hysterectomy client of three days whose

Foundation of Professional incisional dressing is saturated with

serosanguinous fluid.
Nursing Practice 6. Nurse Gail places a client in a four-point restraint following
orders from the physician. The client care plan should include:
1. The nurse In-charge in labor and delivery unit administered a
dose of terbutaline to a client without checking the client’s A. Assess temperature frequently.
pulse. The standard that would be used to determine if the nurse
was negligent is: B. Provide diversional activities.

A. The physician’s orders. C. Check circulation every 15-30 minutes.

B. The action of a clinical nurse specialist who is D. Socialize with other patients once a shift.
recognized expert in the field.
7. A male client who has severe burns is receiving H2 receptor
C. The statement in the drug literature about antagonist therapy. The nurse In-charge knows the purpose of
administration of terbutaline. this therapy is to:

D. The actions of a reasonably prudent nurse with A. Prevent stress ulcer

similar education and experience.
B. Block prostaglandin synthesis
2. Nurse Trish is caring for a female client with a history of GI
bleeding, sickle cell disease, and a platelet count of 22,000/μl. C. Facilitate protein synthesis.
The female client is dehydrated and receiving dextrose 5% in
half-normal saline solution at 150 ml/hr. The client complains of D. Enhance gas exchange
severe bone pain and is scheduled to receive a dose of morphine
8. The doctor orders hourly urine output measurement for a
sulfate. In administering the medication, Nurse Trish should
postoperative male client. The nurse Trish records the following
avoid which route?
amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9
A. I.V a.m.: 60 ml. Based on these amounts, which action should the
nurse take?
B. I.M
A. Increase the I.V. fluid infusion rate
C. Oral
B. Irrigate the indwelling urinary catheter
D. S.C
C. Notify the physician
3. Dr. Garcia writes the following order for the client who has
been recently admitted “Digoxin .125 mg P.O. once daily.” To D. Continue to monitor and record hourly urine
prevent a dosage error, how should the nurse document this output
order onto the medication administration record?
9. Tony, a basketball player twist his right ankle while playing
A. “Digoxin .1250 mg P.O. once daily” on the court and seeks care for ankle pain and swelling. After
the nurse applies ice to the ankle for 30 minutes, which
B. “Digoxin 0.1250 mg P.O. once daily” statement by Tony suggests that ice application has been
effective?
C. “Digoxin 0.125 mg P.O. once daily”
A. “My ankle looks less swollen now”.
D. “Digoxin .125 mg P.O. once daily”
B. “My ankle feels warm”.
4. A newly admitted female client was diagnosed with deep vein
thrombosis. Which nursing diagnosis should receive the highest C. “My ankle appears redder now”.
priority?
D. “I need something stronger for pain relief”
A. Ineffective peripheral tissue perfusion related to
venous congestion. 10.The physician prescribes a loop diuretic for a client. When
administering this drug, the nurse anticipates that the client may
B. Risk for injury related to edema. develop which electrolyte imbalance?

C. Excess fluid volume related to peripheral A. Hypernatremia

vascular disease.
B. Hyperkalemia
D. Impaired gas exchange related to increased
blood flow. C. Hypokalemia

5. Nurse Betty is assigned to the following clients. The client D. Hypervolemia

that the nurse would see first after endorsement?
11.She finds out that some managers have
A. A 34 year-old post operative appendectomy benevolent-authoritative style of management. Which of the
client of five hours who is complaining of pain. following behaviors will she exhibit most likely?

B. A 44 year-old myocardial infarction (MI) client A. Have condescending trust and confidence in
who is complaining of nausea. their subordinates.

C. A 26 year-old client admitted for dehydration B. Gives economic and ego awards.
whose intravenous (IV) has infiltrated.
C. Communicates downward to staffs.
D. A 63 year-old post operative’s abdominal
D. Allows decision making among subordinates.
12. Nurse Amy is aware that the following is true about C. Hyperactive bowel sounds
functional nursing
D. Sudden onset of continuous epigastric and back
A. Provides continuous, coordinated and pain.
comprehensive nursing services.
19. Which dietary guidelines are important for nurse Oliver to
B. One-to-one nurse patient ratio. implement in caring for the client with burns?

