recognize the system is functioning correctly
peptic ulcer.
d. Decrease the amount of suction pressure
477
30. A client who has been diagnosed of
477
hypertension is
A surgery has been scheduled and a nasogastric
being taught to restrict intake of sodium. The
tube is
nurse
inserted. The nurse should place the client
would know that the teachings are effective if
before
the client
surgery in
states that…
a. Sims position
a. I can eat celery sticks and carrots
b. Supine position
b. I can eat broiled scallops
c. Semi-fowlers position
c. I can eat shredded wheat cereal
d. Dorsal recumbent position
d. I can eat spaghetti on rye bread
28. Which nursing intervention ensures
31. A male client with a history of cirrhosis and
adequate
alcoholism is admitted with severe dyspnea
ventilating exchange after surgery?
resulted to
a. Remove the airway only when client is fully
ascites. The nurse should be aware that the
conscious
ascites is
b. Assess for hypoventilation by auscultating the
most likely the result of increased…
lungs
a. Pressure in the portal vein b. Normal saline nose drops will need to be
administered
b. Production of serum albumin
preoperatively
c. Secretion of bile salts
c. After surgery, nasal packing will be in place 8
d. Interstitial osmotic pressure
to 10
32. A newly admitted client is diagnosed with
days
Hodgkin’s
d. Aspirin containing medications should not be
disease undergoes an excisional cervical lymph
taken 14
node
days before surgery
biopsy under local anesthesia. What does the
nurse 35. Paul is admitted to the hospital due to
metabolic
assess first after the procedure?
acidosis caused by Diabetic ketoacidosis (DKA).
a. Vital signs
The
b. Incision site
nurse prepares which of the following
c. Airway medications as an

d. Level of consciousness initial treatment for this problem?

33. A client has 15% blood loss. Which of the a. Regular insulin
following
b. Potassium
nursing assessment findings indicates
c. Sodium bicarbonate
hypovolemic
d. Calcium gluconate
shock?
36. Dr. Marquez tells a client that an increase
a. Systolic blood pressure less than 90mm Hg
intake of
b. Pupils unequally dilated
foods that are rich in Vitamin E and beta-
c. Respiratory rate of 4 breath/min carotene are

d. Pulse rate less than 60bpm important for healthier skin. The nurse teaches
the client
34. Nurse Lucy is planning to give pre operative
teaching that excellent food sources of both of these
substances
to a client who will be undergoing rhinoplasty.
Which of are:

the following should be included? a. Fish and fruit jam

a. Results of the surgery will be immediately b. Oranges and grapefruit

noticeable
c. Carrots and potatoes
postoperatively
d. Spinach and mangoes c. “I should avoid fatty foods as long as I live”

37. A client has Gastroesophageal Reflux 478

Disease (GERD).
478
The nurse should teach the client that after
d. “Most people can tolerate regular diet after
every meals,
this type
the client should…
of surgery”
a. Rest in sitting position
40. Nurse Rachel teaches a client who has been
b. Take a short walk recently

c. Drink plenty of water diagnosed with hepatitis A about untoward

signs and
d. Lie down at least 30 minutes
symptoms related to Hepatitis that may
38. After gastroscopy, an adaptation that
develop. The
indicates major
one that should be reported immediately to the
complication would be:
physician is:
a. Nausea and vomiting
a. Restlessness
b. Abdominal distention
b. Yellow urine
c. Increased GI motility
c. Nausea
d. Difficulty in swallowing
d. Clay- colored stools
39. A client who has undergone a
cholecystectomy asks 41. Which of the following antituberculosis
drugs can
the nurse whether there are any dietary
restrictions that damage the 8th cranial nerve?

must be followed. Nurse Hilary would recognize a. Isoniazid (INH)

that the
b. Paraoaminosalicylic acid (PAS)
dietary teaching was well understood when the
c. Ethambutol hydrochloride (myambutol)
client
d. Streptomycin
tells a family member that:
42. The client asks Nurse Annie the causes of
a. “Most people need to eat a high protein diet
peptic
for 12
ulcer. Nurse Annie responds that recent
months after surgery”
research
b. “I should not eat those foods that upset me
indicates that peptic ulcers are the result of
before the
which of the
surgery”
following:
a. Genetic defect in gastric mucosa leg appears shorter that the other leg. The
affected leg is
b. Stress
painful, swollen and beginning to become
c. Diet high in fat
ecchymotic.
d. Helicobacter pylori infection
The nurse interprets that the client is
43. Ryan has undergone subtotal gastrectomy. experiencing:
The nurse
a. Fracture
should expect that nasogastric tube drainage
b. Strain
will be
c. Sprain
what color for about 12 to 24 hours after
surgery? d. Contusion

a. Bile green 46. Nurse Jenny is instilling an otic solution into

an adult
b. Bright red
male client left ear. Nurse Jenny avoids doing
c. Cloudy white
which of
d. Dark brown
the following as part of the procedure
44. Nurse Joan is assigned to come for client
a. Pulling the auricle backward and upward
who has
b. Warming the solution to room temperature
just undergone eye surgery. Nurse Joan plans to
teach c. Pacing the tip of the dropper on the edge of
ear canal
the client activities that are permitted during
the post d. Placing client in side lying position

operative period. Which of the following is best 47. Nurse Bea should instruct the male client
with an
recommended for the client?
ileostomy to report immediately which of the
a. Watching circus
following
b. Bending over
symptom?
c. Watching TV
a. Absence of drainage from the ileostomy for 6
d. Lifting objects or more

45. A client suffered from a lower leg injury and hours

seeks
b. Passage of liquid stool in the stoma
treatment in the emergency room. There is a
c. Occasional presence of undigested food
prominent
d. A temperature of 37.6 °C
deformity to the lower aspect of the leg, and
the injured
48. Jerry has diagnosed with appendicitis. He 1. B. Left sided heart failure causes fluid
develops a
accumulation in the capillary network of the
fever, hypotension and tachycardia. The nurse
lung. Fluid eventually enters alveolar spaces and
suspects
causes crackling sounds at the end of
which of the following complications?
inspiration.
a. Intestinal obstruction
2. B. Morphine is a central nervous system
b. Peritonitis
depressant used to relieve the pain associated
c. Bowel ischemia
with myocardial infarction, it also decreases
d. Deficient fluid volume
apprehension and prevents cardiogenic shock.
49. Which of the following compilations should
3. D. Seeing yellow spots and colored vision are
the nurse
common symptoms of digitalis toxicity
carefully monitors a client with acute
pancreatitis. 4. C. When diuretics are taken in the morning,
a. Myocardial Infarction client will void frequently during daytime and
b. Cirrhosis will not need to void frequently at night.
c. Peptic ulcer 5. B. The primary goal of therapy for the client
with
d. Pneumonia
pulmonary edema or heart failure is increasing
50. Which of the following symptoms during the
icteric cardiac output. Pulmonary edema is an acute
phase of viral hepatitis should the nurse expect medical emergency requiring immediate
the
intervention.
client to inhibit?
6. C. Decerebrate posturing is the extension of
a. Watery stool the
b. Yellow sclera extremities after a stimulus, which may occur
c. Tarry stool with upper brain stem injury.
d. Shortness of breath 7. C. The most frequent side effects of Cascara
479 Sagrada (Laxative) is abdominal cramps and
479 nausea.
ANSWERS and RATIONALES for MEDICAL 8. D. Administration of Intravenous Nitroglycerin
SURGICAL
infusion requires pump for accurate control of
NURSING Part 1
medication.
9. A. By the 2nd day of hospitalization after 17. D. Discomfort or pain is a problem that

suffering a Myocardial Infarction, Clients are originates in the kidney. It is felt at the

able to perform care without chest pain costovertebral angle on the affected side.

10. B. The left side of the body will be affected 18. A. Perfusion can be best estimated by blood
in a
pressure, which is an indirect reflection of the
right-sided brain attack.
adequacy of cardiac output.
11. A. After nephrectomy, it is necessary to
19. C. Myoclonic seizure is characterized by
measure
sudden
urine output hourly. This is done to assess the
uncontrollable jerking movements of a single or
effectiveness of the remaining kidney also to
multiple muscle group.
detect renal failure early.
20. D. Nicotine (Nicotrol) is given in controlled
12. B. The lumen of the arteries can be assessed and
by
decreasing doses for the management of
cardiac catheterization. Angina is usually caused
nicotine withdrawal syndrome.
by narrowing of the coronary arteries.
21. D. Raynaud’s disease is characterized by
13. C. Blood pressure is monitored to detect
vasospasms of the small cutaneous arteries that
hypotension which may indicate shock or
involves fingers and toes.
hemorrhage. Apical pulse is taken to detect
22. A. Urine testing provides an indirect
dysrhythmias related to cardiac irritability. measure

14. A. Protamine Sulfate is used to prevent that maybe influenced by kidney function while

continuous bleeding in client who has blood glucose testing is a more direct and

undergone open heart surgery. accurate measure.

15. C. The use of electronic toothbrush, 23. C. One liter of fluid approximately weighs
irrigation 2.2

device or dental floss may cause bleeding of pounds. A 4.5 pound weight loss equals to

gums, allowing bacteria to enter and increasing approximately 2L.

the risk of endocarditis. 24. A. Osmosis is the movement of fluid from an

16. B. Weight gain due to retention of fluids and area of lesser solute concentration to an area of

worsening heart failure causes exertional greater solute concentration.

dyspnea in clients with mitral regurgitation.

25. D. Forearm muscle weakness is a probable leading to ineffective air exchange.
sign
33. A. Typical signs and symptoms of
of radial nerve injury caused by crutch pressure hypovolemic

on the axillae. shock includes systolic blood pressure of less

26. B. Neutropenic client is at risk for infection than 90 mm Hg.

especially bacterial infection of the 34. D. Aspirin containing medications should not
be
gastrointestinal and respiratory tract.
taken 14 days before surgery to decrease the
27. C. Semi-fowlers position will localize the
spilled risk of bleeding.

stomach contents in the lower part of the 35. A. Metabolic acidosis is anaerobic
metabolism
abdominal cavity.
caused by lack of ability of the body to use
28. C. Positioning the client laterally with the
neck circulating glucose. Administration of insulin

extended does not obstruct the airway so that corrects this problem.

drainage of secretions and oxygen and carbon 36. D. Beta-carotene and Vitamin E are
antioxidants
dioxide exchange can occur.
which help to inhibit oxidation. Vitamin E is
29. B. Excessive bubbling indicates an air leak
which found in the following foods: wheat germ, corn,

must be eliminated to permit lung expansion. nuts, seeds, olives, spinach, asparagus and
other
30. C. Wheat cereal has a low sodium content.
green leafy vegetables. Food sources of
31. A. Enlarged cirrhotic liver impinges the
betacarotene
portal
include dark green vegetables, carrots,
system causing increased hydrostatic pressure
mangoes and tomatoes.
resulting to ascites.
37. A. Gravity speeds up digestion and prevents
32. C. Assessing for an open airway is the
priority. reflux of stomach contents into the esophagus.

The procedure involves the neck, the anesthesia 38. B. Abdominal distension may be associated
with
may have affected the swallowing reflex or the
pain, may indicate perforation, a complication
480
that could lead to peritonitis.
480
39. D. It may take 4 to 6 months to eat anything,
inflammation may have closed in on the airway
but
most people can eat anything they want. 49. D. A client with acute pancreatitis is prone to

40. D. Clay colored stools are indicative of complications associated with respiratory
hepatic
system.
obstruction
50. B. Liver inflammation and obstruction block
41. D. Streptomycin is an aminoglycoside and the

damage on the 8th cranial nerve (ototoxicity) is normal flow of bile. Excess bilirubin turns the
a
skin and sclera yellow and the urine dark and
common side effect of aminoglycosides.
frothy.
42. D. Most peptic ulcer is caused by Helicopter
481
pylori which is a gram negative bacterium.
481
43. D. 12 to 24 hours after subtotal gastrectomy
MEDICAL SURGICAL NURSING Part 2
gastric drainage is normally brown, which
1. A client is scheduled for insertion of an
indicates digested food. inferior vena

44. C. Watching TV is permissible because the cava (IVC) filter. Nurse Patricia consults the
eye physician

does not need to move rapidly with this activity, about withholding which regularly scheduled
medication
and it does not increase intraocular pressure.
on the day before the surgery?
45. A. Common signs and symptoms of fracture
a. Potassium Chloride
include pain, deformity, shortening of the
b. Warfarin Sodium
extremity, crepitus and swelling.
c. Furosemide
46. C. The dropper should not touch any object
or d. Docusate

any part of the client’s ear. 2. A nurse is planning to assess the corneal
reflex on
47. A. Sudden decrease in drainage or onset of
unconscious client. Which of the following is the
severe abdominal pain should be reported
safest
immediately to the physician because it could
stimulus to touch the client’s cornea?
mean that obstruction has been developed.
a. Cotton buds
48. B. Complications of acute appendicitis are
b. Sterile glove
peritonitis, perforation and abscess
c. Sterile tongue depressor
development.
d. Wisp of cotton
3. A female client develops an infection at the finding should be most indicative sign of
catheter increasing

insertion site. The nurse in charge uses the term intracranial pressure?

“iatrogenic” when describing the infection a. Intermittent tachycardia

because it
b. Polydipsia
resulted from:
c. Tachypnea
a. Client’s developmental level
d. Increased restlessness
b. Therapeutic procedure
7. A hospitalized client had a tonic-clonic seizure
c. Poor hygiene while

d. Inadequate dietary patterns walking in the hall. During the seizure the nurse
priority
4. Nurse Carol is assessing a client with
Parkinson’s should be:

disease. The nurse recognize bradykinesia when a. Hold the clients arms and leg firmly
the
b. Place the client immediately to soft surface
client exhibits:
c. Protects the client’s head from injury
a. Intentional tremor
d. Attempt to insert a tongue depressor
b. Paralysis of limbs between the

c. Muscle spasm client’s teeth

d. Lack of spontaneous movement 8. A client has undergone right

pneumonectomy. When
5. A client who suffered from automobile
accident turning the client, the nurse should plan to
position the
complains of seeing frequent flashes of light.
The nurse client either:

should expect: a. Right side-lying position or supine

a. Myopia b. High fowlers

b. Detached retina c. Right or left side lying position

c. Glaucoma d. Low fowler’s position

d. Scleroderma 9. Nurse Jenny should caution a female client

who is
6. Kate with severe head injury is being
monitored by the sexually active in taking Isoniazid (INH) because
the drug
nurse for increasing intracranial pressure (ICP).
Which has which of the following side effects?
a. Prevents ovulation c. Reduce intestinal peristalsis

b. Has a mutagenic effect on ova d. Conserve energy

c. Decreases the effectiveness of oral 13. Nurse KC should regularly assess the client’s
contraceptives ability to

d. Increases the risk of vaginal infection metabolize the total parenteral nutrition (TPN)
solution
10. A client has undergone gastrectomy. Nurse
Jovy is adequately by monitoring the client for which of
the
aware that the best position for the client is:
following signs:
a. Left side lying
a. Hyperglycemia
b. Low fowler’s
b. Hypoglycemia
c. Prone
c. Hypertension
d. Supine
d. Elevate blood urea nitrogen concentration
11. During the initial postoperative period of the
client’s 14. A female client has an acute pancreatitis.
Which of
stoma. The nurse evaluates which of the
following the following signs and symptoms the nurse
would
observations should be reported immediately to
the expect to see?

physician? a. Constipation

a. Stoma is dark red to purple b. Hypertension

b. Stoma is oozes a small amount of blood 482

c. Stoma is lightly edematous 482

d. Stoma does not expel stool c. Ascites

12. Kate which has diagnosed with ulcerative d. Jaundice

colitis is
15. A client is suspected to develop tetany after
following physician’s order for bed rest with a
bathroom
subtotal thyroidectomy. Which of the following
privileges. What is the rationale for this activity
symptoms might indicate tetany?
restriction?
a. Tingling in the fingers
a. Prevent injury
b. Pain in hands and feet
b. Promote rest and comfort
c. Tension on the suture lines
d. Bleeding on the back of the dressing have done the same

16. A 58 year old woman has newly diagnosed 19. A client has been diagnosed with
with glomerulonephritis

hypothyroidism. The nurse is aware that the complains of thirst. The nurse should offer:
signs and
a. Juice
symptoms of hypothyroidism include:
b. Ginger ale
a. Diarrhea
c. Milk shake
b. Vomiting
d. Hard candy
c. Tachycardia
20. A client with acute renal failure is aware that
d. Weight gain the

17. A client has undergone for an ileal conduit, most serious complication of this condition is:
the nurse
a. Constipation
in charge should closely monitor the client for
b. Anemia
occurrence of which of the following
c. Infection
complications
d. Platelet dysfunction
related to pelvic surgery?
21. Nurse Karen is caring for clients in the OR.
a. Ascites
The nurse
b. Thrombophlebitis
is aware that the last physiologic function that
c. Inguinal hernia the client

d. Peritonitis loss during the induction of anesthesia is:

18. Dr. Marquez is about to defibrillate a client a. Consciousness

in
b. Gag reflex
ventricular fibrillation and says in a loud voice
c. Respiratory movement
“clear”.
d. Corneal reflex
What should be the action of the nurse?
22. The nurse is assessing a client with pleural
a. Places conductive gel pads for defibrillation
effusion.
on the
The nurse expect to find:
client’s chest
a. Deviation of the trachea towards the involved
b. Turn off the mechanical ventilator
side
c. Shuts off the client’s IV infusion
b. Reduced or absent of breath sounds at the
d. Steps away from the bed and make sure all base of the
others
lung c. Coolness of the skin

c. Moist crackles at the posterior of the lungs d. Presence of “hot spot” on the cast

d. Increased resonance with percussion of the 26. Nurse Rhia is performing an otoscopic
involved examination

area on a female client with a suspected diagnosis of

23. A client admitted with newly diagnosed with mastoiditis. Nurse Rhia would expect to note
which of
Hodgkin’s disease. Which of the following would
the the following if this disorder is present?

nurse expect the client to report? a. Transparent tympanic membrane

a. Lymph node pain b. Thick and immobile tympanic membrane

b. Weight gain c. Pearly colored tympanic membrane

c. Night sweats d. Mobile tympanic membrane

d. Headache 27. Nurse Jocelyn is caring for a client with

nasogastric
24. A client has suffered from fall and sustained
a leg tube that is attached to low suction. Nurse
Jocelyn
injury. Which appropriate question would the
nurse ask assesses the client for symptoms of which acid-
base
the client to help determine if the injury caused
disorder?
fracture?
a. Respiratory alkalosis
a. “Is the pain sharp and continuous?”
b. Respiratory acidosis
b. “Is the pain dull ache?”
c. Metabolic acidosis
c. “Does the discomfort feel like a cramp?”
d. Metabolic alkalosis
d. “Does the pain feel like the muscle was
stretched?” 28. A male adult client has undergone a lumbar
puncture
25. The Nurse is assessing the client’s casted
extremity to obtain cerebrospinal fluid (CSF) for analysis.
Which of
for signs of infection. Which of the following
findings is the following values should be negative if the
CSF is
indicative of infection?
normal?
a. Edema
a. Red blood cells
b. Weak distal pulse
b. White blood cells
483 32. Which of the following is not a sign of

483 thromboembolism?

c. Insulin a. Edema

d. Protein b. Swelling

29. A client is suspected of developing diabetes c. Redness

insipidus. Which of the following is the most d. Coolness

effective
33. Nurse Becky is caring for client who begins
assessment? to

a. Taking vital signs every 4 hours experience seizure while in bed. Which action
should the
b. Monitoring blood glucose
nurse implement to prevent aspiration?
c. Assessing ABG values every other day
a. Position the client on the side with head
d. Measuring urine output hourly
flexed
30. A 58 year old client is suffering from acute
forward
phase of
b. Elevate the head
rheumatoid arthritis. Which of the following
would the c. Use tongue depressor between teeth

nurse in charge identify as the lowest priority of d. Loosen restrictive clothing

the plan
34. A client has undergone bone biopsy. Which
of care? nursing

a. Prevent joint deformity action should the nurse provide after the
procedure?
b. Maintaining usual ways of accomplishing task
a. Administer analgesics via IM
c. Relieving pain
b. Monitor vital signs
d. Preserving joint function
c. Monitor the site for bleeding, swelling and
31. Among the following, which client is
hematoma
autotransfusion
formation
possible?
d. Keep area in neutral position
a. Client with AIDS
35. A client is suffering from low back pain.
b. Client with ruptured bowel
Which of the
c. Client who is in danger of cardiac arrest
following exercises will strengthen the lower
d. Client with wound infection back

muscle of the client?

a. Tennis nursing intervention should the nurse prioritize
in
b. Basketball
maintaining cerebral perfusion?
c. Diving
a. Administer diuretics
d. Swimming
b. Administer analgesics
36. A client with peptic ulcer is being assessed
by the c. Provide hygiene

nurse for gastrointestinal perforation. The nurse d. Hyperoxygenate before and after suctioning
should
40. When discussing breathing exercises with a
monitor for:
postoperative client, Nurse Hazel should include
a. (+) guaiac stool test which

b. Slow, strong pulse of the following teaching?

c. Sudden, severe abdominal pain a. Short frequent breaths

d. Increased bowel sounds b. Exhale with mouth open

37. A client has undergone surgery for retinal c. Exercise twice a day

detachment. Which of the following goal should d. Place hand on the abdomen and feel it rise
be
41. Louie, with burns over 35% of the body,
prioritized? complains of

a. Prevent an increase intraocular pressure chilling. In promoting the client’s comfort, the
nurse
b. Alleviate pain
should:
c. Maintain darkened room
a. Maintain room humidity below 40%
d. Promote low-sodium diet
b. Place top sheet on the client
38. A Client with glaucoma has been prescribed
with c. Limit the occurrence of drafts

miotics. The nurse is aware that miotics is for: d. Keep room temperature at 80 degrees

a. Constricting pupil 42. Nurse Trish is aware that temporary

heterograft (pig
b. Relaxing ciliary muscle
skin) is used to treat burns because this graft
c. Constricting intraocular vessel
will:
d. Paralyzing ciliary muscle
a. Relieve pain and promote rapid
39. When suctioning an unconscious client, epithelialization
which
b. Be sutured in place for better adherence
c. Debride necrotic epithelium d. Change in bowel habits

d. Concurrently used with topical antimicrobials 46. Louis develops peritonitis and sepsis after
surgical
43. Mark has multiple abrasions and a laceration
to the repair of ruptures diverticulum. The nurse in
charge
trunk and all four extremities says, “I can’t eat
all this should expect an assessment of the client to
reveal:
food”. The food that the nurse should suggest to
be a. Tachycardia

eaten first should be: b. Abdominal rigidity

a. Meat loaf and coffee c. Bradycardia

484 d. Increased bowel sounds

484 47. Immediately after liver biopsy, the client is

placed on
b. Meat loaf and strawberries
the right side, the nurse is aware that that this
c. Tomato soup and apple pie
position
d. Tomato soup and buttered bread
should be maintained because it will:
44. Tony returns form surgery with permanent
a. Help stop bleeding if any occurs
colostomy. During the first 24 hours the
b. Reduce the fluid trapped in the biliary ducts
colostomy does
c. Position with greatest comfort
not drain. The nurse should be aware that:
d. Promote circulating blood volume
a. Proper functioning of nasogastric suction
48. Tony has diagnosed with hepatitis A. The
b. Presurgical decrease in fluid intake
information
c. Absence of gastrointestinal motility
from the health history that is most likely linked
d. Intestinal edema following surgery to

45. When teaching a client about the signs of hepatitis A is:

colorectal
a. Exposed with arsenic compounds at work
cancer, Nurse Trish stresses that the most
b. Working as local plumber
common
c. Working at hemodialysis clinic
complaint of persons with colorectal cancer is:
d. Dish washer in restaurants
a. Abdominal pain
49. Nurse Trish is aware that the laboratory test
b. Hemorrhoids
result
c. Change in caliber of stools
that most likely would indicate acute unconscious client. Which of the following is the
pancreatitis is an
safest stimulus to touch the client’s cornea?
elevated:
a. Cotton buds
a. Serum bilirubin level
b. Sterile glove
b. Serum amylase level
c. Sterile tongue depressor
c. Potassium level
d. Wisp of cotton
d. Sodium level
3. A female client develops an infection at the
50. Dr. Marquez orders serum electrolytes. To catheter
determine
insertion site. The nurse in charge uses the term
the effect of persistent vomiting, Nurse Trish
“iatrogenic” when describing the infection
should be
because it
most concerned with monitoring the:
resulted from:
a. Chloride and sodium levels
a. Client’s developmental level
b. Phosphate and calcium levels
b. Therapeutic procedure
c. Protein and magnesium levels
c. Poor hygiene
d. Sulfate and bicarbonate levels
d. Inadequate dietary patterns
485
4. Nurse Carol is assessing a client with
485 Parkinson’s

MEDICAL SURGICAL NURSING Part 2 disease. The nurse recognize bradykinesia when
the
1. A client is scheduled for insertion of an
inferior vena client exhibits:

cava (IVC) filter. Nurse Patricia consults the a. Intentional tremor

physician
b. Paralysis of limbs
about withholding which regularly scheduled
c. Muscle spasm
medication on the day before the surgery?
d. Lack of spontaneous movement
a. Potassium Chloride
5. A client who suffered from automobile
b. Warfarin Sodium accident

c. Furosemide complains of seeing frequent flashes of light.

The
d. Docusate
nurse should expect:
2. A nurse is planning to assess the corneal
reflex on a. Myopia
b. Detached retina d. Low fowler’s position

c. Glaucoma 9. Nurse Jenny should caution a female client

who is
d. Scleroderma
sexually active in taking Isoniazid (INH) because
6. Kate with severe head injury is being
the
monitored by the
drug has which of the following side effects?
nurse for increasing intracranial pressure (ICP).
a. Prevents ovulation
Which finding should be most indicative sign of
b. Has a mutagenic effect on ova
increasing intracranial pressure?
c. Decreases the effectiveness of oral
a. Intermittent tachycardia
contraceptives
b. Polydipsia
d. Increases the risk of vaginal infection
c. Tachypnea
10. A client has undergone gastrectomy. Nurse
d. Increased restlessness
Jovy is
7. A hospitalized client had a tonic-clonic seizure
aware that the best position for the client is:
while
a. Left side lying
walking in the hall. During the seizure the nurse
b. Low fowler’s
priority should be:
c. Prone
a. Hold the clients arms and leg firmly
d. Supine
b. Place the client immediately to soft surface
11. During the initial postoperative period of the
c. Protects the client’s head from injury
client’s
d. Attempt to insert a tongue depressor
stoma. The nurse evaluates which of the
between
following
the client’s teeth
observations should be reported immediately to
8. A client has undergone right the
pneumonectomy. When
physician?
turning the client, the nurse should plan to
a. Stoma is dark red to purple
position
b. Stoma is oozes a small amount of blood
the client either:
c. Stoma is lightly edematous
a. Right side-lying position or supine
d. Stoma does not expel stool
b. High fowlers
12. Kate which has diagnosed with ulcerative
c. Right or left side lying position
colitis is
following physician’s order for bed rest with subtotal thyroidectomy. Which of the following

bathroom privileges. What is the rationale for symptoms might indicate tetany?
this
a. Tingling in the fingers
activity restriction?
b. Pain in hands and feet
a. Prevent injury
c. Tension on the suture lines
b. Promote rest and comfort
d. Bleeding on the back of the dressing
c. Reduce intestinal peristalsis
16. A 58 year old woman has newly diagnosed
d. Conserve energy with

13. Nurse KC should regularly assess the client’s hypothyroidism. The nurse is aware that the
ability to signs

metabolize the total parenteral nutrition (TPN) and symptoms of hypothyroidism include:

solution adequately by monitoring the client for a. Diarrhea

which of the following signs: b. Vomiting

a. Hyperglycemia c. Tachycardia

b. Hypoglycemia d. Weight gain

c. Hypertension 17. A client has undergone for an ileal conduit,

the nurse
d. Elevate blood urea nitrogen concentration
in charge should closely monitor the client for
14. A female client has an acute pancreatitis.
Which of occurrence of which of the following
complications
the following signs and symptoms the nurse
would related to pelvic surgery?

expect to see? a. Ascites

a. Constipation b. Thrombophlebitis

486 c. Inguinal hernia

486 d. Peritonitis

b. Hypertension 18. Dr. Marquez is about to defibrillate a client

in
c. Ascites
ventricular fibrillation and says in a loud voice
d. Jaundice
“clear”. What should be the action of the nurse?
15. A client is suspected to develop tetany after
a a. Places conductive gel pads for defibrillation
on
the client’s chest The nurse expect to find:

b. Turn off the mechanical ventilator a. Deviation of the trachea towards the involved

c. Shuts off the client’s IV infusion side

d. Steps away from the bed and make sure all b. Reduced or absent of breath sounds at the

others have done the same base of the lung

19. A client has been diagnosed with c. Moist crackles at the posterior of the lungs
glomerulonephritis
d. Increased resonance with percussion of the
complains of thirst. The nurse should offer:
involved area
a. Juice
23. A client admitted with newly diagnosed with
b. Ginger ale
Hodgkin’s disease. Which of the following would
c. Milk shake the

d. Hard candy nurse expect the client to report?

20. A client with acute renal failure is aware that a. Lymph node pain
the
b. Weight gain
most serious complication of this condition is:
c. Night sweats
a. Constipation
d. Headache
b. Anemia
24. A client has suffered from fall and sustained
c. Infection a leg

d. Platelet dysfunction injury. Which appropriate question would the

nurse
21. Nurse Karen is caring for clients in the OR.
The nurse ask the client to help determine if the injury
caused
is aware that the last physiologic function that
the fracture?

client loss during the induction of anesthesia is: a. “Is the pain sharp and continuous?”

a. Consciousness b. “Is the pain dull ache?”

b. Gag reflex c. “Does the discomfort feel like a cramp?”

c. Respiratory movement d. “Does the pain feel like the muscle was

d. Corneal reflex stretched?”

22. The nurse is assessing a client with pleural 25. The Nurse is assessing the client’s casted
effusion. extremity
for signs of infection. Which of the following 487
findings
487
is indicative of infection?
Which of the following values should be
a. Edema negative if

b. Weak distal pulse the CSF is normal?

c. Coolness of the skin a. Red blood cells

d. Presence of “hot spot” on the cast b. White blood cells

26. Nurse Rhia is performing an otoscopic c. Insulin

examination
d. Protein
on a female client with a suspected diagnosis of
29. A client is suspected of developing diabetes
mastoiditis. Nurse Rhia would expect to note
insipidus. Which of the following is the most
which
effective assessment?
of the following if this disorder is present?
a. Taking vital signs every 4 hours
a. Transparent tympanic membrane
b. Monitoring blood glucose
b. Thick and immobile tympanic membrane
c. Assessing ABG values every other day
c. Pearly colored tympanic membrane
d. Measuring urine output hourly
d. Mobile tympanic membrane
30. A 58 year old client is suffering from acute
27. Nurse Jocelyn is caring for a client with
phase of
nasogastric
rheumatoid arthritis. Which of the following
tube that is attached to low suction. Nurse
would
Jocelyn
the nurse in charge identify as the lowest
assesses the client for symptoms of which acid-
priority of
base
the plan of care?
disorder?
a. Prevent joint deformity
a. Respiratory alkalosis
b. Maintaining usual ways of accomplishing task
b. Respiratory acidosis
c. Relieving pain
c. Metabolic acidosis
d. Preserving joint function
d. Metabolic alkalosis
31. Among the following, which client is
28. A male adult client has undergone a lumbar
autotransfusion
puncture
possible?
to obtain cerebrospinal fluid (CSF) for analysis.
a. Client with AIDS 35. A client is suffering from low back pain.
Which of the
b. Client with ruptured bowel
following exercises will strengthen the lower
c. Client who is in danger of cardiac arrest
back
d. Client with wound infection
muscle of the client?
32. Which of the following is not a sign of
a. Tennis
thromboembolism?
b. Basketball
a. Edema
c. Diving
b. Swelling
d. Swimming
c. Redness
36. A client with peptic ulcer is being assessed
d. Coolness by the

33. Nurse Becky is caring for client who begins nurse for gastrointestinal perforation. The nurse
to
should monitor for:
experience seizure while in bed. Which action
a. (+) guaiac stool test
should
b. Slow, strong pulse
the nurse implement to prevent aspiration?
c. Sudden, severe abdominal pain
a. Position the client on the side with head
d. Increased bowel sounds
flexed forward
37. A client has undergone surgery for retinal
b. Elevate the head
detachment. Which of the following goal should
c. Use tongue depressor between teeth
be
d. Loosen restrictive clothing
prioritized?
34. A client has undergone bone biopsy. Which
a. Prevent an increase intraocular pressure
nursing
b. Alleviate pain
action should the nurse provide after the
procedure? c. Maintain darkened room

a. Administer analgesics via IM d. Promote low-sodium diet

b. Monitor vital signs 38. A Client with glaucoma has been prescribed
with
c. Monitor the site for bleeding, swelling and
miotics. The nurse is aware that miotics is for:
hematoma formation
a. Constricting pupil
d. Keep area in neutral position
b. Relaxing ciliary muscle
c. Constricting intraocular vessel a. Relieve pain and promote rapid

d. Paralyzing ciliary muscle epithelialization

39. When suctioning an unconscious client, b. Be sutured in place for better adherence
which
c. Debride necrotic epithelium
nursing intervention should the nurse prioritize
d. Concurrently used with topical antimicrobials
in
488
maintaining cerebral perfusion?
488
a. Administer diuretics
43. Mark has multiple abrasions and a laceration
b. Administer analgesics
to the
c. Provide hygiene
trunk and all four extremities says, “I can’t eat
d. Hyperoxygenate before and after suctioning all this

40. When discussing breathing exercises with a food”. The food that the nurse should suggest to
be
postoperative client, Nurse Hazel should include
eaten first should be:
which of the following teaching?
a. Meat loaf and coffee
a. Short frequent breaths
b. Meat loaf and strawberries
b. Exhale with mouth open
c. Tomato soup and apple pie
c. Exercise twice a day
d. Tomato soup and buttered bread
d. Place hand on the abdomen and feel it rise
44. Tony returns form surgery with permanent
41. Louie, with burns over 35% of the body,
complains of colostomy. During the first 24 hours the
colostomy
chilling. In promoting the client’s comfort, the
nurse does not drain. The nurse should be aware that:

should: a. Proper functioning of nasogastric suction

a. Maintain room humidity below 40% b. Presurgical decrease in fluid intake

b. Place top sheet on the client c. Absence of gastrointestinal motility

c. Limit the occurrence of drafts d. Intestinal edema following surgery

d. Keep room temperature at 80 degrees 45. When teaching a client about the signs of
colorectal
42. Nurse Trish is aware that temporary
heterograft (pig cancer, Nurse Trish stresses that the most
common
skin) is used to treat burns because this graft
will: complaint of persons with colorectal cancer is:
a. Abdominal pain 49. Nurse Trish is aware that the laboratory test
result
b. Hemorrhoids
that most likely would indicate acute
c. Change in caliber of stools
pancreatitis is
d. Change in bowel habits
an elevated:
46. Louis develops peritonitis and sepsis after
a. Serum bilirubin level
surgical
b. Serum amylase level
repair of ruptures diverticulum. The nurse in
charge c. Potassium level

should expect an assessment of the client to d. Sodium level

reveal:
50. Dr. Marquez orders serum electrolytes. To
a. Tachycardia determine

b. Abdominal rigidity the effect of persistent vomiting, Nurse Trish

should
c. Bradycardia
be most concerned with monitoring the:
d. Increased bowel sounds
a. Chloride and sodium levels
47. Immediately after liver biopsy, the client is
placed on b. Phosphate and calcium levels

the right side, the nurse is aware that that this c. Protein and magnesium levels

position should be maintained because it will: d. Sulfate and bicarbonate levels

a. Help stop bleeding if any occurs 489

b. Reduce the fluid trapped in the biliary ducts 489

c. Position with greatest comfort ANSWERS and RATIONALES for MEDICAL

SURGICAL
d. Promote circulating blood volume
NURSING Part 2
48. Tony has diagnosed with hepatitis A. The
information 1. B. In preoperative period, the nurse should
consult
from the health history that is most likely linked
to with the physician about withholding Warfarin

hepatitis A is: Sodium to avoid occurrence of hemorrhage.

a. Exposed with arsenic compounds at work 2. D. A client who is unconscious is at greater

risk for
b. Working as local plumber
corneal abrasion. For this reason, the safest way
c. Working at hemodialysis clinic
to
d. Dish washer in restaurants
test the cornel reflex is by touching the cornea
lightly with a wisp of cotton. placed in a low fowler’s position. This relaxes

3. B. Iatrogenic infection is caused by the heath abdominal muscles and provides maximum
care
respiratory and cardiovascular function.
provider or is induced inadvertently by medical
11. A. Dark red to purple stoma indicates
treatment or procedures. inadequate

4. D. Bradykinesia is slowing down from the blood supply.

initiation
12. C. The rationale for activity restriction is to
and execution of movement. help

5. B. This symptom is caused by stimulation of reduce the hypermotility of the colon.

retinal
13. A. During Total Parenteral Nutrition (TPN)
cells by ocular movement.
administration, the client should be monitored
6. D. Restlessness indicates a lack of oxygen to
regularly for hyperglycemia.
the brain
14. D. Jaundice may be present in acute
stem which impairs the reticular activating
pancreatitis
system.
owing to obstruction of the biliary duct.
7. C. Rhythmic contraction and relaxation
associated 15. A. Tetany may occur after thyroidectomy if
the
with tonic-clonic seizure can cause repeated
banging parathyroid glands are accidentally injured or
of head. removed.
8. A. Right side lying position or supine position 16. D. Typical signs of hypothyroidism includes
permits weight
ventilation of the remaining lung and prevent gain, fatigue, decreased energy, apathy, brittle
fluid nails,
from draining into sutured bronchial stump. dry skin, cold intolerance, constipation and
9. C. Isoniazid (INH) interferes in the numbness.
effectiveness of oral
17. B. After a pelvic surgery, there is an
contraceptives and clients of childbearing age increased chance
should
of thrombophlebitits owing to the pelvic
be counseled to use an alternative form of birth
manipulation that can interfere with circulation
control while taking this drug. and
10. B. A client who has had abdominal surgery is promote venous stasis.
best
18. D. For the safety of all personnel, if the 25. D. Signs and symptoms of infection under a
defibrillator casted

paddles are being discharged, all personnel area include odor or purulent drainage and the
must
presence of “hot spot” which are areas on the
stand back and be clear of all the contact with cast
the
that are warmer than the others.
client or the client’s bed.
26. B. Otoscopic examnation in a client with
19. D. Hard candy will relieve thirst and increase mastoiditis

carbohydrates but does not supply extra fluid. reveals a dull, red, thick and immobile
tymphanic
20. C. Infection is responsible for one third of
the membrane with or without perforation.

traumatic or surgically induced death of clients 27. D. Loss of gastric fluid via nasogastric suction
with or

renal failure as well as medical induced acute vomiting causes metabolic alkalosis because of
renal the

failure (ARF) loss of hydrochloric acid which is a potent acid

in the
21. C. There is no respiratory movement in stage
4 of body.

anesthesia, prior to this stage, respiration is 28. A. The adult with normal cerebrospinal fluid
has no
depressed but present.
red blood cells.
22. B. Compression of the lung by fluid that
accumulates 29. D. Measuring the urine output to detect
excess
at the base of the lungs reduces expansion and
air amount and checking the specific gravity of
urine
exchange.
samples to determine urine concentration are
23. C. Assessment of a client with Hodgkin’s
disease appropriate measures to determine the onset of

most often reveals enlarged, painless lymph diabetes insipidus.

node,
30. B. The nurse should focus more on
fever, malaise and night sweats. developing less

24. A. Fractured pain is generally described as stressful ways of accomplishing routine task.
sharp,
31. C. Autotransfusion is acceptable for the
continuous, and increasing in frequency. client who is
in danger of cardiac arrest. ciliary muscle. These effects widen the filtration

32. D. The client with thromboembolism does angle and permit increased out flow of aqueous
not have
humor.
coolness.
39. D. It is a priority to hyperoxygenate the
33. A. Positioning the client on one side with client before
head flexed
and after suctioning to prevent hypoxia and to
forward allows the tongue to fall forward and
maintain cerebral perfusion.
facilitates drainage secretions therefore
40. D. Abdominal breathing improves lungs
prevents
expansion
aspiration.
41. C. A Client with burns is very sensitive to
490
temperature changes because heat is loss in the
490
burn areas.
34. C. Nursing care after bone biopsy includes
42. A. The graft covers the nerve endings, which
close
reduces
monitoring of the punctured site for bleeding,
pain and provides framework for granulation
swelling and hematoma formation.
43. B. Meat provides proteins and the fruit
35. D. Walking and swimming are very helpful in proteins

strengthening back muscles for the client vitamin C that both promote wound healing.
suffering
44. C. This is primarily caused by the trauma of
from lower back pain. intestinal

36. C. Sudden, severe abdominal pain is the manipulation and the depressive effects
most anesthetics

indicative sign of perforation. When perforation and analgesics.

of
45. D. Constipation, diarrhea, and/or
an ulcer occurs, the nurse maybe unable to hear constipation

bowel sounds at all. alternating with diarrhea are the most common

37. A. After surgery to correct a detached retina, symptoms of colorectal cancer.

prevention of increased intraocular pressure is 46. B. With increased intraabdominal pressure,

the the

priority goal. abdominal wall will become tender and rigid.

38. A. Miotic agent constricts the pupil and 47. A. Pressure applied in the puncture site
contracts indicates
that a biliary vessel was puncture which is a b. Antihypertensive
common
c. Steroids
complication after liver biopsy.
d. Anticonvulsants
48. B. Hepatitis A is primarily spread via fecal-
2. Halfway through the administration of blood,
oral route.
the
Sewage polluted water may harbor the virus.
female client complains of lumbar pain. After
49. B. Amylase concentration is high in the
stopping the infusion Nurse Hazel should:
pancreas and
a. Increase the flow of normal saline
is elevated in the serum when the pancreas
becomes b. Assess the pain further
acutely inflamed and also it distinguishes c. Notify the blood bank
pancreatitis from other acute abdominal d. Obtain vital signs.
problems.
3. Nurse Maureen knows that the positive
50. A. Sodium, which is concerned with the diagnosis for
regulation of
HIV infection is made based on which of the
extracellular fluid volume, it is lost with
vomiting. following:

Chloride, which balances cations in the a. A history of high risk sexual behaviors.
extracellular b. Positive ELISA and western blot tests
compartments, is also lost with vomiting, c. Identification of an associated opportunistic
because
infection
sodium and chloride are parallel electrolytes,
d. Evidence of extreme weight loss and high
hyponatremia will accompany.
fever
491
4. Nurse Maureen is aware that a client who has
491 been
MEDICAL SURGICAL NURSING Part 3 diagnosed with chronic renal failure recognizes
1. Marco who was diagnosed with brain tumor an
was adequate amount of high-biologic-value protein
scheduled for craniotomy. In preventing the when the food the client selected from the
development of cerebral edema after surgery, menu
the was:
nurse should expect the use of: a. Raw carrots
a. Diuretics
b. Apple juice 8. Nurse hazel receives emergency laboratory
results for
c. Whole wheat bread
a client with chest pain and immediately
d. Cottage cheese
informs the
5. Kenneth who has diagnosed with uremic
physician. An increased myoglobin level
syndrome
suggests
has the potential to develop complications.
which of the following?
Which
a. Liver disease
among the following complications should the
nurse b. Myocardial damage

anticipates: c. Hypertension

a. Flapping hand tremors d. Cancer

b. An elevated hematocrit level 9. Nurse Maureen would expect the a client

with mitral
c. Hypotension
stenosis would demonstrate symptoms
d. Hypokalemia
associated
6. A client is admitted to the hospital with
with congestion in the:
benign
a. Right atrium
prostatic hyperplasia, the nurse most relevant
b. Superior vena cava
assessment would be:
c. Aorta
a. Flank pain radiating in the groin
d. Pulmonary
b. Distention of the lower abdomen
10. A client has been diagnosed with
c. Perineal edema
hypertension. The
d. Urethral discharge
nurse priority nursing diagnosis would be:
7. A client has undergone with penile implant.
a. Ineffective health maintenance
After 24
b. Impaired skin integrity
hrs of surgery, the client’s scrotum was
edematous c. Deficient fluid volume

and painful. The nurse should: d. Pain

a. Assist the client with sitz bath 11. Nurse Hazel teaches the client with angina
about
b. Apply war soaks in the scrotum
common expected side effects of nitroglycerin
c. Elevate the scrotum using a soft support
including:
d. Prepare for a possible incision and drainage.
a. high blood pressure c. Grains

b. stomach cramps d. Broccoli

c. headache 15. Karen has been diagnosed with aplastic

anemia. The
d. shortness of breath
nurse monitors for changes in which of the
12. The following are lipid abnormalities. Which
following
of the
physiologic functions?
following is a risk factor for the development of
a. Bowel function
atherosclerosis and PVD?
b. Peripheral sensation
a. High levels of low density lipid (LDL)
c. Bleeding tendencies
cholesterol
d. Intake and out put
b. High levels of high density lipid (HDL)
16. Lydia is scheduled for elective splenectomy.
cholesterol
Before
c. Low concentration triglycerides
the clients goes to surgery, the nurse in charge
d. Low levels of LDL cholesterol. final

13. Which of the following represents a assessment would be:

significant risk
a. signed consent
immediately after surgery for repair of aortic
b. vital signs
aneurysm?
c. name band
a. Potential wound infection
d. empty bladder
b. Potential ineffective coping
17. What is the peak age range in acquiring
c. Potential electrolyte balance acute

d. Potential alteration in renal perfusion lymphocytic leukemia (ALL)?

492 a. 4 to 12 years.

492 b. 20 to 30 years

14. Nurse Josie should instruct the client to eat c. 40 to 50 years

which of
d. 60 60 70 years
the following foods to obtain the best supply of
18. Marie with acute lymphocytic leukemia
Vitamin B12? suffers from

a. dairy products nausea and headache. These clinical

manifestations
b. vegetables
may indicate all of the following except c. Hoarseness

a. effects of radiation d. Dysphagia

b. chemotherapy side effects 22. Karina a client with myasthenia gravis is to

receive
c. meningeal irritation
immunosuppressive therapy. The nurse
d. gastric distension
understands
19. A client has been diagnosed with
that this therapy is effective because it:
Disseminated
a. Promotes the removal of antibodies that
Intravascular Coagulation (DIC). Which of the
impair the transmission of impulses
following is contraindicated with the client?
b. Stimulates the production of acetylcholine at
a. Administering Heparin
the neuromuscular junction.
b. Administering Coumadin
c. Decreases the production of autoantibodies
c. Treating the underlying cause
that attack the acetylcholine receptors.
d. Replacing depleted blood products
d. Inhibits the breakdown of acetylcholine at the
20. Which of the following findings is the best
indication neuromuscular junction.

that fluid replacement for the client with 23. A female client is receiving IV Mannitol. An

hypovolemic shock is adequate? assessment specific to safe administration of the

a. Urine output greater than 30ml/hr said drug is:

b. Respiratory rate of 21 breaths/minute a. Vital signs q4h

c. Diastolic blood pressure greater than 90 b. Weighing daily

mmhg c. Urine output hourly

d. Systolic blood pressure greater than 110 d. Level of consciousness q4h

mmhg 24. Patricia a 20 year old college student with

diabetes
21. Which of the following signs and symptoms
would mellitus requests additional information about
the
Nurse Maureen include in teaching plan as an
early advantages of using a pen like insulin delivery

manifestation of laryngeal cancer? devices. The nurse explains that the advantages
of
a. Stomatitis
these devices over syringes includes:
b. Airway obstruction
a. Accurate dose delivery time.

b. Shorter injection time 27. While performing a physical assessment of a

male
c. Lower cost with reusable insulin cartridges
client with gout of the great toe, Nurse Vivian
d. Use of smaller gauge needle.
should
25. A male client’s left tibia was fractured in an
assess for additional tophi (urate deposits) on
automobile accident, and a cast is applied. To the:
assess
a. Buttocks
for damage to major blood vessels from the
b. Ears
fracture
c. Face
tibia, the nurse in charge should monitor the
client d. Abdomen

for: 28. Nurse Katrina would recognize that the

a. Swelling of the left thigh demonstration of crutch walking with tripod gait
was
b. Increased skin temperature of the foot
understood when the client places weight on
c. Prolonged reperfusion of the toes after
the:
blanching
a. Palms of the hands and axillary regions
d. Increased blood pressure
b. Palms of the hand
26. After a long leg cast is removed, the male
c. Axillary regions
client
d. Feet, which are set apart
should:
29. Mang Jose with rheumatoid arthritis states,
a. Cleanse the leg by scrubbing with a brisk
“the only
motion
time I am without pain is when I lie in bed
b. Put leg through full range of motion twice perfectly

daily still”. During the convalescent stage, the nurse in

c. Report any discomfort or stiffness to the charge with Mang Jose should encourage:

physician a. Active joint flexion and extension

493 b. Continued immobility until pain subsides

493 c. Range of motion exercises twice daily

d. Elevate the leg when sitting for long periods d. Flexion exercises three times daily
of
30. A male client has undergone spinal surgery,
the
nurse should: nurse, “What caused me to have a seizure?
Which of
a. Observe the client’s bowel movement and
the following would the nurse include in the
voiding patterns
primary
b. Log-roll the client to prone position
cause of tonic clonic seizures in adults more the
c. Assess the client’s feet for sensation and 20

circulation years?

d. Encourage client to drink plenty of fluids a. Electrolyte imbalance

31. Marina with acute renal failure moves into b. Head trauma
the
c. Epilepsy
diuretic phase after one week of therapy. During
d. Congenital defect
this
34. What is the priority nursing assessment in
phase the client must be assessed for signs of
the first 24
developing:
hours after admission of the client with
a. Hypovolemia thrombotic

b. renal failure CVA?

c. metabolic acidosis a. Pupil size and papillary response

d. hyperkalemia b. cholesterol level

32. Nurse Judith obtains a specimen of clear c. Echocardiogram

nasal
d. Bowel sounds
drainage from a client with a head injury. Which
35. Nurse Linda is preparing a client with
of
multiple
the following tests differentiates mucus from
sclerosis for discharge from the hospital to
cerebrospinal fluid (CSF)? home.

a. Protein Which of the following instruction is most

b. Specific gravity appropriate?

c. Glucose a. “Practice using the mechanical aids that you

d. Microorganism will need when future disabilities arise”.