C. Emphasize the use of group collaboration. A. Provide high-fiber, high-fat diet

D. Concentrates on tasks and activities. B. Provide high-protein, high-carbohydrate diet.

13.Which type of medication order might read “Vitamin K 10 C. Monitor intake to prevent weight gain.
mg I.M. daily × 3 days?”
D. Provide ice chips or water intake.
A. Single order
20.Nurse Hazel will administer a unit of whole blood, which
B. Standard written order priority information should the nurse have about the client?

C. Standing order A. Blood pressure and pulse rate.

D. Stat order B. Height and weight.

14.A female client with a fecal impaction frequently exhibits C. Calcium and potassium levels
which clinical manifestation?
D. Hgb and Hct levels.
A. Increased appetite
21. Nurse Michelle witnesses a female client sustain a fall and
B. Loss of urge to defecate suspects that the leg may be broken. The nurse takes which
priority action?
C. Hard, brown, formed stools
A. Takes a set of vital signs.
D. Liquid or semi-liquid stools
B. Call the radiology department for X-ray.
15.Nurse Linda prepares to perform an otoscopic examination
on a female client. For proper visualization, the nurse should C. Reassure the client that everything will be alright.
position the client’s ear by:
D. Immobilize the leg before moving the client.
A. Pulling the lobule down and back
22.A male client is being transferred to the nursing unit for
B. Pulling the helix up and forward admission after receiving a radium implant for bladder cancer.
The nurse in-charge would take which priority action in the care
C. Pulling the helix up and back of this client?

D. Pulling the lobule down and forward A. Place client on reverse isolation.
16. Which instruction should nurse Tom give to a male client B. Admit the client into a private room.
who is having external radiation therapy:
C. Encourage the client to take frequent rest periods.
A. Protect the irritated skin from sunlight.
D. Encourage family and friends to visit.
B. Eat 3 to 4 hours before treatment.
23.A newly admitted female client was diagnosed with
C. Wash the skin over regularly. agranulocytosis. The nurse formulates which priority nursing
diagnosis?
D. Apply lotion or oil to the radiated area when it is
red or sore. A. Constipation
17.In assisting a female client for immediate surgery, the nurse B. Diarrhea
In-charge is aware that she should:
C. Risk for infection
A. Encourage the client to void following
preoperative medication. D. Deficient knowledge

B. Explore the client’s fears and anxieties about the 24.A male client is receiving total parenteral nutrition suddenly
surgery. demonstrates signs and symptoms of an air embolism. What is
the priority action by the nurse?
C. Assist the client in removing dentures and nail
polish. A. Notify the physician.

D. Encourage the client to drink water prior to B. Place the client on the left side in the
surgery. Trendelenburg position.

18. A male client is admitted and diagnosed with acute C. Place the client in high-Fowlers position.
pancreatitis after a holiday celebration of excessive food and
alcohol. Which assessment finding reflects this diagnosis? D. Stop the total parenteral nutrition.

A. Blood pressure above normal range. 25.Nurse May attends an educational conference on leadership
styles. The nurse is sitting with a nurse employed at a large
B. Presence of crackles in both lung fields. trauma center who states that the leadership style at the trauma
center is task-oriented and directive. The nurse determines that A. Assessment
the leadership style used at the trauma center is:
B. Evaluation
A. Autocratic.
C. Implementation
B. Laissez-faire.
D. Planning and goals
C. Democratic.
32.Which of the following item is considered the single most
D. Situational important factor in assisting the health professional in arriving at
a diagnosis or determining the person’s needs?
26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30
cc/hr. The nurse in-charge is going to hang a 500 cc bag. KCl is A. Diagnostic test results
supplied 20 mEq/10 cc. How many cc’s of KCl will be added to
the IV solution? B. Biographical date

A. .5 cc C. History of present illness

B. 5 cc D. Physical examination

C. 1.5 cc 33.In preventing the development of an external rotation

deformity of the hip in a client who must remain in bed for any
D. 2.5 cc period of time, the most appropriate nursing action would be to
use:
27.A child of 10 years old is to receive 400 cc of IV fluid in an 8
hour shift. The IV drip factor is 60. The IV rate that will deliver A. Trochanter roll extending from the crest of the
this amount is: ileum to the midthigh.