33. A 22 year old client suffered from his first b. “Follow good health habits to change the
tonicclonic
course of the disease”.
seizure. Upon awakening the client asks the
c. “Keep active, use stress reduction strategies,
and avoid fatigue. c. Causing factors

d. “You will need to accept the necessity for a d. Intensity

quiet and inactive lifestyle”. 494

36. The nurse is aware the early indicator of 494

hypoxia in
40. A 65 year old female is experiencing flare up
the unconscious client is: of

a. Cyanosis pruritus. Which of the client’s action could

aggravate
b. Increased respirations
the cause of flare ups?
c. Hypertension
a. Sleeping in cool and humidified environment
d. Restlessness
b. Daily baths with fragrant soap
37. A client is experiencing spinal shock. Nurse
Myrna c. Using clothes made from 100% cotton

should expect the function of the bladder to be d. Increasing fluid intake

which of the following? 41. Atropine sulfate (Atropine) is

contraindicated in all
a. Normal
but one of the following client?
b. Atonic
a. A client with high blood
c. Spastic
b. A client with bowel obstruction
d. Uncontrolled
c. A client with glaucoma
38. Which of the following stage the carcinogen
is d. A client with U.T.I

irreversible? 42. Among the following clients, which among

them is
a. Progression stage
high risk for potential hazards from the surgical
b. Initiation stage
experience?
c. Regression stage
a. 67-year-old client
d. Promotion stage
b. 49-year-old client
39. Among the following components thorough
pain c. 33-year-old client

assessment, which is the most significant? d. 15-year-old client

a. Effect 43. Nurse Jon assesses vital signs on a client

undergone
b. Cause
epidural anesthesia. Which of the following 47. An 83-year-old woman has several
would ecchymotic areas

the nurse assess next? on her right arm. The bruises are probably
caused
a. Headache
by:
b. Bladder distension
a. increased capillary fragility and permeability
c. Dizziness
b. increased blood supply to the skin
d. Ability to move legs
c. self inflicted injury
44. Nurse Katrina should anticipate that all of
the d. elder abuse

following drugs may be used in the attempt to 48. Nurse Anna is aware that early adaptation of
client
control the symptoms of Meniere’s disease
except: with renal carcinoma is:

a. Antiemetics a. Nausea and vomiting

b. Diuretics b. flank pain

c. Antihistamines c. weight gain

d. Glucocorticoids d. intermittent hematuria

45. Which of the following complications 49. A male client with tuberculosis asks Nurse
associated with Brian how

tracheostomy tube? long the chemotherapy must be continued.

Nurse
a. Increased cardiac output
Brian’s accurate reply would be:
b. Acute respiratory distress syndrome (ARDS)
a. 1 to 3 weeks
c. Increased blood pressure
b. 6 to 12 months
d. Damage to laryngeal nerves
c. 3 to 5 months
46. Nurse Faith should recognize that fluid shift
in an d. 3 years and more

client with burn injury results from increase in 50. A client has undergone laryngectomy. The
the: immediate

a. Total volume of circulating whole blood nursing priority would be:

b. Total volume of intravascular plasma a. Keep trachea free of secretions

c. Permeability of capillary walls b. Monitor for signs of infection

d. Permeability of kidney tubules c. Provide emotional support

d. Promote means of communication urine, therefore palpable.

495 7. C. Elevation increases lymphatic drainage,

reducing
495
edema and pain.
ANSWERS and RATIONALES for MEDICAL
SURGICAL 8. B. Detection of myoglobin is a diagnostic tool
to
NURSING Part 3
determine whether myocardial damage has
1. C. Glucocorticoids (steroids) are used for their
antiinflammatory occurred.

action, which decreases the 9. D. When mitral stenosis is present, the left
atrium has
development of edema.
difficulty emptying its contents into the left
2. A. The blood must be stopped at once, and
ventricle
then
because there is no valve to prevent back ward
normal saline should be infused to keep the line
flow
patent and maintain blood volume.
into the pulmonary vein, the pulmonary
3. B. These tests confirm the presence of HIV circulation is
antibodies
under pressure.
that occur in response to the presence of the
10. A. Managing hypertension is the priority for
human
the
immunodeficiency virus (HIV).
client with hypertension. Clients with
4. D. One cup of cottage cheese contains hypertension
approximately
frequently do not experience pain, deficient
225 calories, 27 g of protein, 9 g of fat, 30 mg volume,

cholesterol, and 6 g of carbohydrate. Proteins of or impaired skin integrity. It is the asymptomatic

high biologic value (HBV) contain optimal levels nature of hypertension that makes it so difficult
of to

amino acids essential for life. treat.

5. A. Elevation of uremic waste products causes 11. C. Because of its widespread vasodilating
irritation effects,

of the nerves, resulting in flapping hand nitroglycerin often produces side effects such as
tremors.
headache, hypotension and dizziness.
6. B. This indicates that the bladder is distended
12. A. An increased in LDL cholesterol
with
concentration has
been documented at risk factor for the after 15 years of age.
development
18. D. Acute Lymphocytic Leukemia (ALL) does
of atherosclerosis. LDL cholesterol is not broken not cause

down into the liver but is deposited into the gastric distention. It does invade the central
wall of nervous

the blood vessels. system, and clients experience headaches and

13. D. There is a potential alteration in renal vomiting from meningeal irritation.

perfusion
19. B. Disseminated Intravascular Coagulation
manifested by decreased urine output. The (DIC) has
altered
not been found to respond to oral
renal perfusion may be related to renal artery anticoagulants

embolism, prolonged hypotension, or prolonged such as Coumadin.

aortic cross-clamping during the surgery. 20. A. Urine output provides the most sensitive

14. A. Good source of vitamin B12 are dairy indication of the client’s response to therapy for
products
hypovolemic shock. Urine output should be
and meats.
consistently greater than 30 to 35 mL/hr.
15. C. Aplastic anemia decreases the bone
21. C. Early warning signs of laryngeal cancer
marrow
can vary
production of RBC’s, white blood cells, and
depending on tumor location. Hoarseness
platelets.
lasting 2
The client is at risk for bruising and bleeding
weeks should be evaluated because it is one of
tendencies. the

16. B. An elective procedure is scheduled in most common warning signs.

advance so
22. C. Steroids decrease the body’s immune
that all preparations can be completed ahead of response

time. The vital signs are the final check that thus decreasing the production of antibodies
must be that

completed before the client leaves the room so attack the acetylcholine receptors at the
that
neuromuscular junction
continuity of care and assessment is provided
23. C. The osmotic diuretic mannitol is
for.
contraindicated in
17. A. The peak incidence of Acute Lymphocytic
the presence of inadequate renal function or
Leukemia (ALL) is 4 years of age. It is uncommon heart
failure because it increases the intravascular 30. C. Alteration in sensation and circulation
volume indicates

that must be filtered and excreted by the damage to the spinal cord, if these occurs notify
kidney.
physician immediately.
24. A. These devices are more accurate because
31. A. In the diuretic phase fluid retained during
they are
the
easily to used and have improved adherence in
oliguric phase is excreted and may reach 3 to 5
insulin regimens by young people because the liters

medication can be administered discreetly. daily, hypovolemia may occur and fluids should
be
25. C. Damage to blood vessels may decrease
the replaced.

circulatory perfusion of the toes, this would 32. C. The constituents of CSF are similar to
indicate those of

the lack of blood supply to the extremity. blood plasma. An examination for glucose
content is
26. D. Elevation will help control the edema that
usually done to determine whether a body fluid is a
mucus
occurs.
or a CSF. A CSF normally contains glucose.
27. B. Uric acid has a low solubility, it tends to
33. B. Trauma is one of the primary cause of
precipitate and form deposits at various sites
brain
where
damage and seizure activity in adults. Other
blood flow is least active, including cartilaginous
common causes of seizure activity in adults
tissue such as the ears.
include
28. B. The palms should bear the client’s weight
neoplasms, withdrawal from drugs and alcohol,
to avoid
and
damage to the nerves in the axilla.
vascular disease.
496
34. A. It is crucial to monitor the pupil size and
496 papillary

29. A. Active exercises, alternating extension, response to indicate changes around the cranial
flexion,
nerves.
abduction, and adduction, mobilize exudates in
35. C. The nurse most positive approach is to
the
encourage
joints relieves stiffness and pain.
the client with multiple sclerosis to stay active, older adult client is more likely to have a
use lesseffective

stress reduction techniques and avoid fatigue immune system.

because it is important to support the immune 43. B. The last area to return sensation is in the
perineal
system while remaining active.
area, and the nurse in charge should monitor
36. D. Restlessness is an early indicator of
the
hypoxia. The
client for distended bladder.
nurse should suspect hypoxia in unconscious
client 44. D. Glucocorticoids play no significant role in
disease
who suddenly becomes restless.
treatment.
37. B. In spinal shock, the bladder becomes
completely 45. D. Tracheostomy tube has several potential

atonic and will continue to fill unless the client is complications including bleeding, infection and

catheterized. laryngeal nerve damage.

38. A. Progression stage is the change of tumor 46. C. In burn, the capillaries and small vessels
from the dilate,

preneoplastic state or low degree of malignancy and cell damage cause the release of a
to a histaminelike

fast growing tumor that cannot be reversed. substance. The substance causes the capillary

39. D. Intensity is the major indicative of walls to become more permeable and
severity of pain significant

and it is important for the evaluation of the quantities of fluid are lost.

treatment. 47. A. Aging process involves increased capillary

fragility
40. B. The use of fragrant soap is very drying to
skin and permeability. Older adults have a decreased

hence causing the pruritus. amount of subcutaneous fat and cause an

increased
41. C. Atropine sulfate is contraindicated with
glaucoma incidence of bruise like lesions caused by
collection
patients because it increases intraocular
pressure. of extravascular blood in loosely structured
dermis.
42. A. A 67 year old client is greater risk because
the 48. D. Intermittent pain is the classic sign of
renal
carcinoma. It is primarily due to capillary c. Loose associations
erosion by
d. Neologisms
the cancerous growth.
3. Nurse Monet is caring for a female client who
49. B. Tubercle bacillus is a drug resistant
has suicidal tendency. When accompanying the
organism and
client to the restroom, Nurse Monet should…
takes a long time to be eradicated. Usually a
a. Give her privacy
combination of three drugs is used for minimum
of 6 b. Allow her to urinate
months and at least six months beyond culture c. Open the window and allow her to get
conversion. some fresh air
50. A. Patent airway is the most priority; d. Observe her
therefore
4. Nurse Maureen is developing a plan of care
removal of secretions is necessary. for a
497 female client with anorexia nervosa. Which
action
497
should the nurse include in the plan?
PSYCHIATRIC NURSING Part 1
a. Provide privacy during meals
1. Marco approached Nurse Trish asking for
advice b. Set-up a strict eating plan for the client
on how to deal with his alcohol addiction. Nurse c. Encourage client to exercise to reduce
Trish should tell the client that the only effective anxiety
treatment for alcoholism is: d. Restrict visits with the family
a. Psychotherapy 5. A client is experiencing anxiety attack. The
most
b. Alcoholics anonymous (A.A.)
appropriate nursing intervention should
c. Total abstinence
include?
d. Aversion Therapy
a. Turning on the television
2. Nurse Hazel is caring for a male client who
b. Leaving the client alone
experience false sensory perceptions with no
c. Staying with the client and speaking in
basis in
short sentences
reality. This perception is known as:
d. Ask the client to play with other clients
a. Hallucinations
6. A female client is admitted with a diagnosis of
b. Delusions
delusions of GRANDEUR. This diagnosis reflects a. Encourage to avoid foods
a
b. Identify anxiety causing situations
belief that one is:
c. Eat only three meals a day
a. Being Killed
d. Avoid shopping plenty of groceries
b. Highly famous and important
10. Nurse Tony was caring for a 41 year old
c. Responsible for evil world female

d. Connected to client unrelated to oneself client. Which behavior by the client indicates
adult
7. A 20 year old client was diagnosed with
cognitive development?
dependent personality disorder. Which behavior
is a. Generates new levels of awareness

not most likely to be evidence of ineffective b. Assumes responsibility for her actions

individual coping? c. Has maximum ability to solve problems

a. Recurrent self-destructive behavior and learn new skills

b. Avoiding relationship d. Her perception are based on reality

c. Showing interest in solitary activities 11. A neuromuscular blocking agent is

administered
d. Inability to make choices and decision
to a client before ECT therapy. The Nurse should
without advise
carefully observe the client for?
8. A male client is diagnosed with schizotypal
a. Respiratory difficulties
personality disorder. Which signs would this
client b. Nausea and vomiting

exhibit during social situation? c. Dizziness

a. Paranoid thoughts d. Seizures

b. Emotional affect 12. A 75 year old client is admitted to the

hospital
c. Independence need
with the diagnosis of dementia of the
d. Aggressive behavior
Alzheimer’s
9. Nurse Claire is caring for a client diagnosed
type and depression. The symptom that is
with
unrelated
bulimia. The most appropriate initial goal for a
to depression would be?
client
a. Apathetic response to the environment
diagnosed with bulimia is?
b. “I don’t know” answer to questions
c. Shallow of labile effect c. increasing appropriate sensory

d. Neglect of personal hygiene perception

13. Nurse Trish is working in a mental health d. ensuring constant client and staff
facility;
contact
the nurse priority nursing intervention for a
16. A 39 year old mother with obsessive-
newly
compulsive
admitted client with bulimia nervosa would be
disorder has become immobilized by her
to?
elaborate
a. Teach client to measure I & O
hand washing and walking rituals. Nurse Trish
b. Involve client in planning daily meal
recognizes that the basis of O.C. disorder is
c. Observe client during meals often:

d. Monitor client continuously a. Problems with being too conscientious

14. Nurse Patricia is aware that the major health b. Problems with anger and remorse

complication associated with intractable c. Feelings of guilt and inadequacy

anorexia
d. Feeling of unworthiness and
nervosa would be?
hopelessness
498
17. Mario is complaining to other clients about
498 not

a. Cardiac dysrhythmias resulting to being allowed by staff to keep food in his room.

cardiac arrest Which of the following interventions would be

most
b. Glucose intolerance resulting in
appropriate?
protracted hypoglycemia
a. Allowing a snack to be kept in his room
c. Endocrine imbalance causing cold
b. Reprimanding the client
amenorrhea
c. Ignoring the clients behavior
d. Decreased metabolism causing cold
d. Setting limits on the behavior
intolerance
18. Conney with borderline personality disorder
15. Nurse Anna can minimize agitation in a
who
disturbed client by?
is to be discharge soon threatens to “do
a. Increasing stimulation something”

b. limiting unnecessary interaction to herself if discharged. Which of the following

actions by the nurse would be most important? d. Consistency

a. Ask a family member to stay with the 21. Cely is experiencing alcohol withdrawal
exhibits
client at home temporarily
tremors, diaphoresis and hyperactivity. Blood
b. Discuss the meaning of the client’s
pressure is 190/87 mmhg and pulse is 92 bpm.
statement with her
Which of the medications would the nurse
c. Request an immediate extension for the
expect to
client
administer?
d. Ignore the clients statement because it’s
a. Naloxone (Narcan)
a sign of manipulation
b. Benzlropine (Cogentin)
19. Joey a client with antisocial personality
c. Lorazepam (Ativan)
disorder
d. Haloperidol (Haldol)
belches loudly. A staff member asks Joey, “Do
you 22. Which of the following foods would the
nurse
know why people find you repulsive?” this
Trish eliminate from the diet of a client in
statement most likely would elicit which of the
alcohol
following client reaction?
withdrawal?
a. Depensiveness
a. Milk
b. Embarrassment
b. Orange Juice
c. Shame
c. Soda
d. Remorsefulness
d. Regular Coffee
20. Which of the following approaches would be
23. Which of the following would Nurse Hazel
most appropriate to use with a client suffering
expect to assess for a client who is exhibiting
from
late
narcissistic personality disorder when
signs of heroin withdrawal?
discrepancies
a. Yawning & diaphoresis
exist between what the client states and what
b. Restlessness & Irritability
actually exist?
c. Constipation & steatorrhea
a. Rationalization
d. Vomiting and Diarrhea
b. Supportive confrontation
24. To establish open and trusting relationship
c. Limit setting
with
a female client who has been hospitalized with depression Nurse Trina should say?

severe anxiety, the nurse in charge should? a. It may appear acting out behavior

a. Encourage the staff to have frequent b. Does not respond to conventional

interaction with the client treatment

b. Share an activity with the client c. Is short in duration & resolves easily

c. Give client feedback about behavior d. Looks almost identical to adult

d. Respect client’s need for personal space depression

25. Nurse Monette recognizes that the focus of 28. Nurse Perry is aware that language
development
environmental (MILIEU) therapy is to:
in autistic child resembles:
a. Manipulate the environment to bring
a. Scanning speech
about positive changes in behavior
b. Speech lag
b. Allow the client’s freedom to determine
c. Shuttering
whether or not they will be involved in activities
d. Echolalia
c. Role play life events to meet individual
29. A 60 year old female client who lives alone
needs
tells
d. Use natural remedies rather than drugs
the nurse at the community health center “I
to control behavior really

499 don’t need anyone to talk to”. The TV is my best

499 friend. The nurse recognizes that the client is

using
26. Nurse Trish would expect a child with a
diagnosis the defense mechanism known as?

of reactive attachment disorder to: a. Displacement

a. Have more positive relation with the b. Projection

father than the mother c. Sublimation

b. Cling to mother & cry on separation d. Denial

c. Be able to develop only superficial 30. When working with a male client suffering

relation with the others phobia about black cats, Nurse Trish should

d. Have been physically abuse anticipate that a problem for this client would
be?
27. When teaching parents about childhood
a. Anxiety when discussing phobia client cannot remember facts and fills in the
gaps
b. Anger toward the feared object
with imaginary information. Nurse Benjie is
c. Denying that the phobia exist
aware
d. Distortion of reality when completing
that this is typical of?
daily routines
a. Flight of ideas
31. Linda is pacing the floor and appears
b. Associative looseness
extremely
c. Confabulation
anxious. The duty nurse approaches in an
attempt to d. Concretism

alleviate Linda’s anxiety. The most therapeutic 34. Nurse Joey is aware that the signs &
symptoms
question by the nurse would be?
that would be most specific for diagnosis
a. Would you like to watch TV?
anorexia
b. Would you like me to talk with you?
are?
c. Are you feeling upset now?
a. Excessive weight loss, amenorrhea &
d. Ignore the client
abdominal distension
32. Nurse Penny is aware that the symptoms
b. Slow pulse, 10% weight loss & alopecia
that
c. Compulsive behavior, excessive fears &
distinguish post traumatic stress disorder from
other nausea

anxiety disorder would be: d. Excessive activity, memory lapses & an

a. Avoidance of situation & certain increased pulse

activities that resemble the stress 35. A characteristic that would suggest to Nurse

b. Depression and a blunted affect when Anne that an adolescent may have bulimia
would be:
discussing the traumatic situation
a. Frequent regurgitation & re-swallowing
c. Lack of interest in family & others
of food
d. Re-experiencing the trauma in dreams or
b. Previous history of gastritis
flashback
c. Badly stained teeth
33. Nurse Benjie is communicating with a male
client d. Positive body image

with substance-induced persisting dementia; 36. Nurse Monette is aware that extremely
the
depressed clients seem to do best in settings a. Helps the client focus on the inability to
where
deal with reality
they have:
b. Helps the client control the anxiety
a. Multiple stimuli
c. Is under the client’s conscious control
b. Routine Activities
d. Is used by the client primarily for
c. Minimal decision making
secondary gains
d. Varied Activities
40. A 32 year old male graduate student, who
37. To further assess a client’s suicidal potential. has

Nurse Katrina should be especially alert to the become increasingly withdrawn and neglectful
client of his

expression of: work and personal hygiene, is brought to the

a. Frustration & fear of death psychiatric hospital by his parents. After

detailed
b. Anger & resentment
assessment, a diagnosis of schizophrenia is
c. Anxiety & loneliness
made. It
d. Helplessness & hopelessness
is unlikely that the client will demonstrate:
38. A nursing care plan for a male client with
a. Low self esteem
bipolar
b. Concrete thinking
I disorder should include:
c. Effective self boundaries
a. Providing a structured environment
d. Weak ego
b. Designing activities that will require the
41. A 23 year old client has been admitted with
client to maintain contact with reality
a
c. Engaging the client in conversing about
diagnosis of schizophrenia says to the nurse
current affairs “Yes, its

500 march, March is little woman”. That’s literal you

500 know”. These statement illustrate:

d. Touching the client provide assurance a. Neologisms

39. When planning care for a female client using b. Echolalia

ritualistic behavior, Nurse Gina must recognize c. Flight of ideas

that
d. Loosening of association
the ritual:
42. A long term goal for a paranoid male client encourage talking
who
b. Rake the client into the dayroom to be
has unjustifiably accused his wife of having
with other clients
many
c. Sit beside the client in silence and
extramarital affairs would be to help the client
occasionally ask open-ended question
develop:
d. Leave the client alone and continue with
a. Insight into his behavior
providing care to the other clients
b. Better self control
45. Nurse Tina is caring for a client with delirium
c. Feeling of self worth
and
d. Faith in his wife
states that “look at the spiders on the wall”.
43. A male client who is experiencing disordered What

thinking about food being poisoned is admitted should the nurse respond to the client?
to
a. “You’re having hallucination, there are
the mental health unit. The nurse uses which
no spiders in this room at all”
communication technique to encourage the
b. “I can see the spiders on the wall, but
client to
they are not going to hurt you”
eat dinner?
c. “Would you like me to kill the spiders”
a. Focusing on self-disclosure of own food
d. “I know you are frightened, but I do not
preference
see spiders on the wall”
b. Using open ended question and silence
46. Nurse Jonel is providing information to a
c. Offering opinion about the need to eat
community group about violence in the family.
d. Verbalizing reasons that the client may
Which statement by a group member would
not choose to eat
indicate
44. Nurse Nina is assigned to care for a client
a need to provide additional information?
diagnosed with Catatonic Stupor. When Nurse
a. “Abuse occurs more in low-income
Nina
families”
enters the client’s room, the client is found lying
on b. “Abuser Are often jealous or selfcentered”
the bed with a body pulled into a fetal position. c. “Abuser use fear and intimidation”
Nurse Nina should? d. “Abuser usually have poor self-esteem”
a. Ask the client direct questions to
47. During electroconvulsive therapy (ECT) the d. The client maintains contact with a crisis
client
counselor
receives oxygen by mask via positive pressure
49. Nurse Tina is caring for a client with
ventilation. The nurse assisting with this depression
procedure
who has not responded to antidepressant
knows that positive pressure ventilation is
medication. The nurse anticipates that what
necessary
treatment procedure may be prescribed?
because?
a. Neuroleptic medication
a. Anesthesia is administered during the
b. Short term seclusion
procedure
c. Psychosurgery
b. Decrease oxygen to the brain increases
d. Electroconvulsive therapy
confusion and disorientation
50. Mario is admitted to the emergency room
c. Grand mal seizure activity depresses
with
respirations
drug-included anxiety related to over ingestion
d. Muscle relaxations given to prevent of

injury during seizure activity depress prescribed antipsychotic medication. The most
respirations.
important piece of information the nurse in
48. When planning the discharge of a client with charge

chronic anxiety, Nurse Chris evaluates should obtain initially is the:

achievement
a. Length of time on the med.
of the discharge maintenance goals. Which goal
b. Name of the ingested medication & the
would be most appropriately having been
amount ingested
included
c. Reason for the suicide attempt
in the plan of care requiring evaluation?
d. Name of the nearest relative & their phone
a. The client eliminates all anxiety from
number
daily situations
502
b. The client ignores feelings of anxiety
502
c. The client identifies anxiety producing
ANSWERS and RATIONALES for PSYCHIATRIC
situations
NURSING Part 1
501

501
1. C. Total abstinence is the only effective 8. A. Clients with schizotypal personality
treatment for disorder

alcoholism. experience excessive social anxiety that can lead

to
2. A. Hallucinations are visual, auditory,
gustatory, tactile paranoid thoughts.

or olfactory perceptions that have no basis in 9. B. Bulimia disorder generally is a maladaptive

reality. coping

3. D. The Nurse has a responsibility to observe response to stress and underlying issues. The
client
continuously the acutely suicidal client. The
Nurse should identify anxiety causing situation that

should watch for clues, such as communicating stimulate the bulimic behavior and then learn
new
suicidal thoughts, and messages; hoarding
ways of coping with the anxiety.
medications and talking about death.
10. A. An adult age 31 to 45 generates new level
4. B. Establishing a consistent eating plan and
of
monitoring
awareness.
client’s weight are important to this disorder.
11. A. Neuromuscular Blocker, such as
5. C. Appropriate nursing interventions for an
anxiety SUCCINYLCHOLINE (Anectine) produces
respiratory
attack include using short sentences, staying
with depression because it inhibits contractions of

the client, decreasing stimuli, remaining calm respiratory muscles.

and
12. C. With depression, there is little or no
medicating as needed. emotional

6. B. Delusion of grandeur is a false belief that involvement therefore little alteration in affect.
one is
13. D. These clients often hide food or force
highly famous and important. vomiting;

7. D. Individual with dependent personality therefore they must be carefully monitored.

disorder
14. A. These clients have severely depleted
typically shows indecisiveness submissiveness levels of
and
sodium and potassium because of their
clinging behavior so that others will make starvation
decisions
diet and energy expenditure, these electrolytes
with them. are
necessary for cardiac functioning. what actually exists to increase responsibility for

15. B. Limiting unnecessary interaction will self.

decrease
21. C. The nurse would most likely administer
stimulation and agitation.
benzodiazepine, such as lorazepan (ativan) to
16. C. Ritualistic behavior seen in this disorder is the
aimed
client who is experiencing symptom: The client’s
at controlling guilt and inadequacy by
experiences symptoms of withdrawal because
maintaining an
of the
absolute set pattern of behavior.
rebound phenomenon when the sedation of the
17. D. The nurse needs to set limits in the CNS
client’s
from alcohol begins to decrease.
manipulative behavior to help the client control
22. D. Regular coffee contains caffeine which
dysfunctional behavior. A consistent approach acts as
by the
psychomotor stimulants and leads to feelings of
staff is necessary to decrease manipulation.
anxiety and agitation. Serving coffee top the
18. B. Any suicidal statement must be assessed client
by the
may add to tremors or wakefulness.
nurse. The nurse should discuss the client’s
23. D. Vomiting and diarrhea are usually the late
statement with her to determine its meaning in signs of

terms of suicide. heroin withdrawal, along with muscle spasm,

fever,
19. A. When the staff member ask the client if
he nausea, repetitive, abdominal cramps and
backache.
wonders why others find him repulsive, the
client is 24. D. Moving to a client’s personal space
increases the
likely to feel defensive because the question is
feeling of threat, which increases anxiety.
belittling. The natural tendency is to
counterattack 25. A. Environmental (MILIEU) therapy aims at
having
the threat to self image.
everything in the client’s surrounding area
20. B. The nurse would specifically use
toward
supportive
helping the client.
confrontation with the client to point out
26. C. Children who have experienced
discrepancies between what the client states
attachment
and
difficulties with primary caregiver are not able 34. A. These are the major signs of anorexia
to nervosa.

trust others and therefore relate superficially Weight loss is excessive (15% of expected
weight).
27. A. Children have difficulty verbally
expressing their 35. C. Dental enamel erosion occurs from
repeated selfinduced
feelings, acting out behavior, such as temper
vomiting.
tantrums, may indicate underlying depression.
36. B. Depression usually is both emotional &
28. D. The autistic child repeat sounds or words
physical. A
spoken
simple daily routine is the best, least stressful
by others.
and
29. D. The client statement is an example of the
least anxiety producing.
use of
37. D. The expression of these feeling may
denial, a defense that blocks problem by
indicate that
unconscious refusing to admit they exist.
this client is unable to continue the struggle of
30. A. Discussion of the feared object triggers an life.

emotional response to the object. 38. A. Structure tends to decrease agitation and
anxiety
31. B. The nurse presence may provide the
client with and to increase the client’s feeling of security.

support & feeling of control. 39. B. The rituals used by a client with obsessive

503 compulsive disorder help control the anxiety

level by
503
maintaining a set pattern of action.
32. D. Experiencing the actual trauma in dreams
or 40. C. A person with this disorder would not
have
flashback is the major symptom that
distinguishes adequate self-boundaries.

post traumatic stress disorder from other 41. D. Loose associations are thoughts that are
anxiety
presented without the logical connections
disorder. usually

33. C. Confabulation or the filling in of memory necessary for the listening to interpret the
gaps with message.

imaginary facts is a defense mechanism used by 42. C. Helping the client to develop feeling of
self worth
people experiencing memory deficits.
would reduce the client’s need to use this procedure to prevent injuries during
pathologic seizure.

defenses. 48. C. Recognizing situations that produce

anxiety allows
43. B. Open ended questions and silence are
strategies the client to prepare to cope with anxiety or
avoid
used to encourage clients to discuss their
problem in specific stimulus.

descriptive manner. 49. D. Electroconvulsive therapy is an effective

44. C. Clients who are withdrawn may be treatment for depression that has not
immobile and responded to

mute, and require consistent, repeated medication.

interventions. Communication with withdrawn 50. B. In an emergency, lives saving facts are
obtained
clients requires much patience from the nurse.
The first. The name and the amount of medication

nurse facilitates communication with the client ingested are of outmost important in treating
by this

sitting in silence, asking open-ended question potentially life threatening situation.

and
504
pausing to provide opportunities for the client
504
to
PSYCHIATRIC NURSING Part 2
respond.
1. Nurse Tony should first discuss terminating
45. D. When hallucination is present, the nurse
the nurseclient
should
relationship with a client during the:
reinforce reality with the client.
a. Termination phase when discharge plans are
46. A. Personal characteristics of abuser include
low selfesteem, being made.
immaturity, dependence, insecurity and b. Working phase when the client shows some
jealousy. progress.
47. D. A short acting skeletal muscle relaxant c. Orientation phase when a contract is
such as
established.
succinylcholine (Anectine) is administered
during d. Working phase when the client brings it up.

2. Malou is diagnosed with major depression

spends
majority of the day lying in bed with the sheet a. Roasted chicken
pulled
b. Fresh fish
over his head. Which of the following
c. Salami
approaches by
d. Hamburger
the nurse would be the most therapeutic?
5. When assessing a female client who is
a. Question the client until he responds
receiving
b. Initiate contact with the client frequently
tricyclic antidepressant therapy, which of the
c. Sit outside the clients room following

d. Wait for the client to begin the conversation would

3. Joe who is very depressed exhibits alert the nurse to the possibility that the client
psychomotor is

retardation, a flat affect and apathy. The nurse experiencing anticholinergic effects?
in
a. Urine retention and blurred vision
charge observes Joe to be in need of grooming
b. Respiratory depression and convulsion
and
c. Delirium and Sedation
hygiene. Which of the following nursing actions
d. Tremors and cardiac arrhythmias
would be most appropriate?
6. For a male client with dysthymic disorder,
a. Waiting until the client’s family can
which of
participate
the following approaches would the nurse
in the client’s care
expect to
b. Asking the client if he is ready to take shower
implement?
c. Explaining the importance of hygiene to the
a. ECT
client
b. Psychotherapeutic approach
d. Stating to the client that it’s time for him to
c. Psychoanalysis
take
d. Antidepressant therapy
a shower
7. Danny who is diagnosed with bipolar disorder
4. When teaching Mario with a typical
and
depression about
acute mania, states the nurse, “Where is my
foods to avoid while taking phenelzine(Nardil),
which daughter? I love Louis. Rain, rain go away. Dogs
eat
of the following would the nurse in charge
include? dirt.” The nurse interprets these statements as
indicating which of the following? b. “I know my kids don’t need me anymore
since
a. Echolalia
they’re grown.”
b. Neologism
c. “I couldn’t kill myself because I don’t want to
c. Clang associations
go
d. Flight of ideas
to hell.”
8. Terry with mania is skipping up and down the
d. “I don’t think about killing myself as much as I
hallway
used to.”
practically running into other clients. Which of
the 11. Which of the following activities would
Nurse Trish
following activities would the nurse in charge
expect recommend to the client who becomes very
anxious
to include in Terry’s plan of care?
when thoughts of suicide occur?
a. Watching TV
a. Using exercise bicycle
b. Cleaning dayroom tables
b. Meditating
c. Leading group activity
c. Watching TV
d. Reading a book
d. Reading comics
9. When assessing a male client for suicidal risk,
which of 12. When developing the plan of care for a
client
the following methods of suicide would the
nurse receiving haloperidol, which of the following

identify as most lethal? medications would nurse Monet anticipate

a. Wrist cutting administering if the client developed extra

pyramidal
b. Head banging
side effects?
c. Use of gun
a. Olanzapine (Zyprexa)
d. Aspirin overdose
b. Paroxetine (Paxil)
10. Jun has been hospitalized for major
depression and c. Benztropine mesylate (Cogentin)

suicidal ideation. Which of the following d. Lorazepam (Ativan)

statements
505
indicates to the nurse that the client is
505
improving?

a. “I’m of no use to anyone anymore.”

13. Jon a suspicious client states that “I know chronically mentally ill. The program would be
you nurses most

are spraying my food with poison as you take it likely to help the family with which of the
out following

of the cart.” Which of the following would be issues?

the
a. Developing a support network with other
best response of the nurse?
families
a. Giving the client canned supplements until
b. Feeling more guilty about the client’s illness
the
c. Recognizing the client’s weakness
delusion subsides
d. Managing their financial concern and
b. Asking what kind of poison the client suspects
problems
is
16. When planning care for Dory with
being used
schizotypal
c. Serving foods that come in sealed packages
personality disorder, which of the following
d. Allowing the client to be the first to open the would

cart and get a tray help the client become involved with others?

14. A client is suffering from catatonic a. Attending an activity with the nurse
behaviors. Which
b. Leading a sing a long in the afternoon
of the following would the nurse use to
c. Participating solely in group activities
determine
d. Being involved with primarily one to one
that the medication administered PRN have
been activities
most effective? 17. Which statement about an individual with a
a. The client responds to verbal directions to eat personality disorder is true?
b. The client initiates simple activities without a. Psychotic behavior is common during acute
direction episodes
c. The client walks with the nurse to her room b. Prognosis for recovery is good with
therapeutic
d. The client is able to move all extremities
intervention
occasionally
c. The individual typically remains in the
15. Nurse Hazel invites new client’s parents to
attend the mainstream of society, although he has
problems in
psycho educational program for families of the
social and occupational roles 20. Joy has entered the chemical dependency
unit for
d. The individual usually seeks treatment
willingly treatment of alcohol dependency. Which of the

for symptoms that are personally distressful. following client’s possession will the nurse most

18. Nurse John is talking with a client who has likely place in a locked area?
been
a. Toothpaste
diagnosed with antisocial personality about how
b. Shampoo
to
c. Antiseptic mouthwash
socialize during activities without being
seductive. d. Moisturizer
Nurse John would focus the discussion on which 21. Which of the following assessment would
of provide
the following areas? the best information about the client’s
physiologic
a. Discussing his relationship with his mother
response and the effectiveness of the
b. Asking him to explain reasons for his
medication
seductive
prescribed specifically for alcohol withdrawal?
behavior
a. Sleeping pattern
c. Suggesting to apologize to others for his
b. Mental alertness
behavior
c. Nutritional status
d. Explaining the negative reactions of others
d. Vital signs
toward his behavior
22. After administering naloxone (Narcan), an
19. Tina with a histrionic personality disorder is
opioid
melodramatic and responds to others and
antagonist, Nurse Ronald should monitor the
situations
female
in an exaggerated manner. Nurse Trish would
client carefully for which of the following?
recommend which of the following activities for
a. Respiratory depression
Tina?
b. Epilepsy
a. Baking class
c. Kidney failure
b. Role playing
d. Cerebral edema
c. Scrap book making
23. Which of the following would nurse Ronald
d. Music group use as
the best measure to determine a client’s d. Confusion
progress in
26. Jose is diagnosed with amphetamine
rehabilitation? psychosis and

a. The way he gets along with his parents was admitted in the emergency room. Nurse
Ronald
b. The number of drug-free days he has
would most likely prepare to administer which
c. The kinds of friends he makes
of the
d. The amount of responsibility his job entails
following medication?
24. A female client is brought by ambulance to
a. Librium
the
b. Valium
hospital emergency room after taking an
overdose c. Ativan

506 d. Haldol

506 27. Which of the following liquids would nurse

Leng
of barbiturates is comatose. Nurse Trish would
be administer to a female client who is intoxicated
with
especially alert for which of the following?
phencyclidine (PCP) to hasten excretion of the
a. Epilepsy
chemical?
b. Myocardial Infarction
a. Shake
c. Renal failure
b. Tea
d. Respiratory failure
c. Cranberry Juice
25. Joey who has a chronic user of cocaine
reports that d. Grape juice

he feels like he has cockroaches crawling under 28. When developing a plan of care for a female
his client

skin. His arms are red because of scratching. The with acute stress disorder who lost her sister in
a car
nurse in charge interprets these findings as
possibly accident. Which of the following would the
nurse
indicating which of the following?
expect to initiate?
a. Delusion
a. Facilitating progressive review of the accident
b. Formication
and its consequences
c. Flash back
b. Postponing discussion of the accident until d. Mobilizing the individual’s support system
the
31. Joy’s stream of consciousness is occupied
client brings it up exclusively

c. Telling the client to avoid details of the with thoughts of her father’s death. Nurse
accident Ronald

d. Helping the client to evaluate her sister’s should plan to help Joy through this stage of

behavior grieving, which is known as:

29. The nursing assistant tells nurse Ronald that a. Shock and disbelief
the
b. Developing awareness
client is not in the dining room for lunch. Nurse
c. Resolving the loss
Ronald would direct the nursing assistant to do
d. Restitution
which of the following?
32. When taking a health history from a female
a. Tell the client he’ll need to wait until supper client
to
who has a moderate level of cognitive
eat if he misses lunch impairment

b. Invite the client to lunch and accompany him due to dementia, the nurse would expect to
to note the

the dining room presence of:

c. Inform the client that he has 10 minutes to a. Accentuated premorbid traits

get
b. Enhance intelligence
to the dining room for lunch
c. Increased inhibitions
d. Take the client a lunch tray and let the client
d. Hyper vigilance
eat
33. What is the priority care for a client with a
in his room
dementia
30. The initial nursing intervention for the
resulting from AIDS?
significantothers
a. Planning for remotivational therapy
during shock phase of a grief reaction should
b. Arranging for long term custodial care
be focused on:
c. Providing basic intellectual stimulation
a. Presenting full reality of the loss of the
d. Assessing pain frequently
individuals
34. Jerome who has eating disorder often
b. Directing the individual’s activities at this time
exhibits similar
c. Staying with the individuals involved
symptoms. Nurse Lhey would expect an d. Encourage his participation in programs
adolescent
37. Grace is exhibiting withdrawn patterns of
client with anorexia to exhibit: behavior.

a. Affective instability Nurse Johnny is aware that this type of behavior

b. Dishered, unkempt physical appearance eventually produces feeling of:

c. Depersonalization and derealization a. Repression

d. Repetitive motor mechanisms b. Loneliness

35. The primary nursing diagnosis for a female c. Anger

client
d. Paranoia
with a medical diagnosis of major depression
38. One morning a female client on the
would
inpatient
be:
psychiatric service complains to nurse Hazel that
a. Situational low self-esteem related to altered she

role has been waiting for over an hour for someone

to
b. Powerlessness related to the loss of idealized
accompany her to activities. Nurse Hazel replies
self
to
c. Spiritual distress related to depression
the client “We’re doing the best we can. There
d. Impaired verbal communication related to are a

depression lot of other people on the unit who needs

attention
36. When developing an initial nursing care plan
for a too.” This statement shows that the nurse’s use
of:
male client with a Bipolar I disorder (manic
episode) a. Defensive behavior

nurse Ron should plan to? b. Reality reinforcement

507 c. Limit-setting behavior

507 d. Impulse control

a. Isolate his gym time 39. A nursing diagnosis for a male client with a

b. Encourage his active participation in unit diagnosed multiple personality disorder is

chronic
programs
low self-esteem probably related to childhood
c. Provide foods, fluids and rest
abuse. The most appropriate short term client
outcome would be: tells Nurse Ron, “My heart has stopped and my
veins
a. Verbalizing the need for anxiety medications
have turned to glass!” Nurse Ron is aware that
b. Recognizing each existing personality
this is
c. Engaging in object-oriented activities
an example of:
d. Eliminating defense mechanisms and phobia
a. Somatic delusions
40. A 25 year old male is admitted to a mental
b. Depersonalization
health
c. Hypochondriasis
facility because of inappropriate behavior. The
client d. Echolalia

has been hearing voices, responding to 43. In recognizing common behaviors exhibited
imaginary by male

companions and withdrawing to his room for client who has a diagnosis of schizophrenia,
several nurse

days at a time. Nurse Monette understands that Josie can anticipate:

the
a. Slumped posture, pessimistic out look and
withdrawal is a defense against the client’s fear flight
of:
of ideas
a. Phobia
b. Grandiosity, arrogance and distractibility
b. Powerlessness
c. Withdrawal, regressed behavior and lack of
c. Punishment
social skills
d. Rejection
d. Disorientation, forgetfulness and anxiety
41. When asking the parents about the onset of
44. One morning, nurse Diane finds a disturbed
problems in young client with the diagnosis of client

schizophrenia, Nurse Linda would expect that curled up in the fetal position in the corner of
they the

would relate the client’s difficulties began in: dayroom. The most accurate initial evaluation of
the
a. Early childhood
behavior would be that the client is:
b. Late childhood
a. Physically ill and experiencing abdominal
c. Adolescence
discomfort
d. Puberty
b. Tired and probably did not sleep well last
42. Jose who has been hospitalized with
night
schizophrenia
c. Attempting to hide from the nurse 48. When planning care for a male client using
paranoid
d. Feeling more anxious today
ideation, nurse Jasmin should realize the
45. Nurse Bea notices a female client sitting
importance
alone in the
of:
corner smiling and talking to herself. Realizing
that a. Giving the client difficult tasks to provide

the client is hallucinating. Nurse Bea should: stimulation

a. Invite the client to help decorate the dayroom 508

b. Leave the client alone until he stops talking 508

c. Ask the client why he is smiling and talking b. Providing the client with activities in which

d. Tell the client it is not good for him to talk to success can be achieved

himself c. Removing stress so that the client can relax

46. When being admitted to a mental health d. Not placing any demands on the client
facility, a
49. Nurse Gerry is aware that the defense
young female adult tells Nurse Mylene that the mechanism

voices she hears frighten her. Nurse Mylene commonly used by clients who are alcoholics is:

understands that the client tends to hallucinate a. Displacement

more vividly: b. Denial

a. While watching TV c. Projection

b. During meal time d. Compensation

c. During group activities 50. Within a few hours of alcohol withdrawal,

nurse John
d. After going to bed
should assess the male client for the presence
47. Nurse John recognizes that paranoid
of:
delusions
a. Disorientation, paranoia, tachycardia
usually are related to the defense mechanism
of: b. Tremors, fever, profuse diaphoresis

a. Projection c. Irritability, heightened alertness, jerky

b. Identification movements

c. Repression d. Yawning, anxiety, convulsions

d. Regression 509
509 mood for more days than not over a period of at

ANSWERS and RATIONALES for PSYCHIATRIC least 2 years. Client with dysthymic disorder

NURSING Part 2 benefit from psychotherapeutic approaches that

1. C. When the nurse and client agree to work assist the client in reversing the negative self

together, a contract should be established, the image, negative feelings about the future.

length of the relationship should be discussed in 7. D. Flight of ideas is speech pattern of rapid

terms of its ultimate termination. transition from topic to topic, often without

2. B. The nurse should initiate brief, frequent finishing one idea. It is common in mania.

contacts throughout the day to let the client 8. B. The client with mania is very active &
needs to
know that he is important to the nurse. This will
have this energy channeled in a constructive
positively affect the client’s self-esteem.
task
3. D. The client with depression is preoccupied,
such as cleaning or tidying the room.
has
9. C. A crucial factor is determining the lethality
decreased energy, and is unable to make
of
decisions. The nurse presents the situation, “It’s
a method is the amount of time that occurs
time for a shower”, and assists the client with
between initiating the method & the delivery of
personal hygiene to preserve his dignity and
the lethal impact of the method.
selfesteem.
10. D. The statement “I don’t think about killing
4. C. Foods high in tyramine, those that are
myself as much as I used to.” Indicates a
fermented, pickled, aged, or smoked must be
lessening of suicidal ideation and improvement
avoided because when they are ingested in
in the client’s condition.
combination with MAOIs a hypertensive crisis
11. A. Using exercise bicycle is appropriate for
will occur.
the
5. A. Anticholinergic effects, which result from
client who becomes very anxious when
blockage of the parasympathetic (craniosacral) thoughts

nervous system including urine retention, of suicidal occur.

blurred vision, dry mouth & constipation. 12. C. The drug of choice for a client
experiencing
6. B. Dysthymia is a less severe, chronic
depression extra pyramidal side effects from haloperidol

diagnosed when a client has had a depressed (Haldol) is benztropine mesylate (cogentin)
because of its anti cholinergic properties. problems related to their inflexible behaviors.

13. D. Allowing the client to be the first to open Personality disorders are chronic lifelong
the
patterns of behavior; acute episodes do not
cart & take a tray presents the client with the
occur. Psychotic behavior is usually not
reality that the nurses are not touching the food common,

& tray, thereby dispelling the delusion. although it can occur in either schizotypal

14. B. Although all the actions indicate personality disorder or borderline personality

improvement, the ability to initiate simple disorder. Because these disorders are enduring

activities without directions indicates the most and evasive and the individual is inflexible,

improvement in the catatonic behaviors. prognosis for recovery is unfavorable. Generally,

15. A. Psychoeducational groups for families the individual does not seek treatment because

develop a support network. They provide he does not perceive problems with his own

education about the biochemical etiology of behavior. Distress can occur based on other

psychiatric disease to reduce, not increase people’s reaction to the individual’s behavior.
family
18. D. The nurse would explain the negative
guilt.
reactions of others towards the client’s
16. C. Attending activity with the nurse assists
behaviors to make the clients aware of the
the
impact of his seductive behaviors on others.
client to become involved with others slowly.
19. B. The nurse would use role-playing to teach
The client with schizotypal personality disorder
the
needs support, kindness & gentle suggestion to
client appropriate responses to others and in
improve social skills & interpersonal
various situations. This client dramatizes events,
relationship.
drawn attention to self, and is unaware of and
17. C. An individual with personality disorder
usually does not deal with feelings. The nurse works to
is not hospitalized unless a coexisting Axis I help the client clarify true feelings & learn to
psychiatric disorder is present. Generally, these express them appropriately.
individuals make marginal adjustments and 20. C. Antiseptic mouthwash often contains
alcohol
remain in society, although they typically
& should be kept in locked area, unless labeling
experience relationship and occupational
510
510 client experiencing amphetamine psychosis to

clearly indicates that the product does not decrease agitation & psychotic symptoms,

contain alcohol. including delusions, hallucinations & cognitive

21. D. Monitoring of vital signs provides the best impairment.

information about the client’s overall 27. C. An acid environment aids in the excretion
physiologic of

status during alcohol withdrawal & the PCP. The nurse will definitely give the client with

physiologic response to the medication used. PCP intoxication cranberry juice to acidify the

22. A. After administering naloxone (Narcan) the urine to a ph of 5.5 & accelerate excretion.

nurse should monitor the client’s respiratory 28. A. The nurse would facilitate progressive
review
status carefully, because the drug is short acting
of the accident and its consequence to help the
& respiratory depression may recur after its
client integrate feelings & memories and to
effects wear off.
begin the grieving process.
23. B. The best measure to determine a client’s
29. B. The nurse instructs the nursing assistant
progress in rehabilitation is the number of
to
drugfree
invite the client to lunch & accompany him to
days he has. The longer the client is free of
the dinning room to decrease manipulation,
drugs, the better the prognosis is.
secondary gain, dependency and reinforcement
24. D. Barbiturates are CNS depressants; the
nurse of negative behavior while maintaining the

would be especially alert for the possibility of client’s worth.

respiratory failure. Respiratory failure is the 30. C. This provides support until the individuals

most likely cause of death from barbiturate over coping mechanisms and personal support

dose. systems can be immobilized.

25. B. The feeling of bugs crawling under the 31. C. Resolving a loss is a slow, painful,
skin is continuous

termed as formication, and is associated with process until a mental image of the dead
person,
cocaine use.
almost devoid of negative or undesirable
26. D. The nurse would prepare to administer an
features emerges.
antipsychotic medication such as Haldol to a
32. A. A moderate level of cognitive impairment sub personalities so that interpretation can
due
occur.
to dementia is characterized by increasing
40. D. An aloof, detached, withdrawn posture is
dependence on environment & social structure a

and by increasing psychologic rigidity with means of protecting the self by withdrawing and

accentuated previous traits & behaviors. maintaining a safe, emotional distance.

33. C. This action maintains for as long as 41. C. The usual age of onset of schizophrenia is
possible,
adolescence or early childhood.
the clients intellectual functions by providing an
42. A. Somatic delusion is a fixed false belief
opportunity to use them. about

34. A. Individuals with anorexia often display one’s body.

irritability, hospitality, and a depressed mood. 43. C. These are the classic behaviors exhibited
by
35. D. Depressed clients demonstrate decreased
clients with a diagnosis of schizophrenia.
communication because of lack of psychic or
44. D. The fetal position represents regressed
physical energy.
behavior. Regression is a way of responding to
36. C. The client in a manic episode of the illness
overwhelming anxiety.
often neglects basic needs, these needs are a
45. B. This provides a stimulus that competes
priority to ensure adequate nutrition, fluid, and
with
rest.
and reduces hallucination.
37. B. The withdrawn pattern of behavior
46. D. Auditory hallucinations are most
presents
troublesome
the individual from reaching out to others for
when environmental stimuli are diminished and
sharing the isolation produces feeling of
there are few competing distractions.
loneliness.
47. A. Projection is a mechanism in which inner
38. A. The nurse’s response is not therapeutic
thoughts and feelings are projected onto the
because it does not recognize the client’s needs
environment, seeming to come from outside
but tries to make the client feel guilty for being the

demanding. self rather than from within.