A. 50 cc/ hour B. Pillows under the lower legs.

B. 55 cc/ hour C. Footboard

C. 24 cc/ hour D. Hip-abductor pillow

D. 66 cc/ hour 34.Which stage of pressure ulcer development does the ulcer
extend into the subcutaneous tissue?
28.The nurse is aware that the most important nursing action
when a client returns from surgery is: A. Stage I

A. Assess the IV for type of fluid and rate of flow. B. Stage II

B. Assess the client for presence of pain. C. Stage III

C. Assess the Foley catheter for patency and urine D. Stage IV

output
35.When the method of wound healing is one in which wound
D. Assess the dressing for drainage. edges are not surgically approximated and integumentary
continuity is restored by granulations, the wound healing is
29. Which of the following vital sign assessments that may termed
indicate cardiogenic shock after myocardial infarction?
A. Second intention healing
A. BP – 80/60, Pulse – 110 irregular
B. Primary intention healing
B. BP – 90/50, Pulse – 50 regular
C. Third intention healing
C. BP – 130/80, Pulse – 100 regular
D. First intention healing
D. BP – 180/100, Pulse – 90 irregular
36.An 80-year-old male client is admitted to the hospital with a
30.Which is the most appropriate nursing action in obtaining a diagnosis of pneumonia. Nurse Oliver learns that the client lives
blood pressure measurement? alone and hasn’t been eating or drinking. When assessing him
for dehydration, nurse Oliver would expect to find:
A. Take the proper equipment, place the client in a
comfortable position, and record the appropriate A. Hypothermia
information in the client’s chart.
B. Hypertension
B. Measure the client’s arm, if you are not sure of the
size of cuff to use. C. Distended neck veins

C. Have the client recline or sit comfortably in a D. Tachycardia

chair with the forearm at the level of the heart.
37.The physician prescribes meperidine (Demerol), 75 mg I.M.
D. Document the measurement, which extremity was every 4 hours as needed, to control a client’s postoperative pain.
used, and the position that the client was in during The package insert is “Meperidine, 100 mg/ml.” How many
the measurement. milliliters of meperidine should the
client receive?
31.Asking the questions to determine if the person understands
the health teaching provided by the nurse would be included A. 0.75
during which step of the nursing process?
B. 0.6
 C. 0.5 accidentally, what should the nurse in-charge do immediately?

D. 0.25 A. Clamp the catheter

38. A male client with diabetes mellitus is receiving insulin. B. Call another nurse
Which statement correctly describes an insulin unit?
C. Call the physician
A. It’s a common measurement in the metric system.
D. Apply a dry sterile dressing to the site.
B. It’s the basis for solids in the avoirdupois system.
45.A female client was recently admitted. She has fever, weight
C. It’s the smallest measurement in the apothecary loss, and watery diarrhea is being admitted to the facility. While
system. assessing the client, Nurse Hazel inspects the client’s abdomen
and notice that it is slightly concave. Additional assessment
D. It’s a measure of effect, not a standard measure of should proceed in which order:
weight or quantity.
A. Palpation, auscultation, and percussion.
39.Nurse Oliver measures a client’s temperature at 102° F. What
is the equivalent Centigrade temperature? B. Percussion, palpation, and auscultation.

A. 40.1 °C C. Palpation, percussion, and auscultation.

B. 38.9 °C D. Auscultation, percussion, and palpation.

C. 48 °C 46. Nurse Betty is assessing tactile fremitus in a client with

pneumonia. For this examination, nurse Betty should use the:
D. 38 °C
A. Fingertips
40.The nurse is assessing a 48-year-old client who has come to
the physician’s office for his annual physical exam. One of the B. Finger pads
first physical signs of aging is:
C. Dorsal surface of the hand
A. Accepting limitations while developing assets.
D. Ulnar surface of the hand
B. Increasing loss of muscle tone.
47. Which type of evaluation occurs continuously throughout
C. Failing eyesight, especially close vision. the teaching and learning process?

D. Having more frequent aches and pains. A. Summative

41.The physician inserts a chest tube into a female client to treat B. Informative
a pneumothorax. The tube is connected to water-seal drainage.
The nurse in-charge can prevent chest tube air leaks by: C. Formative

A. Checking and taping all connections. D. Retrospective

B. Checking patency of the chest tube. 48.A 45 year old client, has no family history of breast cancer or
other risk factors for this disease. Nurse John should instruct her
C. Keeping the head of the bed slightly elevated. to have mammogram how often?

D. Keeping the chest drainage system below the level A. Twice per year
of the chest.
B. Once per year
42.Nurse Trish must verify the client’s identity before
administering medication. She is aware that the safest way to C. Every 2 years
verify identity is to:
D. Once, to establish baseline
A. Check the client’s identification band.
49.A male client has the following arterial blood gas values: pH
B. Ask the client to state his name. 7.30; Pao2 89 mmHg; Paco2 50 mmHg; and HCO3 26mEq/L.
Based on these values, Nurse Patricia should expect which
C. State the client’s name out loud and wait a client condition?
to repeat it.
A. Respiratory acidosis
D. Check the room number and the client’s name on
the bed. B. Respiratory alkalosis

43.The physician orders dextrose 5 % in water, 1,000 ml to be C. Metabolic acidosis

infused over 8 hours. The I.V. tubing delivers 15 drops/ml.
Nurse John should run the I.V. infusion at a rate of: D. Metabolic alkalosis

A. 30 drops/minute 50.Nurse Len refers a female client with terminal cancer to a

local hospice. What is the goal of this referral?
B. 32 drops/minute
A. To help the client find appropriate treatment
C. 20 drops/minute options.

D. 18 drops/minute B. To provide support for the client and family in

coping with terminal illness.
44.If a central venous catheter becomes disconnected
 C. To ensure that the client gets counseling regarding C. In front of the client.
health care costs.
D. Behind the client.
D. To teach the client and family about cancer and its
treatment. 57.Nurse Janah is monitoring the ongoing care given to the
potential organ donor who has been diagnosed with brain death.
51.When caring for a male client with a 3-cm stage I pressure The nurse determines that the standard of care had been
ulcer on the coccyx, which of the following actions can the maintained if which of the following data is observed?
nurse institute independently?
A. Urine output: 45 ml/hr
A. Massaging the area with an astringent every 2
hours. B. Capillary refill: 5 seconds

B. Applying an antibiotic cream to the area three C. Serum pH: 7.32

times per day.
D. Blood pressure: 90/48 mmHg
C. Using normal saline solution to clean the ulcer
and applying a protective dressing as necessary. 58. Nurse Amy has an order to obtain a urinalysis from a male
client with an indwelling urinary catheter. The nurse avoids
D. Using a povidone-iodine wash on the ulceration which of the following, which contaminate the specimen?
three times per day.
A. Wiping the port with an alcohol swab before
52.Nurse Oliver must apply an elastic bandage to a client’s inserting the syringe.
ankle and calf. He should apply the bandage beginning at the
client’s: B. Aspirating a sample from the port on the drainage
bag.
A. Knee
C. Clamping the tubing of the drainage bag.
B. Ankle
D. Obtaining the specimen from the urinary drainage
C. Lower thigh bag.

D. Foot 59.Nurse Meredith is in the process of giving a client a bed bath.

In the middle of the procedure, the unit secretary calls the nurse
53.A 10 year old child with type 1 diabetes develops diabetic on the intercom to tell the nurse that there is an emergency
ketoacidosis and receives a continuous insulin infusion. Which phone call. The appropriate nursing action is to:
condition represents the greatest risk to this child?
A. Immediately walk out of the client’s room and
A. Hypernatremia answer the phone call.

B. Hypokalemia B. Cover the client, place the call light within reach,
and answer the phone call.
C. Hyperphosphatemia
C. Finish the bed bath before answering the phone
D. Hypercalcemia call.

54.Nurse Len is administering sublingual nitrglycerin (Nitrostat) D. Leave the client’s door open so the client can be
to the newly admitted client. Immediately afterward, the client monitored and the nurse can answer the phone
may experience: call.

A. Throbbing headache or dizziness 60. Nurse Janah is collecting a sputum specimen for culture and
sensitivity testing from a client who has a productive cough.
B. Nervousness or paresthesia. Nurse Janah plans to implement which intervention to obtain the
specimen?
C. Drowsiness or blurred vision.
A. Ask the client to expectorate a small amount of
D. Tinnitus or diplopia. sputum into the emesis basin.
55.Nurse Michelle hears the alarm sound on the telemetry B. Ask the client to obtain the specimen after
monitor. The nurse quickly looks at the monitor and notes that a breakfast.
client is in a ventricular tachycardia. The nurse rushes to the
client’s room. Upon reaching the client’s bedside, the nurse C. Use a sterile plastic container for obtaining the
would take which action first? specimen.
A. Prepare for cardioversion D. Provide tissues for expectoration and obtaining
the specimen.
B. Prepare to defibrillate the client
61. Nurse Ron is observing a male client using a walker. The
C. Call a code nurse determines that the client is using the walker correctly if
the client:
D. Check the client’s level of consciousness
A. Puts all the four points of the walker flat on the
56.Nurse Hazel is preparing to ambulate a female client. The
floor, puts weight on the hand pieces, and then
best and the safest position for the nurse in assisting the client is
walks into it.
to stand:
B. Puts weight on the hand pieces, moves the walker
A. On the unaffected side of the client.
forward, and then walks into it.
B. On the affected side of the client.
C. Puts weight on the hand pieces, slides the walker
 forward, and then walks into it. 45 degrees.