39. B. The client must recognize the existence of 48. B. This will help the client develop self-
the esteem
and reduce the use of paranoid ideation. should assess a recently hospitalized client for
signs
49. B. Denial is a method of resolving conflict or
of opiate withdrawal. These signs would
escaping unpleasant realities by ignoring their
include:
existence.
a. Rhinorrhea, convulsions, subnormal
511
temperature
511
b. Nausea, dilated pupils, constipation
50. C. Alcohol is a central nervous system
c. Lacrimation, vomiting, drowsiness
depressant. These symptoms are the body’s
d. Muscle aches, papillary constriction, yawning
neurologic adaptation to the withdrawal of
4. A 48 year old male client is brought to the
alcohol. psychiatric

512 emergency room after attempting to jump off a

512 bridge. The client’s wife states that he lost his

job
PSYCHIATRIC NURSING Part 3
several months ago and has been unable to find
1. Francis who is addicted to cocaine withdraws
from the another job. The primary nursing intervention at
this
drug. Nurse Ron should expect to observe:
time would be to assess for:
a. Hyperactivity
a. A past history of depression
b. Depression
b. Current plans to commit suicide
c. Suspicion
c. The presence of marital difficulties
d. Delirium
d. Feelings of excessive failure
2. Nurse John is aware that a serious effect of
inhaling 5. Before helping a male client who has been
sexually
cocaine is?
assaulted, nurse Maureen should recognize that
a. Deterioration of nasal septum the
b. Acute fluid and electrolyte imbalances rapist is motivated by feelings of:
c. Extra pyramidal tract symptoms a. Hostility
d. Esophageal varices b. Inadequacy
3. A tentative diagnosis of opiate addiction, c. Incompetence
Nurse Candy
d. Passion
6. When working with children who have been client experiencing a developmental crisis.
sexually These

abused by a family member it is important for groups are successful because the:
the
a. Crisis intervention worker is a psychologist
nurse to understand that these victims usually
and understands behavior patterns
are
b. Crisis group supplies a workable solution to
overwhelmed with feelings of:
the client’s problem
a. Humiliation
c. Client is encouraged to talk about personal
b. Confusion
problems
c. Self blame
d. Client is assisted to investigate alternative
d. Hatred
approaches to solving the identified problem
7. Joy who has just experienced her second
spontaneous 10. Nurse Ronald could evaluate that the staff’s
abortion expresses anger towards her physician, approach to setting limits for a demanding,
the angry
hospital and the “rotten nursing care”. When client was effective if the client:
assessing the situation, the nurse recognizes a. Apologizes for disrupting the unit’s routine
that the
when something is needed
client may be using the coping mechanism of:
b. Understands the reason why frequent calls to
a. Projection
the staff were made
b. Displacement
c. Discuss concerns regarding the emotional
c. Denial
condition that required hospitalizations
d. Reaction formation
d. No longer calls the nursing staff for assistance
8. The most critical factor for nurse Linda to
determine 11. Nurse John is aware that the therapy that
has the
during crisis intervention would be the client’s:
highest success rate for people with phobias
a. Available situational supports would
b. Willingness to restructure the personality be:
c. Developmental theory a. Psychotherapy aimed at rearranging
maladaptive
d. Underlying unconscious conflict
thought process
9. Nurse Trish suggests a crisis intervention
group to a
b. Psychoanalytical exploration of repressed intestines are rotted from worms chewing on
conflicts them.”

of an earlier development phase This statement indicates a:

c. Systematic desensitization using relaxation a. Jealous delusion

technique b. Somatic delusion

d. Insight therapy to determine the origin of the c. Delusion of grandeur

anxiety and fear d. Delusion of persecution

12. When nurse Hazel considers a client’s 15. Andy is admitted to the psychiatric unit with
placement on a

the continuum of anxiety, a key in determining diagnosis of borderline personality disorder.

the Nurse

degree of anxiety being experienced is the Hilary should expects the assessment to reveal:
client’s:
a. Coldness, detachment and lack of tender
a. Perceptual field feelings

b. Delusional system b. Somatic symptoms

c. Memory state c. Inability to function as responsible parent

d. Creativity level d. Unpredictable behavior and intense

interpersonal
13. In the diagnosis of a possible pervasive
relationships
developmental autistic disorder. The nurse
would 16. PROPRANOLOL (Inderal) is used in the
mental health
513
setting to manage which of the following
513
conditions?
find it most unusual for a 3 year old child to
a. Antipsychotic – induced akathisia and anxiety
demonstrate:
b. Obsessive – compulsive disorder (OCD) to
a. An interest in music reduce

b. An attachment to odd objects ritualistic behavior

c. Ritualistic behavior c. Delusions for clients suffering from

schizophrenia
d. Responsiveness to the parents
d. The manic phase of bipolar illness as a mood
14. Malou with schizophrenia tells Nurse
Melinda, “My stabilizer
17. Which medication can control the extra 20. Initial interventions for Marco with acute
pyramidal anxiety

effects associated with antipsychotic agents? include all except which of the following?

a. Clorazepate (Tranxene) a. Touching the client in an attempt to comfort

him
b. Amantadine (Symmetrel)
b. Approaching the client in calm, confident
c. Doxepin (Sinequan)
manner
d. Perphenazine (Trilafon)
c. Encouraging the client to verbalize feelings
18. Which of the following statements should be and

included when teaching clients about concerns

monoamine
d. Providing the client with a safe, quiet and
oxidase inhibitor (MAOI) antidepressants? private

a. Don’t take aspirin or nonsteroidal place

antiinflammatory
21. Nurse Jessie is assessing a client suffering
drugs (NSAIDs) from stress

b. Have blood levels screened weekly for and anxiety. A common physiological response
leucopenia to

c. Avoid strenuous activity because of the stress and anxiety is:

cardiac
a. Uticaria
effects of the drug
b. Vertigo
d. Don’t take prescribed or over the counter
c. Sedation
medications without consulting the physician
d. Diarrhea
19. Kris periodically has acute panic attacks.
22. When performing a physical examination on
These
a female
attacks are unpredictable and have no apparent
anxious client, nurse Nelli would expect to find
association with a specific object or situation.
which of the following effects produced by the
During
parasympathetic system?
an acute panic attack, Kris may experience:
a. Muscle tension
a. Heightened concentration
b. Hyperactive bowel sounds
b. Decreased perceptual field
c. Decreased urine output
c. Decreased cardiac rate
d. Constipation
d. Decreased respiratory rate
23. Which of the following drugs have been d. Helping the client identify and express
known to be feelings of

effective in treating obsessive-compulsive anxiety and anger

disorder
514
(OCD)?
514
a. Divalproex (depakote) and Lithium (lithobid)
26. Rosana is in the second stage of Alzheimer’s
b. Chlordiazepoxide (Librium) and diazepam disease
(valium)
who appears to be in pain. Which question by
c. Fluvoxamine (Luvox) and clomipramine Nurse
(anafranil)
Jenny would best elicit information about the
d. Benztropine (Cogentin) and diphenhydramine pain?

(benadryl) a. “Where is your pain located?”

24. Tony with agoraphobia has been symptom- b. “Do you hurt? (pause) “Do you hurt?”
free for 4
c. “Can you describe your pain?”
months. Classic signs and symptoms of phobia
d. “Where do you hurt?”
include:
27. Nursing preparation for a client undergoing
a. Severe anxiety and fear
electroconvulsive therapy (ECT) resemble those
b. Withdrawal and failure to distinguish reality used
from
for:
fantasy
a. General anesthesia
c. Depression and weight loss
b. Cardiac stress testing
d. Insomnia and inability to concentrate
c. Neurologic examination
25. Which nursing action is most appropriate
d. Physical therapy
when
28. Jose who is receiving monoamine oxidase
trying to diffuse a client’s impending violent
inhibitor
behavior?
antidepressant should avoid tyramine, a
a. Place the client in seclusion compound

b. Leaving the client alone until he can talk found in which of the following foods?
about his
a. Figs and cream cheese
feelings
b. Fruits and yellow vegetables
c. Involving the client in a quiet activity to divert
c. Aged cheese and Chianti wine
attention
d. Green leafy vegetables a. Suspiciousness, dilated pupils and incomplete
BP
29. Erlinda, age 85, with major depression
b. Agitation, hyperactivity and grandiose
undergoes a sixth electroconvulsive therapy
ideation
(ECT)
c. Combativeness, sweating and confusion
treatment. When assessing the client
immediately d. Emotional lability, euphoria and impaired
memory
after ECT, the nurse expects to find:
32. Discharge instructions for a male client
a. Permanent short-term memory loss and
receiving
hypertension
tricyclic antidepressants include which of the
b. Permanent long-term memory loss and
following information?
hypomania
a. Restrict fluids and sodium intake
c. Transitory short-term memory loss and
b. Don’t consume alcohol
permanent
c. Discontinue if dry mouth and blurred vision
long-term memory loss
occur
d. Transitory short and long term memory loss
d. Restrict fluid and sodium intake
and
33. Important teaching for women in their
confusion
childbearing
30. Barbara with bipolar disorder is being
years who are receiving antipsychotic
treated with
medications
lithium for the first time. Nurse Clint should
includes which of the following?
observe
a. Increased incidence of dysmenorrhea while
the client for which common adverse effect of
taking
lithium?
the drug
a. Polyuria
b. Occurrence of incomplete libido due to
b. Seizures
medication adverse effects
c. Constipation
c. Continuing previous use of contraception
d. Sexual dysfunction during

31. Nurse Fred is assessing a client who has just periods of amenorrhea
been
d. Instruction that amenorrhea is irreversible
admitted to the ER department. Which signs
34. A client refuses to remain on psychotropic
would
medications after discharge from an inpatient
suggest an overdose of an antianxiety agent?
psychiatric unit. Which information should the cope with life. Psychiatric care in this treatment
plan
community health nurse assess first during the
initial is based on which framework?

follow-up with this client? a. Behavioral framework

a. Income level and living arrangements b. Cognitive framework

b. Involvement of family and support systems c. Interpersonal framework

c. Reason for inpatient admission d. Psychodynamic framework

d. Reason for refusal to take medications 38. A nurse who explains that a client’s
psychotic
35. The nurse understands that the therapeutic
effects behavior is unconsciously motivated
understands
of typical antipsychotic medications are
associated that the client’s disordered behavior arises from

with which neurotransmitter change? which of the following?

a. Decreased dopamine level a. Abnormal thinking

b. Increased acetylcholine level b. Altered neurotransmitters

c. Stabilization of serotonin c. Internal needs

d. Stimulation of GABA 515

36. Which of the following best explains why 515

tricyclic
d. Response to stimuli
antidepressants are used with caution in elderly
39. A client with depression has been
patients? hospitalized for

a. Central Nervous System effects treatment after taking a leave of absence from
work.
b. Cardiovascular system effects
The client’s employer expects the client to
c. Gastrointestinal system effects
return to
d. Serotonin syndrome effects
work following inpatient treatment. The client
37. A client with depressive symptoms is given tells

prescribed medications and talks with his the nurse, “I’m no good. I’m a failure”.
therapist According to

about his belief that he is worthless and unable cognitive theory, these statements reflect:
to
a. Learned behavior

b. Punitive superego and decreased self-esteem

c. Faulty thought processes that govern c. The client makes statements of self-
behavior satisfaction

d. Evidence of difficult relationships in the work d. The client’s statements indicate no remorse
for
environment
behaviors
40. The nurse describes a client as anxious.
Which of the 43. The nurse is caring for a client with an
autoimmune
following statement about anxiety is true?
disorder at a medical clinic, where alternative
a. Anxiety is usually pathological
medicine is used as an adjunct to traditional
b. Anxiety is directly observable
therapies. Which information should the nurse
c. Anxiety is usually harmful
teach
d. Anxiety is a response to a threat
the client to help foster a sense of control over
41. A client with a phobic disorder is treated by his

systematic desensitization. The nurse symptoms?

understands
a. Pathophysiology of disease process
that this approach will do which of the
b. Principles of good nutrition
following?
c. Side effects of medications
a. Help the client execute actions that are feared
d. Stress management techniques
b. Help the client develop insight into irrational
fears 44. Which of the following is the most
distinguishing
c. Help the client substitutes one fear for
another feature of a client with an antisocial personality

d. Help the client decrease anxiety disorder?

42. Which client outcome would best indicate a. Attention to detail and order
successful
b. Bizarre mannerisms and thoughts
treatment for a client with an antisocial
c. Submissive and dependent behavior
personality
d. Disregard for social and legal norms
disorder?
45. Which nursing diagnosis is most appropriate
a. The client exhibits charming behavior when
for a
around authority figures
client with anorexia nervosa who expresses
b. The client has decreased episodes of feelings
impulsive
of guilt about not meeting family expectations?
behaviors
a. Anxiety
b. Disturbed body image problem areas to staff or peers since admission
to a
c. Defensive coping
psychiatric unit. Which activity should the nurse
d. Powerlessness
recommend to help this client express himself?
46. A nurse is evaluating therapy with the family
of a a. Art therapy in a small group

client with anorexia nervosa. Which of the b. Basketball game with peers on the unit
following
c. Reading a self-help book on depression
would indicate that the therapy was successful?
d. Watching movie with the peer group
a. The parents reinforced increased decision
49. The home health psychiatric nurse visits a
making
client with
by the client
chronic schizophrenia who was recently
b. The parents clearly verbalize their discharged
expectations
after a prolong stay in a state hospital. The client
for the client
lives in a boarding home, reports no family
c. The client verbalizes that family meals are
involvement, and has little social interaction.
now
The
enjoyable
nurse plan to refer the client to a day treatment
d. The client tells her parents about feelings of
program in order to help him with:
lowself
a. Managing his hallucinations
esteem
b. Medication teaching
47. A client with dysthymic disorder reports to a
nurse c. Social skills training
that his life is hopeless and will never improve in d. Vocational training
the
50. Which activity would be most appropriate
future. How can the nurse best respond using a for a
cognitive approach? severely withdrawn client?
a. Agree with the client’s painful feelings a. Art activity with a staff member
b. Challenge the accuracy of the client’s belief b. Board game with a small group of clients
c. Deny that the situation is hopeless c. Team sport in the gym
d. Present a cheerful attitude d. Watching TV in the dayroom
48. A client with major depression has not 516
verbalized
516 the staff and the hospital because she is unable
to
ANSWERS and RATIONALES for PSYCHIATRIC
deal with the abortion at this time.
NURSING Part 3
8. A. Personal internal strength and supportive
1. B. There is no set of symptoms associated
with individuals are critical factors that can be
employed
cocaine withdrawal, only the depression that
follows to assist the individual to cope with a crisis.

the high caused by the drug. 9. D. Crisis intervention group helps client
reestablish
2. A. Cocaine is a chemical that when inhaled,
causes psychologic equilibrium by assisting them to
explore
destruction of the mucous membranes of the
nose. new alternatives for coping. It considers realistic

3. D. These adaptations are associated with situations using rational and flexible problem
opiate solving

withdrawal which occurs after cessation or methods.

reduction
10. C. This would document that the client feels
of prolonged moderate or heavy use of opiates.
comfortable enough to discuss the problems
4. B. Whether there is a suicide plan is a that
criterion when
have motivated the behavior.
assessing the client’s determination to make
11. C. The most successful therapy for people
another
with
attempt.
phobias involves behavior modification
5. A. Rapists are believed to harbor and act out techniques
hostile
using desensitization.
feelings toward all women through the act of
12. A. Perceptual field is a key indicator of
rape.
anxiety level
6. C. These children often have nonsexual needs
because the perceptual fields narrow as anxiety
met
increases.
by individual and are powerless to refuse.
13. D. One of the symptoms of autistic child
Ambivalence results in self-blame and also guilt.
displays a
7. B. The client’s anger over the abortion is
lack of responsiveness to others. There is little
shifted to
or no

extension to the external environment.

14. B. Somatic delusions focus on bodily 19. B. Panic is the most severe level of anxiety.
functions or During

systems and commonly include delusion about panic attack, the client experiences a decrease
foul in the

odor emissions, insect manifestations, internal perceptual field, becoming more focused on
self,
parasites and misshapen parts.
less aware of surroundings and unable to
15. D. A client with borderline personality
process
displays a
information from the environment. The
pervasive pattern of unpredictable behavior,
decreased
mood
perceptual field contributes to impaired
and self image. Interpersonal relationships may
attention
be
and inability to concentrate.
intense and unstable and behavior may be
20. A. The emergency nurse must establish
inappropriate and impulsive.
rapport and
16. A. Propranolol is a potent beta adrenergic
trust with the anxious client before using
blocker
therapeutic
and producing a sedating effect, therefore it is
touch. Touching an anxious client may actually
used
increase anxiety.
to treat antipsychotic induced akathisia and
anxiety. 21. D. Diarrhea is a common physiological
response to
17. B. Amantadine is an anticholinergic drug
used to stress and anxiety.

relive drug-induced extra pyramidal adverse 22. B. The parasympathetic nervous system
effects would

such as muscle weakness, involuntary muscle produce incomplete G.I. motility resulting in

movements, pseudoparkinsonism and tar dive hyperactive bowel sounds, possibly leading to

dyskinesia. diarrhea.

18. C. MAOI antidepressants when combined 23. C. The antidepressants fluvoxamine and
with a
clomipramine have been effective in the
number of drugs can cause life-threatening treatment

hypertensive crisis. It’s imperative that a client of OCD.

checks with his physician and pharmacist before 24. A. Phobias cause severe anxiety (such as
panic
taking any other medications.
attack) that is out of proportion to the threat of 29. D. ECT commonly causes transitory short
the and long

feared object or situation. Physical signs and term memory loss and confusion, especially in

symptoms of phobias include profuse sweating, geriatric clients. It rarely results in permanent
poor short

motor control, tachycardia and elevated B.P. and long term memory loss.

25. D. In many instances, the nurse can diffuse 30. A. Polyuria commonly occurs early in the
treatment
impending violence by helping the client
identify and with lithium and could result in fluid volume
deficit.
express feelings of anger and anxiety. Such
31. D. Signs of anxiety agent overdose include
statement as “What happened to get you this
emotional
angry?” may help the client verbalizes feelings
lability, euphoria and impaired memory.
rather
32. B. Drinking alcohol can potentiate the
than act on them.
sedating
26. B. When speaking to a client with
action of tricyclic antidepressants. Dry mouth
Alzheimer’s
and
disease, the nurse should use close-ended
blurred vision are normal adverse effects of
questions.
tricyclic
Those that the client can answer with “yes” or
antidepressants.
“no”
33. C. Women may experience amenorrhea,
whenever possible and avoid questions that
which is
require
reversible, while taking antipsychotics.
the client to make choices. Repeating the
Amenorrhea
question
doesn’t indicate cessation of ovulation thus, the
aids comprehension.
client can still be pregnant.
27. A. The nurse should prepare a client for ECT
in a 34. D. The first are for assessment would be the
client’s
manner similar to that for general anesthesia.
reason for refusing medication. The client may
517
not
517
understand the purpose for the medication,
28. C. Aged cheese and Chianti wine contain may be
high
experiencing distressing side effects, or may be
concentrations of tyramine.
concerned about the cost of medicine. In any increased risk factors for cardiac problems
case, because

the nurse cannot provide appropriate of their age and other medical conditions. The
intervention
remaining side effects would apply to any client
before assessing the client’s problem with the
taking a TCA and are not particular to an elderly
medication. The patient’s income level, living
person.
arrangements, and involvement of family and
37. B. Cognitive thinking therapy focuses on the
support systems are relevant issues following client’s

determination of the client’s reason for refusing misperceptions about self, others and the world
that
medication. The nurse providing follow-up care
impact functioning and contribute to symptoms.
would have access to the client’s medical record
and Using medications to alter neurotransmitter
activity
should already know the reason for inpatient
is a psychobiologic approach to treatment. The
admission.
other
35. A. Excess dopamine is thought to be the
answer choices are frameworks for care, but hey
chemical
are
cause for psychotic thinking. The typical
not applicable to this situation.
antipsychotics act to block dopamine receptors
38. C. The concept that behavior is motivated
and
and has
therefore decrease the amount of
meaning comes from the psychodynamic
neurotransmitter
framework. According to this perspective,
at the synapses. The typical antipsychotics do
behavior
not
arises from internal wishes or needs. Much of
increase acetylcholine, stabilize serotonin,
what
stimulate
motivates behavior comes from the
GABA.
unconscious.
36. B. The TCAs affect norepinephrine as well as
The remaining responses do not address the
other
internal
neurotransmitters, and thus have significant
forces thought to motivate behavior.
cardiovascular side effects. Therefore, they are
39. C. The client is demonstrating faulty thought
used
processes that are negative and that govern his
with caution in elderly clients who may have
behavior in his work situation – issues that are
typically examined using a cognitive theory part of the phobic response.

approach. Issues involving learned behavior are 42. B. A client with antisocial personality
best disorder

explored through behavior theory, not cognitive typically has frequent episodes of acting
impulsively
theory. Issues involving ego development are
the with poor ability to delay self-gratification.

focus of psychoanalytic theory. Option 4 is Therefore, decreased frequency of impulsive

incorrect
behaviors would be evidence of improvement.
because there is no evidence in this situation
Charming behavior when around authority
that
figures
the client has conflictual relationships in the
and statements indicating no remorse are
work
examples
environment.
of symptoms typical of someone with this
40. D. Anxiety is a response to a threat arising disorder
from
and would not indicate successful treatment.
internal or external stimuli. Selfsatisfaction

41. A. Systematic desensitization is a behavioral would be viewed as a positive change if

therapy
the client expresses low self-esteem; however
technique that helps clients with irrational fears this is
and
not a characteristic of a client with antisocial
avoidance behavior to face the thing they fear,
personality disorder.
without experiencing anxiety. There is no
43. D. In autoimmune disorders, stress and the
attempt to
response
promote insight with this procedure, and the
to stress can exacerbate symptoms. Stress
client
management techniques can help the client
will not be taught to substitute one fear for
reduce
another.
the psychological response to stress, which in
Although the client’s anxiety may decrease with
turn
successful confrontation of irrational fears, the
518
purpose of the procedure is specifically related
518
to
will help reduce the physiologic stress response.
performing activities that typically are avoided
This
as
will afford the client an increased sense of 46. A. One of the core issues concerning the
control family of a

over his symptoms. The nurse can address the client with anorexia is control. The family’s

remaining answer choices in her teaching about acceptance of the client’s ability to make
the
independent decisions is key to successful
client’s disease and treatment; however, family
knowledge
intervention. Although the remaining options
alone will not help the client to manage his may
stress
occur during the process of therapy, they would
effectively enough to control symptoms. not

44. D. Disregard for established rules of society necessarily indicate a successful outcome; the
is the
central family issues of dependence and
most common characteristic of a client with
independence are not addresses on these
antisocial personality disorder. Attention to responses.
detail
47. B. Use of cognitive techniques allows the
and order is characteristic of someone with nurse to

obsessive compulsive disorder. Bizarre help the client recognize that this negative
mannerisms beliefs

and thoughts are characteristics of a client with may be distortions and that, by changing his

schizoid or schizotypal disorder. Submissive and thinking, he can adopt more positive beliefs that
are
dependent behaviors are characteristic of
someone realistic and hopeful. Agreeing with the client’s

with a dependent personality. feelings and presenting a cheerful attitude are

not
45. D. The client with anorexia typically feels
powerless, consistent with a cognitive approach and would
not
with a sense of having little control over any
aspect be helpful in this situation. Denying the client’s

of life besides eating behavior. Often, parental feelings is belittling and may convey that the
nurse
expectations and standards are quite high and
lead does not understand the depth of the client’s

to the clients’ sense of guilt over not measuring distress.

up.
48. A. Art therapy provides a nonthreatening
vehicle for
the expression of feelings, and use of a small generally takes place in a rehabilitation facility;
group the

will help the client become comfortable with client described in this situation would not be a
peers
candidate for this service.
in a group setting. Basketball is a competitive
50. A. The best approach with a withdrawn
game
client is to
that requires energy; the client with major
initiate brief, nondemanding activities on a one-
depression is not likely to participate in this toone
activity.
basis. This approach gives the nurse an
Recommending that the client read a self-help
opportunity to establish a trusting relationship
book
with
may increase, not decrease his isolation.
the client. A board game with a group clients or
Watching
playing a team sport in the gym may overwhelm
movie with a peer group does not guarantee
a
that
severely withdrawn client. Watching TV is a
interaction will occur; therefore, the client may
solitary
remain isolated.
activity that will reinforce the client’s
49. C. Day treatment programs provide clients withdrawal
with
from others.
chronic, persistent mental illness training in
519
social
519
skills, such as meeting and greeting people,
asking PROFESSIONAL ADJUSTMENT
questions or directions, placing an order in a 1. A nurse who would like to practice nursing in
the
restaurant, taking turns in a group setting
activity. Philippines can obtain a license to practice by:
Although management of hallucinations and A. Paying the professional tax after taking the
board
medication teaching may also be part of the
exams
program offered in a day treatment, the nurse is
B. Passing the board exams and taking the oath
referring the client in this situation because of
of
his
professionals
need for socialization skills. Vocational training
C. Paying the examination fee before taking the
board
exams Answer: (A) The country of origin has similar
preparation
D. Undergoing the interview conducted by the
Board of for a nurse and has laws allowing Filipino nurses
to
Nursing and taking the board exams
practice in their country.
Answer: (B) Passing the board exams and taking
the oath According to the Philippine Nurses Act of 2002,
foreign
of professionals
nurses wanting to practice in the Philippines
For a nurse to obtain a license to practice
must show
nursing in the
proof that his/her country of origin meets the
Philippines, s/he must pass the board
two
examinations and
essential conditions: a) the requirements for
then take the oath of professionals before the
registration
Board of
between the two countries are substantially the
Nursing.
same;
2. Reciprocity of license to practice requires that
and b) the country of origin of the foreign nurse
the
has laws
country of origin of the interested foreign nurse
allowing the Filipino nurse to practice in his/her
complies with the following conditions: country

A. The country of origin has similar preparation just like its own citizens.
for a
3. Nurses practicing the profession in the
nurse and has laws allowing Filipino nurses to Philippines and
practice in
are employed in government hospitals are
their country. required to

B. The Philippines is recognized by the country pay taxes such as:

of origin
A. Both income tax and professional tax
as one that has high quality of nursing
B. Income tax only since they are exempt from
education
paying
C. The country of origin requires Filipinos to take
professional tax
their
C. Professional tax which is paid by all nurses
own board examination
employed
D. The country of origin exempts Filipinos from
in both government and private hospitals
passing
D. Income tax which paid every March 15 and
their licensure examination
professional tax which is paid every January 31. Answer: (D) Filipino citizen or a citizen of a
country
Answer: (B) Income tax only since they are
exempt from where we have reciprocity; graduate of BSN
from a
paying professional tax
recognized school and of good moral character
According to the Magna Carta for Public Health
Workers, RA 9173 section 13 states that the qualifications
to take
government nurses are exempted from paying
the board exams are: Filipino citizen or citizen of
professional tax. Hence, as an employee in the
a
government, s/he will pay only the income tax.
country where the Philippines has reciprocity; of
4. According to RA 9173 Philippine Nursing Act good
of 2002, a
moral character and graduate of BSN from a
graduate nurse who wants to take must recognized
licensure
school of nursing. There is no explicit provision
examination must comply with the following about the

qualifications: age requirement in RA 9173 unlike in RA7164

(old law).
A. At least 21 years old, graduate of BSN from a
5. Which of the following is TRUE about
recognized school, and of good moral character membership to
B. At least 18 years old, graduate of BSN from a the Philippine Nurses Association (PNA)?
recognized school and of good moral character A. Membership to PNA is mandatory and is
C. At least 18 years old, provided that when s/he stipulated in
passes the Philippine Nursing Act of 2002
the board exams, s/he must be at least 21 years B. Membership to PNA is compulsory for newly
old; BSN
registered nurses wanting to enter the practice
graduate of a recognized school, and of good of
moral
nursing in the country
character
C. Membership to PNA is voluntary and is
D. Filipino citizen or a citizen of a country where encouraged by
we have
the PRC Code of Ethics for Nurses
reciprocity; graduate of BSN from a recognized
school D. Membership to PNA is required by
government
and of good moral character
hospitals prior to employment
Answer: (C) Membership to PNA is voluntary Answer: (C) May apply for re-issuance of his/her
and is license

encouraged by the PRC Code of Ethics for based on certain conditions stipulated in RA
Nurses 9173

Membership to any organization, including the RA 9173 sec. 24 states that for equity and
PNA, is justice, a

520 revoked license maybe re-issued provided that

the
520
following conditions are met: a) the cause for
only voluntary and this right to join any
revocation
organization is
of license has already been corrected or
guaranteed in the 1987 constitution of the
removed; and,
Philippines.
b) at least four years has elapsed since the
However, the PRC Code of Ethics states that one
license has
of the
been revoked.
ethical obligations of the professional nurse
towards the 7. According to the current nursing law, the
minimum
profession is to be an active member of the
accredited educational qualification for a faculty member
of a
professional organization.
college of nursing is:
6. When the license of the nurse is revoked, it
means A. Only a Master of Arts in Nursing is acceptable

that the nurse: B. Masters degree in Nursing or in the related

fields
A. Is no longer allowed to practice the
profession for the C. At least a doctorate in nursing

rest of her life D. At least 18 units in the Master of Arts in

Nursing
B. Will never have her/his license re-issued since
it has Program

been revoked Answer: (B) Masters degree in Nursing or in the

related
C. May apply for re-issuance of his/her license
based on fields

certain conditions stipulated in RA 9173 According to RA 9173 sec. 27, the educational

D. Will remain unable to practice professional qualification of a faculty member teaching in a

nursing college of
nursing must be masters degree which maybe in govern the practice of nursing
nursing
B. The Board can investigate violations of the
or related fields like education, allied health nursing law
professions,
and code of ethics
psychology.
C. The Board can visit a school applying for a
8. The educational qualification of a nurse to permit in
become a
collaboration with CHED
supervisor in a hospital is:
D. The Board prepares the board examinations
A. BSN with at least 9 units of post graduate
Answer: (B) The Board can investigate violations
studies in
of the
nursing administration
nursing law and code of ethics
B. Master of Arts in Nursing major in
Quasi-judicial power means that the Board of
administration
Nursing
C. At least 2 years experience as a headnurse
has the authority to investigate violations of the
D. At least 18 units of post graduate studies in nursing
nursing
law and can issue summons, subpoena or
administration subpoena

Answer: (A) BSN with at least 9 units of post duces tecum as needed.
graduate
10. When a nurse causes an injury to the patient
studies in nursing administration and the

According to RA 9173 sec. 29, the educational injury caused becomes the proof of the
negligent act,
qualification to be a supervisor in a hospital is at
least 9 the presence of the injury is said to exemplify
the
units of postgraduate studies in nursing
administration. principle of:

A masters degree in nursing is required for the A. Force majeure

chief
B. Respondeat superior
nurse of a secondary or tertiary hospital.
C. Res ipsa loquitur
9. The Board of Nursing has quasi-judicial
D. Holdover doctrine
power. An
Answer: (C) Res ipsa loquitur
example of this power is:
Res ipsa loquitur literally means the thing
A. The Board can issue rules and regulations
speaks for
that will
itself. This means in operational terms that the doing any action that will cause the patient
injury harm. This is

caused is the proof that there was a negligent the meaning of the bioethical principle:
act.
A. Non-maleficence
11. Ensuring that there is an informed consent
B. Beneficence
on the
C. Justice
part of the patient before a surgery is done,
illustrates D. Solidarity
the bioethical principle of: Answer: (A) Non-maleficence
A. Beneficence Non-maleficence means do not cause harm or
do any
B. Autonomy
action that will cause any harm to the
C. Truth telling/veracity
patient/client. To
D. Non-maleficence
do good is referred as beneficence.
Answer: (B) Autonomy
13. When the patient is asked to testify in court,
Informed consent means that the patient fully s/he

understands what will be the surgery to be must abide by the ethical principle of:
done, the
A. Privileged communication
risks involved and the alternative solutions so
B. Informed consent
that when
C. Solidarity
s/he give consent it is done with full knowledge
and is D. Autonomy
521 Answer: (A) Privileged communication
521 All confidential information that comes to the
given freely. The action of allowing the patient knowledge of the nurse in the care of her/his
to decide patients is
whether a surgery is to be done or not considered privileged communications. Hence,
exemplifies the s/he is
bioethical principle of autonomy. not allowed to just reveal the confidential
information
12. When a nurse is providing care to her/his
patient, arbitrarily. S/he may only be allowed to break
the seal of
s/he must remember that she is duty bound not
to do secrecy in certain conditions. One such
condition is when
the court orders the nurse to testify in a criminal means that the nurse is still duty bound to give
or the basic

medico-legal case. nursing care to the terminally ill patient and

ensure that
14. When the doctor orders “do not
resuscitate”, this the spiritual needs of the patient is taken cared
of.
means that
15. Which of the following statements is TRUE
A. The nurse need not give due care to the
of
patient since
abortion in the Philippines?
s/he is terminally ill
A. Induced abortion is allowed in cases of rape
B. The patient need not be given food and water
and
after all
incest
s/he is dying
B. Induced abortion is both a criminal act and an
C. The nurses and the attending physician
should not do unethical act for the nurse

any heroic or extraordinary measures for the C. Abortion maybe considered acceptable if the
patient mother

D. The patient need not be given ordinary care is unprepared for the pregnancy
so that
D. A nurse who performs induced abortion will
her/his dying process is hastened have no

Answer: (C) The nurses and the attending legal accountability if the mother requested that
physician the

should not do any heroic or extraordinary abortion done on her.

measures for
Answer: (B) Induced abortion is both a criminal
the patient act and

Do not resuscitate” is a medical order which is an unethical act for the nurse
written
Induced abortion is considered a criminal act
on the chart after the doctor has consulted the which is
family
punishable by imprisonment which maybe up to
and this means that the members of the health a
team are
maximum of 12 years if the nurse gets paid for
not required to give extraordinary measures but it. Also,
cannot
the PRC Code of Ethics states that the nurse
withhold the basic needs like food, water, and must
air. It also
respect life and must not do any action that will a country club where every one is happy
destroy including the

life. Abortion is an act that destroys life albeit at manager.

the
2. Her former manager demonstrated passion
beginning of life. for serving

522 her staff rather than being served. She takes

time to
522
listen, prefers to be a teacher first before being
LEADERSHIP and MANAGEMENT
a leader,
1. Ms. Castro is newly-promoted to a patient
which is characteristic of
care
A. Transformational leader
manager position. She updates her knowledge
on the B. Transactional leader

theories in management and leadership in order C. Servant leader

to
D. Charismatic leader
become effective in her new role. She learns
Answer: (C) Servant leader
that some
Servant leaders are open-minded, listen deeply,
managers have low concern for services and
try to
high
fully understand others and not being
concern for staff. Which style of management
judgmental
refers to
3. On the other hand, Ms. Castro notices that
this?
the Chief
A. Organization Man
Nurse Executive has charismatic leadership
B. Impoverished Management style. Which

C. Country Club Management of the following behaviors best describes this

style?
D. Team Management
A. Possesses inspirational quality that makes
Answer: (C) Country Club Management
followers
Country club management style puts concern
gets attracted of him and regards him with
for the
reverence
staff as number one priority at the expense of
B. Acts as he does because he expects that his
the
behavior
delivery of services. He/she runs the
will yield positive results
department just like
C. Uses visioning as the core of his leadership
D. Matches his leadership style to the situation would make him become a good manager. It can
at hand. only

Answer: (A) Possesses inspirational quality that predict a manager’s potential of becoming a
makes good one.

followers gets attracted of him and regards him 5. She reads about Path Goal theory. Which of
with the

reverence following behaviors is manifested by the leader

who uses
Charismatic leaders make the followers feel at
ease in this theory?

their presence. They feel that they are in good A. Recognizes staff for going beyond
hands expectations by

whenever the leader is around. giving them citations

4. Which of the following conclusions of Ms. B. Challenges the staff to take individual
Castro accountability

about leadership characteristics is TRUE? for their own practice

A. There is a high correlation between the C. Admonishes staff for being laggards.

communication skills of a leader and the ability D. Reminds staff about the sanctions for non
to get
performance.
the job done.
Answer: (A) Recognizes staff for going beyond
B. A manager is effective when he has the ability
expectations by giving them citations
to plan
Path Goal theory according to House and
well.
associates
C. Assessment of personal traits is a reliable tool
rewards good performance so that others would
for
do the
predicting a manager’s potential.
same
D. There is good evidence that certain personal
6. One leadership theory states that “leaders
qualities
are born
favor success in managerial role.
and not made,” which refers to which of the
Answer: (C) Assessment of personal traits is a following
reliable
theories?
tool for predicting a manager’s potential.
A. Trait
It is not conclusive that certain qualities of a
B. Charismatic
person
C. Great Man practice in some magnet hospitals. Which of the

D. Situational following describes this style of leadership?

Answer: (C) Great Man A. Leadership behavior is generally determined

by the
Leaders become leaders because of their birth
right. This relationship between the leader’s personality
and the
is also called Genetic theory or the Aristotelian
theory specific situation

7. She came across a theory which states that B. Leaders believe that people are basically
the good and

leadership style is effective dependent on the need not be closely controlled

situation.
C. Leaders rely heavily on visioning and inspire
Which of the following styles best fits a situation members
when
to achieve results
the followers are self-directed, experts and
D. Leadership is shared at the point of care.
arematured
Answer: (D) Leadership is shared at the point of
individuals?
care.
523
Shared governance allows the staff nurses to
523 have the

A. Democratic authority, responsibility and accountability for

their own
B. Authoritarian
practice.
C. Laissez faire
9. Ms. Castro learns that some leaders are
D. Bureaucratic
transactional
Answer: (C) Laissez faire
leaders. Which of the following does NOT
Laissez faire leadership is preferred when the characterize a
followers
transactional leader?
know what to do and are experts in the field.
A. Focuses on management tasks
This
B. Is a caretaker
leadership style is relationship-oriented rather
than taskcentered. C. Uses trade-offs to meet goals

8. She surfs the internet for more information D. Inspires others with vision
about
Answer: (D) Inspires others with vision
leadership styles. She reads about shared
Inspires others with a vision is characteristic of a
leadership as a
transformational leader. He is focused more on A. Call for a staff meeting and take this up in the
the dayto- agenda.

day operations of the department/unit. B. Seek help from her manager.

10. She finds out that some managers have C. Develop a strategic action on how to deal
benevolentauthoritative with these

style of management. Which of the concerns.

following behaviors will she exhibit most likely? D. Ignore the issues since these will be resolved

A. Have condescending trust and confidence in naturally.

their
Answer: (A) Call for a staff meeting and take this
subordinates up in

B. Gives economic or ego awards the agenda.

C. Communicates downward to the staff This will allow for the participation of every staff
in the
D. Allows decision making among subordinates
unit. If they contribute to the solutions of the
Answer: (A) Have condescending trust and
problem,
confidence in
they will own the solutions; hence the chance
their subordinates
for
Benevolent-authoritative managers
compliance would be greater.
pretentiously show
12. She knows that there are external forces
their trust and confidence to their followers
that
11. Harry is a Unit Manager I the Medical Unit.
influence changes in his unit. Which of the
He is not
following is
satisfied with the way things are going in his
NOT an external force?
unit. Patient
A. Memo from the CEO to cut down on
satisfaction rate is 60% for two consecutive
electrical
months and
consumption
staff morale is at its lowest. He decides to plan
and B. Demands of the labor sector to increase
wages
initiate changes that will push for a turnaround
in the C. Low morale of staff in her unit

condition of the unit. Which of the following D. Exacting regulatory and accreditation
actions is a standards

priority for Harry? Answer: (C) Low morale of staff in her unit
Low morale of staff is an internal factor that D. rules to be followed
affects only
Answer: (B) system used to deliver care
the unit. All the rest of the options emanate
A system used to deliver care. In the 70’s it was
from the
termed
top executive or from outside the institution.
as methods of patient assignment; in the early
13. After discussing the possible effects of the 80’s it
low
was called modalities of patient care then
patient satisfaction rate, the staff started to list patterns of
down
nursing care in the 90’s until recently authors
possible strategies to solve the problems head- called it
on.
nursing care systems.
Should they decide to vote on the best change
15. Which of the following is TRUE about
strategy,
functional
which of the following strategies is referred to
nursing?
this?
A. Concentrates on tasks and activities
A. Collaboration
B. Emphasizes use of group collaboration
B. Majority rule
C. One-to-one nurse-patient ratio
C. Dominance
D. Provides continuous, coordinated and
D. Compromise
comprehensive
Answer: (B) Majority rule
nursing services
Majority rule involves dividing the house and
Answer: (A) Concentrates on tasks and activities
the highest
Functional nursing is focused on tasks and
524
activities and
524
not on the holistic care of the patients
vote wins.1/2 + 1 is a majority.
16. Functional nursing has some advantages,
14. One staff suggests that they review the which one
pattern of
is an EXCEPTION?
nursing care that they are using, which is
A. Psychological and sociological needs are
described as a
emphasized.
A. job description
B. Great control of work activities.
B. system used to deliver care
C. Most economical way of delivering nursing
C. manual of procedure services.
D. Workers feel secure in dependent role B. Preparing a nursing care plan in collaboration
with the
Answer: (A) Psychological and sociological needs
are patient

emphasized. C. Consulting with the physician

When the functional method is used, the D. Coordinating with other members of the
psychological team

and sociological needs of the patients are Answer: (B) Preparing a nursing care plan in
neglected; the
collaboration with the patient
patients are regarded as ‘tasks to be done ‘
The best source of information about the
17. He raised the issue on giving priority to priority needs
patient
of the patient is the patient himself. Hence using
needs. Which of the following offers the best a
way for
nursing care plan based on his expressed
setting priority? priority needs

A. Assessing nursing needs and problems would ensure meeting his needs effectively.

B. Giving instructions on how nursing care needs 19. When Harry uses team nursing as a care
are to delivery

be met system, he and his team need to assess the

priority of
C. Controlling and evaluating the delivery of
nursing care care for a group of patients, which of the
following
D. Assigning safe nurse: patient ratio
should be a priority?
Answer: (A) Assessing nursing needs and
problems A. Each patient as listed on the worksheet

This option follows the framework of the B. Patients who needs least care
nursing process
C. Medications and treatments required for all
at the same time applies the management patients
process of
D. Patients who need the most care
planning, organizing, directing and controlling
Answer: (D) Patients who need the most care
18. Which of the following is the best guarantee
In setting priorities for a group of patients, those
that the
who
patient’s priority needs are met?
need the most care should be number-one
A. Checking with the relative of the patient priority to
ensure that their critical needs are met 525
adequately. The
located within the heart of the metropolis. He
needs of other patients who need less care ca thinks of
be
scheduling planning workshop with his staff in
attended to later or even delegated to assistive order to

personnel according to rules on delegation. ensure an effective and efficient management of

the
20. She is hopeful that her unit will make a big
department. Should he decide to conduct a
turnaround in the succeeding months. Which of
strategic
the
planning workshop, which of the following is
following actions of Harry demonstrates that he
NOT a
has
characteristic of this activity?
reached the third stage of change?
A. Long-term goal-setting
A. Wonders why things are not what it used to
be B. Extends to 3-5 years in the future

B. Finds solutions to the problems C. Focuses on routine tasks

C. Integrate the solutions to his day-to-day D. Determines directions of the organization

activities
Answer: (C) Focuses on routine tasks
D. Selects the best change strategy
Strategic planning involves options A, B and D
Answer: (C) Integrate the solutions to his day-to- except C
day
which is attributed to operational planning
activities
22. Which of the following statements refer to
Integrate the solutions to his day-to-day the vision
activities is a
of the hospital?
expected to happen during the third stage of
A. The Good Shepherd Medical Center is a
change
trendsetter in
when the change agent incorporate the selected
tertiary health care in the Philippines in the next
solutions to his system and begins to create a five
change.
years
21. Julius is a newly-appointed nurse manager
B. The officers and staff of The Good Shepherd
of The
Medical
Good Shepherd Medical Center, a tertiary
Center believe in the unique nature of the
hospital
human person
525
C. All the nurses shall undergo continuing will likely depict this organizational relationship?
competency
A. Box
training program.
B. Solid line
D. The Good Shepherd Medical Center aims to
C. Broken line
provide a
D. Dotted line
patient-centered care in a total healing
environment. Answer: (C) Broken line
Answer: (A) The Good Shepherd Medical Center This is a staff relationship hence it is depicted by
is a a
trendsetter in tertiary health care in the broken line in the organizational structure
Philippines in
25. He likewise stresses the need for all the
the next five years employees
A vision refers to what the institution wants to to follow orders and instructions from him and
become not from
within a particular period of time. anyone else. Which of the following principles
does he
23. The statement, “The Good Shepherd
Medical Center refer to?
aims to provide patient-centered care in a total A. Scalar chain
healing
B. Discipline
environment” refers to which of the following?
C. Unity of command
A. Vision
D. Order
B. Goal
Answer: (C) Unity of command
C. Philosophy
The principle of unity of command means that
D. Mission
employees should receive orders coming from
Answer: (B) Goal only one
24. Julius plans to revisit the organizational manager and not from two managers. This
chart of the averts the
department. He plans to create a new position possibility of sowing confusion among the
of a members of
Patient Educator who has a coordinating the organization
relationship
26. Julius orients his staff on the patterns of
with the head nurse in the unit. Which of the reporting
following
relationship throughout the organization. Which corps’ among the members of the unit. Which
of the of the

following principles refer to this? following remarks of the staff indicates that they

A. Span of control understand what he pointed out?

B. Hierarchy 526

C. Esprit d’ corps 526

D. Unity of direction A. “Let’s work together in harmony; we need to

be
Answer: (B) Hierarchy
supportive of one another”
Hierarchy refers to the pattern of reporting or
the formal B. “In order that we achieve the same results;
we must
line of authority in an organizational structure.
all follow the directives of Julius and not from
27. He emphasizes to the team that they need
other
to put
managers.”
their efforts together towards the attainment of
the C. “We will ensure that all the resources we
need are
goals of the program. Which of the following
principles available when needed.”

refers to this? D. “We need to put our efforts together in order

to raise
A. Span of control
the bar of excellence in the care we provide to
B. Unity of direction
all our
C. Unity of command
patients.”
D. Command responsibility
Answer: (A) “Let’s work together in harmony;
Answer: (B) Unity of direction we need

Unity of direction means having one goal or one to be supportive of one another”

objective for the team to pursue; hence all The principle of ‘esprit d’ corps’ refers to
members of promoting

the organization should put their efforts harmony in the workplace, which is essential in
together
maintaining a climate conducive to work.
towards the attainment of their common goal or
29. He discusses the goal of the department.
objective. Which of

28. Julius stresses the importance of promoting the following statements is a goal?
‘esprit d
A. Increase the patient satisfaction rate following behaviors indicate that this is attained
by the
B. Eliminate the incidence of delayed
administration of group?

medications A. Proactive and caring with one another

C. Establish rapport with patients. B. Competitive and perfectionist

D. Reduce response time to two minutes. C. Powerful and oppositional

Answer: (A) Increase the patient satisfaction D. Obedient and uncomplaining

rate
Answer: (A) Proactive and caring with one
Goal is a desired result towards which efforts another
are
Positive culture is based on humanism and
directed. Options AB, C and D are all objectives affiliative
which
norms
are aimed at specific end.
32. Stephanie is a new Staff Educator of a
30. He wants to influence the customary way of private tertiary
thinking
hospital. She conducts orientation among new
and behaving that is shared by the members of staff
the
nurses in her department. Joseph, one of the
department. Which of the following terms refer new staff
to this?
nurses, wants to understand the channel of
A. Organizational chart
communication, span of control and lines of
B. Cultural network
communication. Which of the following will
C. Organizational structure provide this

D. Organizational culture information?

Answer: (D) Organizational culture A. Organizational structure

An organizational culture refers to the way the B. Policy

members
C. Job description
of the organization think together and do things
D. Manual of procedures
around
Answer: (A) Organizational structure
them together. It’s their way of life in that
organization Organizational structure provides information
on the
31. He asserts the importance of promoting a
positive channel of authority, i.e., who reports to whom
and with
organizational culture in their unit. Which of the
what authority; the number of people who 35. Centralized organizations have some
directly advantages.

reports to the various levels of hierarchy and Which of the following statements are TRUE?
the lines of
1. Highly cost-effective
communication whether line or staff.
2. Makes management easier
33. Stephanie is often seen interacting with the
3. Reflects the interest of the worker
medical
527
intern during coffee breaks and after duty
hours. What 527
type of organizational structure is this? 4. Allows quick decisions or actions.
A. Formal A. 1 & 2
B. Informal B. 2 & 4
C. Staff C. 2, 3& 4
D. Line D. 1, 2, & 4
Answer: (B) Informal Answer: (A) 1 & 2
This is usually not published and oftentimes Centralized organizations are needs only a few
concealed. managers
34. She takes pride in saying that the hospital hence they are less expensive and easier to
has a manage
decentralized structure. Which of the following 36. Stephanie delegates effectively if she has
is NOT authority
compatible with this type of model? to act, which is BEST defined as:
A. Flat organization A. having responsibility to direct others
B. Participatory approach B. being accountable to the organization
C. Shared governance C. having legitimate right to act
D. Tall organization D. telling others what to do
Answer: (D) Tall organization Answer: (C) having legitimate right to act
Tall organizations are highly centralized Authority is a legitimate or official right to give
organizations
command. This is an officially sanctioned
where decision making is centered on one responsibility
authority
37. Regardless of the size of a work group,
level. enough staff
must be available at all times to accomplish 39. Stephanie considers shifting to
certain transformational

purposes. Which of these purposes in NOT leadership. Which of the following statements
included? best

A. Meet the needs of patients describes this type of leadership?

B. Provide a pair of hands to other units as A. Uses visioning as the essence of leadership.
needed
B. Serves the followers rather than being
C. Cover all time periods adequately. served.