D. Walks into the walker, puts weight on the hand D. Left side-lying with the head of the bed elevated
pieces, and then puts all four points of the walker 45 degrees.
flat on the floor.
67.Nurse John develops methods for data gathering. Which of
62.Nurse Amy has documented an entry regarding client care in the following criteria of a good instrument refers to the ability of
the client’s medical record. When checking the entry, the nurse the instrument to yield the same results upon its repeated
realizes that incorrect information was documented. How does administration?
the nurse correct this error?
A. Validity
A. Erases the error and writes in the correct
information. B. Specificity

B. Uses correction fluid to cover up the incorrect C. Sensitivity

information and writes in the correct information.
D. Reliability
C. Draws one line to cross out the incorrect
information and then initials the change. 68.Harry knows that he has to protect the rights of human
research subjects. Which of the following actions of Harry
D. Covers up the incorrect information completely ensures anonymity?
using a black pen and writes in the correct
information A. Keep the identities of the subject secret

63.Nurse Ron is assisting with transferring a client from the B. Obtain informed consent
operating room table to a stretcher. To provide safety to the
client, the nurse should: C. Provide equal treatment to all the subjects of the
study.
A. Moves the client rapidly from the table to the
stretcher. D. Release findings only to the participants of the
study
B. Uncovers the client completely before transferring
to the stretcher. 69.Patient’s refusal to divulge information is a limitation
because it is beyond the control of Tifanny”. What type of
C. Secures the client safety belts after transferring to research is appropriate for this study?
the stretcher.
A. Descriptive- correlational
D. Instructs the client to move self from the table to
the stretcher. B. Experiment

64.Nurse Myrna is providing instructions to a nursing assistant C. Quasi-experiment

assigned to give a bed bath to a client who is on contact
D. Historical
precautions. Nurse Myrna instructs the nursing assistant to use
which of the following protective items when giving bed bath? 70.Nurse Ronald is aware that the best tool for data gathering is?
A. Gown and goggles A. Interview schedule
B. Gown and gloves B. Questionnaire
C. Gloves and shoe protectors C. Use of laboratory data
D. Gloves and goggles D. Observation
65. Nurse Oliver is caring for a client with impaired mobility 71.Monica is aware that there are times when only manipulation
that occurred as a result of a stroke. The client has right sided of study variables is possible and the elements of control or
arm and leg weakness. The nurse would suggest that the client randomization are not attendant. Which type of research is
use which of the following assistive devices that would provide referred to this?
the best stability for ambulating?
A. Field study
A. Crutches
B. Quasi-experiment
B. Single straight-legged cane
C. Solomon-Four group design
C. Quad cane
D. Post-test only design
D. Walker
72.Cherry notes down ideas that were derived from the
66.A male client with a right pleural effusion noted on a chest description of an investigation written by the person who
X-ray is being prepared for thoracentesis. The client experiences conducted it. Which type of reference source refers to this?
severe dizziness when sitting upright. To provide a safe
environment, the nurse assists the client to which position for A. Footnote
the procedure?
B. Bibliography
A. Prone with head turned toward the side supported
by a pillow. C. Primary source

B. Sims’ position with the head of the bed flat. D. Endnotes

C. Right side-lying with the head of the bed elevated 73.When Nurse Trish is providing care to his patient, she must
remember that her duty is bound not to do doing any action that A. Plans to include whoever is there during his study.
will cause the patient harm. This is the meaning of the bioethical
principle: B. Determines the different nationality of patients
frequently admitted and decides to get
A. Non-maleficence representations samples from each.