D. Allow for growth and development of nursing C. Maintains full trust and confidence in the
staff.
subordinates
Answer: (B) Provide a pair of hands to other
D. Possesses innate charisma that makes others
units as
feel
needed
good in his presence.
Providing a pair of hands for other units is not a
Answer: (A) Uses visioning as the essence of
purpose
leadership.
in doing an effective staffing process. This is a
Transformational leadership relies heavily on
function of
visioning as
a staffing coordinator at a centralized model.
the core of leadership.
38. Which of the following guidelines should be
40. As a manager, she focuses her energy on
least
both the
considered in formulating objectives for nursing
quality of services rendered to the patients as
care?
well as the
A. Written nursing care plan
welfare of the staff of her unit. Which of the
B. Holistic approach following

C. Prescribed standards management styles does she adopt?

D. Staff preferences A. Country club management

Answer: (D) Staff preferences B. Organization man management

Staff preferences should be the least priority in C. Team management

formulating objectives of nursing care. D. Authority-obedience management

Individual
Answer: (C) Team management
preferences should be subordinate to the
Team management has a high concern for
interest of the
services and
patients.
high concern for staff. B. Is not beneficial; hence it should be
prevented at all
41. Katherine is a young Unit Manager of the
Pediatric times

Ward. Most of her staff nurses are senior to her, C. May result in poor performance
very
D. May create leaders
articulate, confident and sometimes aggressive.
528
Katherine feels uncomfortable believing that
528
she is the
Answer: (B) Is not beneficial; hence it should be
scapegoat of everything that goes wrong in her
prevented at all times
department. Which of the following is the best
action Conflicts are beneficial because it surfaces out
issues in
that she must take?
the open and can be solved right away. Likewise,
A. Identify the source of the conflict and
understand the members of the team become more
conscientious with
points of friction
their work when they are aware that other
B. Disregard what she feels and continue to
members of
work
the team are watching them.
independently
43. Katherine tells one of the staff, “I don’t have
C. Seek help from the Director of Nursing
time to
D. Quit her job and look for another
discuss the matter with you now. See me in my
employment.
office
Answer: (A) Identify the source of the conflict
later” when the latter asks if they can talk about
and
an
understand the points of friction
issue. Which of the following conflict resolution
This involves a problem solving approach, which
strategies did she use?
addresses the root cause of the problem.
A. Smoothing
42. As a young manager, she knows that conflict
B. Compromise
occurs
C. Avoidance
in any organization. Which of the following
statements D. Restriction
regarding conflict is NOT true? Answer: (C) Avoidance
A. Can be destructive if the level is too high This strategy shuns discussing the issue head-on
and
prefers to postpone it to a later time. In effect performance.
the
B. Using agency standards as a guide.
problem remains unsolved and both parties are
C. Determine areas of strength and weaknesses
in a loselose
D. Focusing activity on the correction of
situation.
identified
44. Kathleen knows that one of her staff is
behavior.
experiencing
Answer: (D) Focusing activity on the correction
burnout. Which of the following is the best
of
thing for her
identified behavior.
to do?
Performance appraisal deal with both positive
A. Advise her staff to go on vacation.
and
B. Ignore her observations; it will be resolved
negative performance; is not meant to be a
even
fault-finding
without intervention
activity
C. Remind her to show loyalty to the institution.
46. Which of the following statements is NOT
D. Let the staff ventilate her feelings and ask true about
how she
performance appraisal?
can be of help.
A. Informing the staff about the specific
Answer: (D) Let the staff ventilate her feelings impressions of
and ask
their work help improve their performance.
how she can be of help.
B. A verbal appraisal is an acceptable substitute
Reaching out and helping the staff is the most for a
effective
written report
strategy in dealing with burn out. Knowing that
C. Patients are the best source of information
someone
regarding
is ready to help makes the staff feel important;
personnel appraisal.
hence
D. The outcome of performance appraisal rests
her self-worth is enhanced.
primarily
45. She knows that performance appraisal
with the staff.
consists of all
Answer: (C) Patients are the best source of
the following activities EXCEPT:
information
A. Setting specific standards and activities for
regarding personnel appraisal.
individual
The patient can be a source of information appropriate?
about the
A. She asks another nurse to attest the session
performance of the staff but it is never the best as a
source.
witness.
Directly observing the staff is the best source of
B. She informs the staff that she may ask
information for personnel appraisal. another nurse

47. There are times when Katherine evaluates to read the appraisal before the session is over.
her staff
C. She tells the staff that the session is
as she makes her daily rounds. Which of the managercentered.
following is
D. The session is private between the two
NOT a benefit of conducting an informal members.
appraisal?
Answer: (D) The session is private between the
A. The staff member is observed in natural two
setting.
members.
B. Incidental confrontation and collaboration is
The session is private between the manager and
allowed.
the
C. The evaluation is focused on objective data
529
systematically.
529
D. The evaluation may provide valid information
staff and remains to be so when the two parties
for
do not
compilation of a formal report.
divulge the information to others.
Answer: (C) The evaluation is focused on
49. Alexandra is tasked to organize the new
objective data
wing of the
systematically.
hospital. She was given the authority to do as
Collecting objective data systematically can not she deems
be
fit. She is aware that the director of nursing has
achieved in an informal appraisal. It is focused
substantial trust and confidence in her
on what
capabilities,
actually happens in the natural work setting.
communicates through downward and upward
48. She conducts a 6-month performance channels
review session
and usually uses the ideas and opinions of her
with a staff member. Which of the following staff.
actions is
Which of the following is her style of this?
management?
A. Staffing
A. Benevolent –authoritative
B. Scheduling
B. Consultative
C. Recruitment
C. Exploitive-authoritative
D. Induction
D. Participative
Answer: (A) Staffing
Answer: (B) Consultative
Staffing is a management function involving
A consultative manager is almost like a putting the
participative
best people to accomplish tasks and activities to
manager. The participative manager has attain
complete trust
the goals of the organization.
and confidence in the subordinate, always uses
52. She checks the documentary requirements
the
for the
opinions and ideas of subordinates and
applicants for staff nurse position. Which one is
communicates in
NOT
all directions.
necessary?
52. She decides to illustrate the organizational
A. Certificate of previous employment
structure.
B. Record of related learning experience (RLE)
Which of the following elements is NOT
included? C. Membership to accredited professional
organization
A. Level of authority
D. Professional identification card
B. Lines of communication
Answer: (B) Record of related learning
C. Span of control
experience (RLE)
D. Unity of direction
Record of RLE is not required for employment
Answer: (D) Unity of direction purposes

Unity of direction is a management principle, but it is required for the nurse’s licensure
not an examination.

element of an organizational structure. 53. Which phase of the employment process

includes
51. She plans of assigning competent people to
fill the getting on the payroll and completing
documentary
roles designed in the hierarchy. Which process
refers to requirements?
A. Orientation B. Middle

B. Induction C. Rightmost box

C. Selection D. Bottom

D. Recruitment Answer: (C) Rightmost box

Answer: (B) Induction The leftmost box is occupied by the highest

authority
This step in the recruitment process gives time
for the while the lowest level worker occupies the
rightmost
staff to submit all the documentary
requirements for box.

employment. 56. She decides to have a decentralized staffing

system.
54. She tries to design an organizational
structure that Which of the following is an advantage of this
system of
allows communication to flow in all directions
and staffing?

involve workers in decision making. Which form A. greater control of activities

of
B. Conserves time
organizational structure is this?
530
A. Centralized
530
B. Decentralized
C. Compatible with computerization
C. Matrix
D. Promotes better interpersonal relationship
D. Informal
Answer: (D) Promotes better interpersonal
Answer: (B) Decentralized relationship

Decentralized structures allow the staff to make Decentralized structures allow the staff to solve

decisions on matters pertaining to their practice decisions by themselves, involve them in

and decision

communicate in downward, upward, lateral and making; hence they are always given
opportunities to
diagonal flow.
interact with one another.
55. In a horizontal chart, the lowest level worker
is 57. Aubrey thinks about primary nursing as a
system to
located at the
deliver care. Which of the following activities is
A. Leftmost box
NOT
done by a primary nurse? difference lies in the fact that the members in
modular
A. Collaborates with the physician
nursing are paraprofessional workers.
B. Provides care to a group of patients together
with a 59. St. Raphael Medical Center just opened its
new
group of nurses
Performance Improvement Department. Ms.
C. Provides care for 5-6 patients during their
Valencia is
hospital
appointed as the Quality Control Officer. She
stay.
commits
D. Performs comprehensive initial assessment
herself to her new role and plans her strategies
Answer: (B) Provides care to a group of patients to realize
together
the goals and objectives of the department.
with a group of nurses Which of the

This function is done in team nursing where the following is a primary task that they should
nurse is perform to

a member of a team that provides care for a have an effective control system?
group of
A. Make an interpretation about strengths and
patients.
weaknesses
58. Which pattern of nursing care involves the
B. Identify the values of the department
care given
C. Identify structure, process, outcome
by a group of paraprofessional workers led by a
standards &
professional nurse who take care of patients
criteria
with the
D. Measure actual performances
same disease conditions and are located
geographically Answer: (B) Identify the values of the
department
near each other?
Identify the values of the department will set
A. Case method
the guiding
B. Modular nursing
principles within which the department will
C. Nursing case management operate its

D. Team nursing activities

Answer: (B) Modular nursing 60. Ms. Valencia develops the standards to be
followed.
Modular nursing is a variant of team nursing.
The
Among the following standards, which is to be done to address the needs of the patients.
considered as a
62. The following are basic steps in the
structure standard? controlling

A. The patients verbalized satisfaction of the process of the department. Which of the
nursing following is

care received NOT included?

B. Rotation of duty will be done every four A. Measure actual performance

weeks for all
B. Set nursing standards and criteria
patient care personnel.
C. Compare results of performance to standards
C. All patients shall have their weights taken and
recorded
objectives
D. Patients shall answer the evaluation form
D. Identify possible courses of action
before
Answer: (D) Identify possible courses of action
discharge
This is a step in a quality control process and not
Answer: (B) Rotation of duty will be done every
a basic
four
step in the control process.
weeks for all patient care personnel.
63. Which of the following statements refers to
Structure standards include management
criteria?
system,
A. Agreed on level of nursing care
facilities, equipment, materials needed to
deliver care to B. Characteristics used to measure the level of
nursing
patients. Rotation of duty is a management
system. care
61. When she presents the nursing procedures 531
to be
531
followed, she refers to what type of standards?
C. Step-by-step guidelines
A. Process
D. Statement which guide the group in decision
B. Outcome making
C. Structure and problem solving
D. Criteria Answer: (B) Characteristics used to measure the
level of
Answer: (A) Process
nursing care
Process standards include care plans, nursing
procedure
Criteria are specific characteristics used to shall be provided for all patients and their
measure the families.

standard of care. Answer: (C) Patients’ reports 95% satisfaction

rate prior
64. She wants to ensure that every task is
carried out as to discharge from the hospital.

planned. Which of the following tasks is NOT This refers to an outcome standard, which is a
included in result of

the controlling process? the care that is rendered to the patient.

A. Instructing the members of the standards 66. Which of the following is evidence that the
committee
controlling process is effective?
to prepare policies
A. The things that were planned are done
B. Reviewing the existing policies of the hospital
B. Physicians do not complain.
C. Evaluating the credentials of all nursing staff
C. Employees are contended
D. Checking if activities conform to schedule
D. There is an increase in customer satisfaction
Answer: (A) Instructing the members of the rate.
standards
Answer: (A) The things that were planned are
committee to prepare policies done

Instructing the members involves a directing Controlling is defined as seeing to it that what is
function. planned

65. Ms. Valencia prepares the process is done.

standards. Which
67. Ms. Valencia is responsible to the number of
of the following is NOT a process standard?
personnel reporting to her. This principle refers
A. Initial assessment shall be done to all patients to:
within
A. Span of control
twenty four hours upon admission.
B. Unity of command
B. Informed consent shall be secured prior to
C. Carrot and stick principle
any
D. Esprit d’ corps
invasive procedure
Answer: (A) Span of control
C. Patients’ reports 95% satisfaction rate prior to
Span of control refers to the number of workers
discharge from the hospital.
who
D. Patient education about their illness and
report directly to a manager.
treatment
68. She notes that there is an increasing unrest B. Length of stay
of the
C. Age of patients
staff due to fatigue brought about by shortage
D. Absence of complications
of staff.
Answer: (C) Age of patients
Which action is a priority?
An extraneous variable is not the primary
A. Evaluate the overall result of the unrest
concern of the
B. Initiate a group interaction
researcher but has an effect on the results of
C. Develop a plan and implement it the study.

D. Identify external and internal forces. Adult patients may be young, middle or late
adult.
Answer: (B) Initiate a group interaction
2. He thinks of an appropriate theoretical
Initiate a group interaction will be an
framework.
opportunity to
Whose theory addresses the four modes of
discuss the problem in the open.
adaptation?
532
A. Martha Rogers
532
B. Sr. Callista Roy
NURSING RESEARCH Part 1
C. Florence Nightingale
1. Kevin is a member of the Nursing Research
D. Jean Watson
Council of
Answer: (B) Sr. Callista Roy
the hospital. His first assignment is to determine
the Sr. Callista Roy developed the Adaptation Model
which
level of patient satisfaction on the care they
received involves the physiologic mode, self-concept
mode, role
from the hospital. He plans to include all adult
patients function mode and dependence mode

admitted from April to May, with average length 3. He opts to use a self-report method. Which of
of stay the

of 3-4 days, first admission, and with no following is NOT TRUE about this method?
complications.
A. Most direct means of gathering information
Which of the following is an extraneous variable
B. Versatile in terms of content coverage
of the
C. Most accurate and valid method of data
study?
gathering
A. Date of admission
D. Yields information that would be difficult to Salary of staff nurses is not an indicator of
gather by patient

another method satisfaction, hence need not be included as a

variable in
Answer: (C) Most accurate and valid method of
data the study.

gathering 6. He plans to use a Likert Scale to determine

The most serious disadvantage of this method is A. degree of agreement and disagreement

accuracy and validity of information gathered B. compliance to expected standards

4. Which of the following articles would Kevin C. level of satisfaction

least
D. degree of acceptance
consider for his review of literature?
Answer: (A) degree of agreement and
A. “Story-Telling and Anxiety Reduction Among disagreement
Pediatric
Likert scale is a 5-point summated scale used to
Patients”
determine the degree of agreement or
B. “Turnaround Time in Emergency Rooms” disagreement of

C. “Outcome Standards in Tertiary Health Care the respondents to a statement in a study.

Institutions” 7. He checks if his instruments meet the criteria

for
D. “Environmental Manipulation and Client
Outcomes” evaluation. Which of the following criteria refers
to the
Answer: (B) “Turnaround Time in Emergency
Rooms” consistency or the ability to yield the same
response
The article is for pediatric patients and may not
be upon its repeated administration?

relevant for adult patients. A. Validity

5. Which of the following variables will he likely B. Reliability

EXCLUDE
C. Sensitivity
in his study?
D. Objectivity
A. Competence of nurses
Answer: (B) Reliability
B. Caring attitude of nurses
Reliability is repeatability of the instrument; it
C. Salary of nurses can elicit

D. Responsiveness of staff the same responses even with varied

administration of
Answer: (C) Salary of nurses
the instrument 10. He plans for his sampling method. Which
sampling
8. Which criteria refer to the ability of the
instrument to method gives equal chance to all units in the
population
detect fine differences among the subjects
being to get picked?

studied? A. Random

A. Sensitivity B. Accidental

B. Reliability C. Quota

C. Validity D. Judgment

D. Objectivity Answer: (A) Random

Answer: (A) Sensitivity Random sampling gives equal chance for all the

533 elements in the population to be picked as part

of the
533
sample.
Sensitivity is an attribute of the instrument that
allow 11. Raphael is interested to learn more about

the respondents to distinguish differences of transcultural nursing because he is assigned at

the options the family

where to choose from suites where most patients come from different
cultures
9. Which of the following terms refer to the
degree to and countries. Which of the following designs is

which an instrument measures what it is appropriate for this study?

supposed to be
A. Grounded theory
measure?
B. Ethnography
A. Validity
C. Case study
B. Reliability
D. Phenomenology
C. Meaningfulness
Answer: (B) Ethnography
D. Sensitivity
Ethnography is focused on patterns of behavior
Answer: (A) Validity of

Validity is ensuring that the instrument contains selected people within a culture

appropriate questions about the research topic 12. The nursing theorist who developed
transcultural
nursing theory is phenomenon.

A. Dorothea Orem 14. He systematically plans his sampling plan.

Should he
B. Madeleine Leininger
decides to include whoever patients are
C. Betty Newman
admitted during
D. Sr. Callista Roy
the study he uses what sampling method?
Answer: (B) Madeleine Leininger
A. Judgment
Madeleine Leininger developed the theory on
B. Accidental
transcultural theory based on her observations
C. Random
on the
D. Quota
behavior of selected people within a culture
Answer: (B) Accidental
13. Which of the following statements best
describes a Accidental sampling is a non-probability
sampling
phenomenological study?
method which includes those who are at the
A. Involves the description and interpretation of
site during
cultural
data collection.
behavior
15. He finally decides to use judgment sampling.
B. Focuses on the meaning of experiences as
Which
those who
of the following actions of Raphael is correct?
experience it
A. Plans to include whoever is there during his
C. Involves an in-depth study of an individual or
study.
group
B. Determines the different nationality of
D. Involves collecting and analyzing data that
patients
aims to
frequently admitted and decides to get
develop theories grounded in real-world
representations
observations
samples from each.
Answer: (B) Focuses on the meaning of
experiences as C. Assigns numbers for each of the patients,
place these
those who experience it
in a fishbowl and draw 10 from it.
Phenomenological study involves understanding
the D. Decides to get 20 samples from the admitted
patients
meaning of experiences as those who
experienced the Answer: (B) Determines the different nationality
of
patients frequently admitted and decides to get 17. Which of the following items refer to the
sense of
representations samples from each.
closure that Raphael experiences when data
Judgment sampling involves including samples
collection
according
ceases to yield any new information?
to the knowledge of the investigator about the
A. Saturation
participants in the study.
B. Precision
16. He knows that certain patients who are in a
C. Limitation
specialized research setting tend to respond
D. Relevance
psychologically to the conditions of the study.
This is Answer: (A) Saturation

534 Saturation is achieved when the investigator can

not
534
extract new responses from the informants, but
referred to as
instead,
A. Bias
gets the same responses repeatedly.
B. Hawthorne effect
18. In qualitative research the actual analysis of
C. Halo effect data

D. Horns effect begins with:

Answer: (B) Hawthorne effect A. search for themes

Hawthorne effect is based on the study of Elton B. validation of thematic analysis

Mayo
C. weave the thematic strands together
and company about the effect of an
D. quasi statistics
intervention done to
Answer: (A) search for themes
improve the working conditions of the workers
on their The investigator starts data analysis by looking
for
productivity. It resulted to an increased
productivity but themes from the verbatim responses of the
informants.
not due to the intervention but due to the
psychological 19. Raphael is also interested to know the
coping
effects of being observed. They performed
differently abilities of patients who are newly diagnosed to
have
because they were under observation.
terminal cancer. Which of the following types of
research is appropriate? of the research process?

A. Phenomenological A. Formulating the research hypothesis

B. Ethnographic B. Review related literature

C. Grounded Theory C. Formulating and delimiting the research

problem
D. Case Study
D. Design the theoretical and conceptual
Answer: (C) Grounded Theory
framework
Grounded theory inductively develops a theory
Answer: (B) Review related literature
based on
After formulating and delimiting the research
the observed processes involving selected
problem,
people
the researcher conducts a review of related
20. Which of the following titles of the study is
literature to
appropriate for this study?
determine the extent of what has been done on
A. Lived Experiences of Terminally-Ill Cancer the
Patients
study by previous researchers.
B. Coping Skills of Terminally-Ill Cancer Patients
22. Which of the following codes of research
in a
ethics
Selected Hospital
requires informed consent in all cases governing
C. Two Case Studies of Terminally-Ill Patients in human
Manila
subjects?
D. Beliefs & Practices of Patients with Terminal
A. Helsinki Declaration
Cancer
B. Nuremberg Code
Answer: (B) Coping Skills of Terminally-Ill Cancer
Patients C. Belmont Report

in a Selected Hospital D. ICN Code of Ethics

The title has a specific phenomenon, sample Answer: (A) Helsinki Declaration
and
Helsinki Declaration is the first international
research locale. attempt to

21. Ms. Montana plans to conduct a research on set up ethical standards in research involving
the use human

of a new method of pain assessment scale. research subjects.

Which of the
23. Which of the following ethical principles was
following is the second step in the NOT
conceptualizing phase
articulated in the Belmont Report? the nature of the study and the subject's rights?

A. Beneficence A. Debriefing

B. Respect for human dignity B. Full disclosure

C. Justice C. Informed consent

D. Non-maleficence D. Cover data collection

Answer: (D) Non-maleficence Answer: (B) Full disclosure

Non-maleficence is not articulated in the Full disclosure is giving the subjects of the
Belmont research

Report. It only includes beneficence, respect for information that they deserve to know prior to
human the

535 conduct of the study.

535 26. After the review session has been

completed, Karen
dignity and justice.
and the staff signed the document. Which of the
24. Which one of the following criteria should
be following is the purpose of this?

considered as a top priority in nursing care? A. Agree about the content of the evaluation.

A. Avoidance of destructive changes B. Signify disagreement of the content of the

evaluation.
B. Preservation of life
C. Document that Karen and the staff reviewed
C. Assurance of safety
the
D. Preservation of integrity
evaluation.
Answer: (B) Preservation of life
D. Serve as basis for future evaluation.
The preservation of life at all cost is a primary
Answer: (C) Document that Karen and the staff
responsibility of the nurse. This is embodied in reviewed
the Code
the evaluation.
of Ethics for registered nurses ( BON Resolution
Signing the document is done to serve as a
220 s.
proof that
2004).
performance review was conducted during that
25. Which of the following procedures ensures date and
that the
time.
investigator has fully described to prospective
27. Which of the following is NOT true about a
subjects
hypothesis? Hypothesis is:
A. testable 29. Which of the following procedures ensures
that Ms.
B. proven
Montana has fully described to prospective
C. stated in a form that it can be accepted or
subjects the
rejected
nature of the study and the subject’s rights?
D. states a relationship between variables
A. Debriefing
Answer: (B) proven
B. Full disclosure
Hypothesis is not proven; it is either accepted or
C. Informed consent
rejected. Hypothesis is testable and is defined as
a D. Covert data collection

statement that predicts the relationship Answer: (B) Full disclosure

between
Full disclosure is giving the subjects of the
variables research

28. Which of the following measures will best information that they deserve to know prior to
prevent the

manipulation of vulnerable groups? conduct of the study

A. Secure informed consent 30. This technique refers to the use of multiple
referents
B. Payment of stipends for subjects
to draw conclusions about what constitutes the
C. Protect privacy of patient
truth
D. Ensure confidentiality of data
A. Triangulation
Answer: (A) Secure informed consent
B. Experiment
Securing informed consent will free the
C. Meta-analysis
researcher from
D. Delphi technique
being accused of manipulating the subjects
because by Answer: (A) Triangulation

so doing he/she gives ample opportunity for the Triangulation makes use of different sources of
subjects
information such as triangulation in design,
to weigh the advantages/disadvantages of being researcher

included in the study prior to giving his consent. and instrument.

This is
31. The statement, “Ninety percent (90%) of the
done without any element of force, coercion,
respondents are female staff nurses validates
threat or
previous
even inducement.
research findings (Santos, 2001; Reyes, 2005) Patient Care Services Division. She plans to
that the conduct a

nursing profession is largely a female dominated literature search for her study.

profession is an example of Which of the following is the first step in

selecting
A. implication
appropriate materials for her review?
B. interpretation
A. Track down most of the relevant resources
536
B. Copy relevant materials
536
C. Organize materials according to function
C. analysis
D. Synthesize literature gathered.
D. conclusion
Answer: (A) Track down most of the relevant
Answer: (B) interpretation
resources
Interpretation includes the inferences of the
The first step in the review of related literature
researcher
is to
about the findings of the study.
track down relevant sources before copying
32. The study is said to be completed when Ms. these. The

Montana achieved which of the following last step is to synthesize the literature gathered.
activities?
34. She knows that the most important
A. Published the results in a nursing journal. categories of

B. Presented the study in a research forum. information in literature review is the:

C. The results of the study is used by the nurses A. research findings

in the
B. theoretical framework
hospital
C. methodology
D. Submitted the research report to the CEO.
D. opinions
Answer: (C) The results of the study is used by
Answer: (A) research findings
the nurses
The research findings is the most important
in the hospital
category of
The last step in the research process is the
information that the researcher should copy
utilization of
because
the research findings.
this will give her valuable information as to what
33. Situation: Stephanie is a nurse researcher of has
the
been discovered in past studies about the same Abstract contains concise description of the
topic. background

35. She also considers accessing electronic data of the study, research questions, research
bases for objectives,

her literature review. Which of the following is methods, findings, implications to nursing
the most practice as

useful electronic database for nurses? well as keywords used in the study.

A. CINAHL 37. She notes down ideas that were derived

from the
B. MEDLINE
description of an investigation written by the
C. HealthSTAR
person
D. EMBASE
who conducted it. Which type of reference
Answer: (A) CINAHL source refers

This refers to Cumulative Index to Nursing and to this?

Allied
A. Footnote
Health Literature which is a rich source for
B. Bibliography
literature
C. Primary source
review for nurses. The rest of the sites are for
medicine, D. Endnotes

pharmacy and other health-related sites. Answer: (C) Primary source

36. While reviewing journal articles, Stephanie This refers to a primary source which is a direct
got account

interested in reading the brief summary of the of the investigation done by the investigator. In
article contrast

placed at the beginning of the journal report. to this is a secondary source, which is written by
Which of
someone other than the original researcher.
the following refers to this?
38. She came across a study which is referred to
A. Introduction as

B. Preface meta-analysis. Which of the following

statements best
C. Abstract
defines this type of study?
D. Background
A. Treats the findings from one study as a single
Answer: (C) Abstract
piece of

data
B. Findings from multiple studies are combined D. Experimental
to yield a
Answer: (A) Case study
data set which is analyzed as individual data
Case study focuses on in-depth investigations of
C. Represents an application of statistical single
procedures to
entity or small number of entities. It attempts to
findings from each report analyze

D. Technique for quantitatively combining and and understand issues of importance to history,
thus
development or circumstances of the person or
integrating the results of multiple studies on a entity
given
under study.
537
40. Stephanie is finished with the steps in the
537 conceptual

topic. phase when she has conducted the LAST step,

which is
Answer: (D) Technique for quantitatively
combining and A. formulating and delimiting the problem.

thus integrating the results of multiple studies B. review of related literature

on a given
C. develop a theoretical framework
topic.
D. formulate a hypothesis
Though all the options are correct, the best
Answer: (D) formulate a hypothesis
definition is
The last step in the conceptualizing phase of the
option D because it combines quantitatively the
results research process is formulating a hypothesis.
The rest
and at the same time it integrates the results of
the are the first three steps in this phase.
different studies as one finding. 41. She states the hypothesis of the study.
Which of the
39. This kind of research gathers data in detail
about a following is a null hypothesis?
individual or groups and presented in narrative A. Infants who are breastfed have the same
form, weight as
which is those who are bottle fed.
A. Case study B. Bottle-fed infants have lower weight than
breast-fed
B. Historical
infants
C. Analytical
C. Cuddled infants sleep longer than those who hospital. She is tasked to conduct a research on
are left the

by themselves to sleep. effects of structured discharge plan for post-

open heart
D. Children of absentee parents are more prone
to surgery patients.

experience depression than those who live with She states the significance of the research
both problem.

parents. Which of the following statements is the MOST

Answer: (A) Infants who are breastfed have the significant for this study?
same
A. Improvement in patient care
weight as those who are bottle fed.
B. Development of a theoretical basis for
Null hypothesis predicts that there is no change, nursing
no
C. Increase the accountability of nurses.
difference or no relationship between the
D. Improves the image of nursing
variables in
Answer: (A) Improvement in patient care
the study
The ultimate goal of conducting research is to
42. She notes that the dependent variable in the
improve
hypothesis “Duration of sleep of cuddled infants
patient care which is achieved by enhancing the
is
practice
longer than those infants who are not cuddled
of nurses when they utilize research results in
by
their
mothers” is
practice.
A. Cuddled infants
44. Regardless of the significance of the study,
B. Duration of sleep the

C. Infants feasibility of the study needs to be considered.

Which of
D. Absence of cuddling
the following is considered a priority?
Answer: (B) Duration of sleep
A. Availability of research subjects
Duration of sleep is the ‘effect’ (dependent
variable) of B. Budgetary allocation

cuddling ‘cause’ (independent variable). C. Time frame

43. Situation: Aretha is a nurse researcher in a D. Experience of the researcher

tertiary
Answer: (A) Availability of research subjects
Availability is the most important criteria to be 3. Formally articulates the goals of the study

considered by the researcher in determining 4. Sometimes worded as an intent

whether
A. 1, 2, 3
the study is feasible or not. No matter how
B. 2, 3, 4
significant
C. 1, 3, 4
the study may be if there are no available
D. 1, 2, 3, 4
subjects/respondents, the study can not push
through. Answer: (D) 1, 2, 3, 4
46. Aretha knows that a good research problem The purposes of a research study covers all the
exhibits options
the following characteristics; which one is NOT indicated.
included?
48. She opts to use interviews in data collection.
538 In
538 addition to validity, what is the other MOST
serious
A. Clearly identified the variables/phenomenon
under weakness of this method?
consideration. A. Accuracy
B. Specifies the population being studied. B. Sensitivity
C. Implies the feasibility of empirical testing C. Objectivity
D. Indicates the hypothesis to be tested. D. Reliability
Answer: (D) Indicates the hypothesis to be Answer: (A) Accuracy
tested.
Accuracy and validity are the most serious
Not all studies require a hypothesis such as weaknesses
qualitative
of the self-report data. This is due to the fact
studies, which does not deal with variables but that the
with
respondents sometimes do not want to tell the
phenomenon or concepts. truth for
47. She states the purposes of the study. Which fear of being rejected or in order to please the
of the
interviewer.
following describe the purpose of a study?
49. She plans to subject her instrument to
1. Establishes the general direction of a study pretesting.
2. Captures the essence of the study Which of the following is NOT achieved in doing
pretesting? to be measuring the appropriate construct. It is
the
A. Determines how much time it takes to
administer the easiest type of validity testing.

instrument package 51. Which of the following questions would

determine
B. Identify parts that are difficult to read or
understand the construct validity of the instrument?

C. Determine the budgetary allocation for the A. “What is this instrument really measuring?”
study
B. “How representative are the questions on
D. Determine if the measures yield data with this test of
sufficient
the universe of questions on this topic?”
variability
C. “Does the question asked looks as though it is
Answer: (C) Determine the budgetary allocation
measuring the appropriate construct?”
for the
D. “Does the instrument correlate highly with an
study
external criterion?
Determining budgetary allocation for the study
is not a Answer: (A) “What is this instrument really
measuring?”
purpose of doing a pretesting of the
instruments. This is Construct validity aims to validate what the
instrument is
done at an earlier stage of the design and
planning really measuring. The more abstract the
concept, the
phase.
more difficult to measure the construct.
50. She tests the instrument whether it looks as
though 52. Which of the following experimental
research
it is measuring appropriate constructs. Which of
the designs would be appropriate for this study if
she wants
following refers to this?
to find out a cause and effect relationship
A. Face validity
between the
B. Content validity
structured discharge plan and compliance to
C. Construct Validity home care

D. Criterion-related validity regimen among the subjects?

Answer: (A) Face validity A. True experiment

Face validity measures whether the instrument B. Quasi experiment

appears
C. Post-test only design variable.

D. Solomon four-group 54. Situation : Alyssa plans to conduct a study

about
Answer: (C) Post-test only design
nursing practice in the country. She decides to
Post- Test only design is appropriate because it
refresh
is
her knowledge about the different types of
impossible to measure the compliance to home
research in
care
order to choose the most appropriate design for
regimen variable prior to the discharge of the
her
patient
study.
from the hospital.
55. She came across surveys, like the Social
539
Weather
539
Station and Pulse Asia Survey. Which of the
53. One hypothesis that she formulated is following is
“Compliance
the purpose of this kind of research?
to home care regimen is greater among patients
A. Obtains information regarding the
who
prevalence,
received the structured discharge plan than
distribution and interrelationships of variables
those who
within a
received verbal discharge instructions.’ Which is
population at a particular time
the
B. Get an accurate and complete data about a
independent variable in this study?
phenomenon.
A. Structured discharge plan
C. Develop a tool for data gathering.
B. Compliance to home care regimen
D. Formulate a framework for the study
C. Post-open heart surgery patients
Answer: (A) Obtains information regarding the
D. Greater compliance
prevalence, distribution and interrelationships
Answer: (A) Structured discharge plan
of
Structured discharge plan is the intervention or
variables within a population at a particular
the
time
‘cause’ in the study that results to an ‘effect’,
Surveys are done to gather information on
which is
people’s
compliance to home care regimen or the
actions, knowledge, intentions, opinions and
dependent
attitudes.
56. She will likely use self-report method. Which Exploratory research is the first level of
of the investigation and

following self-report methods is the most it deals with identifying the variables in the
respected study.

method used in surveys? 58. She reviews qualitative design of research.

Which of
A. Personal interviews
the following is true about ethnographic study?
B. Questionnaires
A. Develops theories that increase the
C. Telephone interviews
knowledge about
D. Rating Scale
a certain phenomenon.
Answer: (A) Personal interviews
B. Focuses on the meanings of life experiences
Personal interviews is the best method of of people
collecting
C. Deals with patterns and experiences of a
survey data because the quality of information defined
they yield
cultural group in a holistic fashion
is higher than other methods and because
D. In-depth investigation of a single entity
relatively few
Answer: (C) Deals with patterns and experiences
people refuse to be interviewed in person.
of a
57. Alyssa reads about exploratory research.
defined cultural group in a holistic fashion
Which of
Ethnographic research deals with the cultural
the following is the purpose of doing this type
patterns
of
and beliefs of certain culture groups.
research?
59. She knows that the purpose of doing
A. Inductively develops a theory based on
ethnographic
observations
study is to:
about processes involving selected people
A. Understand the worldview of a cultural group
B. Makes new knowledge useful and practical.
B. Study the life experiences of people
C. Identifies the variables in the study
C. Determine the relationship between variables
D. Finds out the cause and effect relationship
between D. Investigate intensively a single entity

variables Answer: (A) Understand the worldview of a

cultural
Answer: (C) Identifies the variables in the study
group
The aim of ethnographers is to learn from the B. Randomization
members
C. Control
of a cultural group by understanding their way
D. Trial
of life as
Answer: (D) Trial
they perceive and live it.
Trial is not an element of experimental research.
60. Alyssa wants to learn more about
experimental Manipulation of variables, randomization and
control are
design. Which is the purpose of this research?
the three elements of this type of research
A. Test the cause and effect relationship among
the 62. Alyssa knows that there are times when only
variable under a controlled situation manipulation of study variables is possible and
the
B. Identify the variables in the study
elements of control or randomization are not
C. Predicts the future based on current
attendant.
intervention
Which type of research is referred to this?
D. Describe the characteristics, opinions,
attitudes or A. Field study
behaviors of certain population about a current B. Quasi-experiment
issue or
C. Solomon-Four group design
event
D. Post-test only design
540
Answer: (B) Quasi-experiment
540
Quasi-experiment is done when randomization
Answer: (A) Test the cause and effect and
relationship
control of the variables are not possible.
among the variable under a controlled situation
63. One of the related studies that she reads is a
Experimental research is a Level III investigation
which phenomenological research. Which of the
following
determines the cause and effect relationship
between questions is answered by this type of qualitative

variables. research?

61. She knows that there are three elements of A. ” What is the way of life of this cultural
group?”
experimental research. Which is NOT included?
B. “What is the effect of the intervention to the
A. Manipulation
dependent variable?”
C. “What the essence of the phenomenon is as and Development Department of a tertiary
hospital is
experienced by these people?”
tasked to conduct a research study about the
D. “What is the core category that is central in
increased
explaining
incidence of nosocomial infection in the
what is going on in that social scene?”
hospital.
Answer: (C) “What the essence of the
Which of the following ethical issues should he
phenomenon is as
consider
experienced by these people?”
in the conduct of his study?
Phenomenological research deals with the
1. Confidentiality of information given to him by
meaning of
the
experiences as those who experienced the
subjects
phenomenon
2. Self-determination which includes the right to
understand it.
withdraw from the study group
64. Other studies are categorized according to
the time 3. Privacy or the right not to be exposed publicly

frame. Which of the following refers to a study 4. Full disclosure about the study to be
of conducted

variables in the present which is linked to a A. 1, 2, 3

variable that
B. 1, 3, 4
occurred in the past?
C. 2, 3, 4
A. Prospective design
D. 1, 2, 3, 4
B. Retrospective design
Answer: (D) 1, 2, 3, 4
C. Cross sectional study
This includes all the options as these are the
D. Longitudinal study four basic

Answer: (B) Retrospective design rights of subjects for research.

Retrospective studies are done in order to 66. Which of the following is the best tool for
establish a data

correlation between present variables and the gathering?

antecedent factors that have caused it. A. Interview schedule

65. Situation : Harry a new research staff of the B. Questionnaire

Research
C. Use of laboratory data.

D. Observation
Answer: (C) Use of laboratory data. Answer: (A) Descriptive- correlational

Incidence of nosocomial infection is best Descriptive- correlational study is the most

collected appropriate

through the use of biophysiologic measures, for this study because it studies the variables
particularly that could

in vitro measurements, hence laboratory data is be the antecedents of the increased incidence
of
essential.
nosocomial infection.
67. During data collection, Harry encounters a
patient 69. In the statement, “Frequent hand washing
of health
who refuses to talk to him. Which of the
following is a workers decreases the incidence of nosocomial

limitation of the study? infections among post-surgery patients”, the

dependent
A. Patient’s refusal to fully divulge information.
variable is
541
A. incidence of nosocomial infections
541
B. decreases
B. Patients with history of fever and cough
C. frequent hand washing
C. Patients admitted or who seeks consultation
at the ER D. post-surgery patients

and doctors offices Answer: (A) incidence of nosocomial infections

D. Contacts of patients with history of fever and The dependent variable is the incidence of
cough nosocomial

Answer: (A) Patient’s refusal to fully divulge infection, which is the outcome or effect of the
information.
independent variable, frequent hand washing.
Patient’s refusal to divulge information is a
70. Harry knows that he has to protect the
limitation
rights of
because it is beyond the control of Harry.
human research subjects. Which of the
68. What type of research is appropriate for this following actions
study?
of Harry ensures anonymity?
A. Descriptive- correlational
A. Keep the identities of the subject secret
B. Experiment
B. Obtain informed consent
C. Quasi-experiment
C. Provide equal treatment to all the subjects of
D. Historical the
study. ability of the instrument to yield the same
results upon
D. Release findings only to the participants of
the study its repeated administration?

Answer: (A) Keep the identities of the subject A. Validity

secret
B. Specificity
Keeping the identities of the research subject
C. Sensitivity
secret will
D. Reliability
ensure anonymity because this will hinder
providing link Answer: (D) Reliability
between the information given to whoever is its Reliability is consistency of the research
source. instrument. It
71. He is oriented to the use of electronic refers to the repeatability of the instrument in
databases for extracting
nursing research. Which of the following will she the same responses upon its repeated
likely administration.
access? 73. Harry is aware of the importance of
controlling
A. MEDLINE
threats to internal validity for experimental
B. National Institute of Nursing Research
research,
C. American Journal of Nursing
which include the following examples EXCEPT:
D. International Council of Nurses
A. History
Answer: (B) National Institute of Nursing
B. Maturation
Research
C. Attrition
National Institute for Nursing Research is a
useful source D. Design
of information for nursing research. The rest of Answer: (D) Design
the
Design is not a threat to internal validity of the
options may be helpful but NINR is the most
useful site instrument just like the other options.

for nurses. 74. His colleague asks about the external validity
of the
72. He develops methods for data gathering.
Which of research findings. Which of the responses of
Harry is
the following criteria of a good instrument
refers to the appropriate? The research findings can be

A. generalized to other settings or samples

B. shown to result only from the effect of the a. Methodology

independent variable b. Review of related literature

C. reflected as results of extraneous variables c. Acknowledgement

D. free of selection biases d. Formulate hypothesis

Answer: (A) generalized to other settings or 3. Which of the following communicate the
samples results of

External validity refers to the generalizability of the research to the readers. They facilitate the
research
description of the data.
findings to other settings or samples. This is an
a. Hypothesis
issue of
b. Statistics
importance to evidence-based nursing practice.
c. Research problem
542
d. Tables and graphs
542
4. In quantitative data, which of the following is
NURSING RESEARCH Part 2
described as the distance in the scoring units of
Situation 1: You are fortunate to be chosen as
the
part of
variable from the highest to the lower?
the research team in the hospital. A review of
the a. Frequency
following IMPORTANT nursing concepts was b. Mean
made:
c. Median
1. A professional nurse can do research for
varied d. Range

reasons except: 5. This expresses the variability of the data in

reference
a. Professional advancement through research
to the mean. It provides as with a numerical
participation
estimate of how far, on the average the separate
b. To validate results of new nursing modalities
observation are from the mean:
c. For financial gains
a. Mode
d. To improve nursing care
b. Standard deviation
2. Each nurse participant was asked to identify a
c. Median
problem. After the identification of the research
d. Frequency
problem, which of the following should be
done?
Situation 2: Survey and statistics are important a. 80
part if
b. 82
research that is necessary to explain the
c. 90
characteristics
d. 85.5
of the population.
10. In the values: 80, 80, 10, 10, 25, 65, 100,
6. According to WHO statistics on the homeless
200, what is
population around the world, which of the
the median?
following
a. 71.25
groups of people in the world
disproportionately b. 22.5
represents the homeless population? c. 10 and 25
a. Hispanics d. 72.5
b. Asians 11. Draw lots, lottery, table of random numbers
or a
c. African Americans
sampling that ensures that each element of the
d. Caucasians
population has an equal and independent
7. All but one of the following in not a measure
chance of
of
being chosen is called:
central tendency:
a. Cluster
a. Mode
b. Simple
b. Variance
543
c. Standard deviation
543
d. Range
c. Stratified
8. In the values: 87, 85, 88, 92, 90, what is the
mean? d. Systematic
a. 88.2 12. An investigator wants to determine some of
the
b. 88.4
problems experienced by diabetic clients when
c. 87
using
d. 90
insulin pump. The investigator went to a clinic
9. In the values: 80, 80, 80, 82, 82, 90, 90, 100, where
what is
he personally knows several diabetic clients
the mode? having
problem with insulin pump. The type of patients while another group of manic patients
sampling
receives the routine drugs. The researcher
done by the investigator is called: however

a. Probability handpicked the experimental group for they are

the
b. Purposive
clients with multiple episodes if bipolar disorder.
c. Snowball
The
d. Incidental
researcher utilized which research design?
13. If the researcher implemented a new
a. Quasi experimental
structured
b. Pure experimental
counseling program with a randomized group of
c. Phenomenological
subject and a routine counseling program with
d. Longitudinal
another randomized group of subject, the
research is Situation 3: As a nurse, you are expected to
participate
utilizing which design?
in initiating or participating in the conduct of
a. Quasi experimental
research
b. Experimental
studies to improve nursing practice. You have to
c. Comparative be

d. Methodological updated on the latest trends and issues

affecting the
14. Which of the following is not true about a
pure profession and the best practices arrived at by
the
experimental research?
profession.
a. There is a control group
16. You are interested to study the effects of
b. There is an experimental group mediation
c. Selection of subjects in the control group is and relaxation on the pain experienced by
randomized cancer

d. There is a careful selection of subjects in the patients. What type of variable is pain?

experimental group a. Dependent

15. The researcher implemented a medication b. Correlational

regimen c. Independent
using a new type of combination drugs to manic d. Demographic
17. You would like to compare the support this?
system of
a. Descriptive
patient with chronic illness and those with acute
b. Correlational, non experimental
illness. How will you best state your problem?
c. Experimental
a. A descriptive study to compare the support
d. Quasi experimental
systems of patients with chronic illness and
19. In any research study where individual
those with acute illness in terms of persons are
demographic
involved, it is important that an informed
data and knowledge about intervention consent of

b. The effects of the types of support system of the study is obtained. The following are
essential
patients with chronic illness and those with
information about the consent that you should
acute illness
disclose to the prospective subjects except:
c. A comparative analysis of the support system
of 544

patients with chronic illness and those with 544

acute illness a. Consent to incomplete disclosure

d. A study to compare the support system of b. Description of benefits, risks, and discomforts

patients with chronic illness and those with c. Explanation of procedure

acute illness d. Assurance of anonymity and confidentiality

e. What are the differences of the support 20. In the hypothesis: “The utilization of
system technology in

being received by patient with chronic illness teaching improves the retention and attention
of the
and patients with acute illness?
nursing students,” which is the dependent
18. You would like to compare the support
variable?
system of
a. Utilization of technology
patients with chronic illness to those with acute
b. Improvement in the retention and attention
illness. Considering that the hypothesis was:
“Clients c. Nursing students

with chronic illness have lesser support system d. Teaching

than
Situation 4: You are an actively practicing nurse
clients with acute illness.” What type of who has
research is
just finished your graduate studies. You learned a. A study examining clients reactions to stress
the
after open heart surgery
value of research and would like to utilize the
b. A study measuring nutrition and weight
knowledge
loss/gain
and skills gained in the application of research
in clients with cancer
to the
c. A study examining oxygen levels after
nursing service. The following questions apply
to endotracheal suctioning
research. d. A study measuring differences in blood
pressure
21. Which type of research inquiry investigates
the before, during and after a procedure
issues of human complexity (e.g. understanding 24. An 85 year old client in a nursing home tells
the a nurse,
human expertise)? “I signed the papers for that research study
because
a. Logical position
the doctor was so insistent and I want him to
b. Naturalistic inquiry
continue taking care of me”. Which client right is
c. Positivism
being violated?
d. Quantitative Research
a. Right of self determination
22. Which of the following studies is based on
b. Right to privacy and confidentiality
quantitative research?
c. Right to full disclosure
a. A study examining the bereavement process
in d. Right not to be harmed
spouses of clients with terminal cancer 25. “A supposition or system of ideas that is
proposed to
b. A study exploring factors influencing weight
explain a given phenomenon”, best defines:
control behavior.
a. A paradigm
c. A study measuring the effects of sleep
b. A concept
deprivation on wound healing
c. A theory
d. A study examining client’s feeling before,
during d. A conceptual framework
and after a bone marrow aspiration Situation 5: Mastery of research design
determination is
23. Which of the following studies is based on
essential in passing the NLE.
qualitative research?
26. Monette wants to know if the length of time Community B, nurse Crystal conducted teaching
she will to

study for the board examination is proportional 545

to
545
her board rating. During the December 2007
Community A and assessed if Community A will
board
have
examination, she studied for six months and
a better status than Community B. This is an
gained
example of:
68%. On June 2008 board exam, she studied for
6 a. Comparative
months again for a total of one year and gained b. Correlational
74%.
c. Experimental
On November 2008, she studied for 6 months
for a d. Qualitative

total of one and a half year and gained 82%. The 29. Faye researched in the development of a
new way to
research design she used is:
measure intelligence by creating a 100-item
a. Comparative
questionnaire that will assess the cognitive skills
b. Correlational of
c. Experimental an individual. The design best suited for this
study is:
d. Qualitative
a. Historical
27. Rodrigo was always eating high fat diet. You
want to b. Methodological
determine if what will be the effect of high c. Survey
cholesterol food to Rodrigo in the next 10 years. d. Case study
You
30. Jay Emmanuelle is conducting a research
will use: study on
a. Comparative how Ralph, an AIDS client lives his life. A design
b. Correlational suited for this is:
c. Historical a. Historical
d. Longitudinal b. Case study
28. Community A was selected randomly as well c. Phenomenological
as
d. Ethnographic
31. Maecee is to perform a study about how c. Phenomenological
nurses
d. Ethnographic
perform surgical asepsis during World War II. A
34. Jezza and Jenny researched about TB – its
design best for this study is:
transmission, causative agent and factors,
a. Historical
treatment, signs and symptoms, as well as
b. Case study
medication and all other in-depth information
c. Phenomenological about

d. Ethnographic tuberculosis. This study is best suited for which

32. Medel conducts sampling at Barangay research design?

Maligaya. He
a. Historical
collected 100 random individuals and determine
b. Case study
who is their favorite actor. 50% said Piolo, 20%
c. Phenomenological
said
d. Ethnographic
John Lloyd, while some answered Sam,
Dingdong, 35. Diana, Arlene, and Sally are to conduct a
study about
Richard, and Derek. Medel conducted what type
of relationship of the number of family members
in the
research study?
household and the electricity bill, which of the
a. Phenomenological
following is the best research design suited for
b. Case study
this
c. Non experimental
study?
d. Survey
1. Descriptive
33. Mark and Toberts visited a tribe located
2. Exploratory
somewhere
3. Explanatory
in China, it is called Shin Jea tribe. They studied
the 4. Correlational
way of life, tradition, and the societal structure 5. Comparative
of
6. Experimental
these people. They will best use which research
a. 1 and 4
design?
b. 2 and 5
a. Historical
c. 3 and 6
b. Case study
d. 1 and 5 d. Sample

e. 2 and 4 39. The device or techniques that Vinz employs

to
Situation 6: As a nurse researcher, Vinz must
have a very collect data is called:

good understanding of the common terms of a. Sample

concept
b. Instrument
used in research.
c. Hypothesis
36. The information that an investigator like Vinz
d. Concept
collects from the subjects or participants in a
40. The use of another person’s ideas or
research study is usually called: wordings

a. Hypothesis without giving appropriate credit results from

b. Data inaccurate or incomplete attribution of

materials to
c. Variable
its resources. Which of the following is referred
d. Concept
to
546
when another person’s idea is inappropriately
546
credited as one’s own?
37. Which of the following usually refers to the
a. Plagiarism
independent variables in doing research?
b. Quotation
a. Result
c. Assumption
b. Cause
d. Paraphrase
c. Output
Nursing Research Suggested Answer Key
d. Effect
CBDDB
38. The recipients of experimental treatment in
BABAD
an
BBBDA
experimental design or the individuals to be
AEAAB
observed in a non-experimental design are
called: BCAAC

a. Setting BDCBC

b. Subjects ADDBD

c. Treatment BBBBA