B. Beneficence C. Assigns numbers for each of the patients, place

these in a fishbowl and draw 10 from it.
C. Justice
D. Decides to get 20 samples from the admitted
D. Solidarity patients

74.When a nurse in-charge causes an injury to a female patient 80. The nursing theorist who developed transcultural nursing
and the injury caused becomes the proof of the negligent act, the theory is:
presence of the injury is said to exemplify the principle of:
A. Florence Nightingale
A. Force majeure
B. Madeleine Leininger
B. Respondeat superior
C. Albert Moore
C. Res ipsa loquitor
D. Sr. Callista Roy
D. Holdover doctrine
81.Marion is aware that the sampling method that gives equal
75.Nurse Myrna is aware that the Board of Nursing has chance to all units in the population to get picked is:
quasi-judicial power. An example of this power is:
A. Random
A. The Board can issue rules and regulations that
will govern the practice of nursing B. Accidental

B. The Board can investigate violations of the C. Quota

nursing law and code of ethics
D. Judgment
C. The Board can visit a school applying for a permit
in collaboration with CHED 82.John plans to use a Likert Scale to his study to determine the:

D. The Board prepares the board examinations A. Degree of agreement and disagreement

76. When the license of nurse Krina is revoked, it means that B. Compliance to expected standards
she:
C. Level of satisfaction
A. Is no longer allowed to practice the profession for
the rest of her life D. Degree of acceptance

B. Will never have her/his license re-issued since it 83.Which of the following theory addresses the four modes of
has been revoked adaptation?

C. May apply for re-issuance of his/her license based A. Madeleine Leininger

on certain conditions stipulated in RA 9173
B. Sr. Callista Roy
D. Will remain unable to practice professional
nursing C. Florence Nightingale

77.Ronald plans to conduct a research on the use of a new D. Jean Watson

method of pain assessment scale. Which of the following is the
84.Ms. Garcia is responsible to the number of personnel
second step in the conceptualizing phase of the research
reporting to her. This principle refers to:
process?
A. Span of control
A. Formulating the research hypothesis
B. Unity of command
B. Review related literature
C. Downward communication
C. Formulating and delimiting the research problem
D. Leader
D. Design the theoretical and conceptual framework
85.Ensuring that there is an informed consent on the part of the
78. The leader of the study knows that certain patients who are
patient before a surgery is done, illustrates the bioethical
in a specialized research setting tend to respond psychologically
principle of:
to the conditions of the study. This referred to as :
A. Beneficence
A. Cause and effect
B. Autonomy
B. Hawthorne effect
C. Veracity
C. Halo effect
D. Non-maleficence
D. Horns effect
86.Nurse Reese is teaching a female client with peripheral
79.Mary finally decides to use judgment sampling on her
vascular disease about foot care; Nurse Reese should include
research. Which of the following actions of is correct?
which instruction? D. To permit veins in the legs to fill with blood.

A. Avoid wearing cotton socks. 93.Which nursing intervention takes highest priority when
caring for a newly admitted client who’s receiving a blood
B. Avoid using a nail clipper to cut toenails. transfusion?

C. Avoid wearing canvas shoes. A. Instructing the client to report any itching,
swelling, or dyspnea.
D. Avoid using cornstarch on feet.
B. Informing the client that the transfusion usually
87.A client is admitted with multiple pressure ulcers. When take 1 ½ to 2 hours.
developing the client’s diet plan, the nurse should include:
C. Documenting blood administration in the client
A. Fresh orange slices care record.
B. Steamed broccoli D. Assessing the client’s vital signs when the
transfusion ends.
C. Ice cream
94.A male client complains of abdominal discomfort and nausea
D. Ground beef patties while receiving tube feedings. Which intervention is most
appropriate for this problem?
88.The nurse prepares to administer a cleansing enema. What is
the most common client position used for this procedure? A. Give the feedings at room temperature.
A. Lithotomy B. Decrease the rate of feedings and the
concentration of the formula.
B. Supine
C. Place the client in semi-Fowler’s position while
C. Prone
feeding.
D. Sims’ left lateral
D. Change the feeding container every 12 hours.
89.Nurse Marian is preparing to administer a blood transfusion.
95.Nurse Patricia is reconstituting a powdered medication in a
Which action should the nurse take first?
vial. After adding the solution to the powder, she nurse should:
A. Arrange for typing and cross matching of the
A. Do nothing.
client’s blood.
B. Invert the vial and let it stand for 3 to 5 minutes.
B. Compare the client’s identification wristband with
the tag on the unit of blood. C. Shake the vial vigorously.
C. Start an I.V. infusion of normal saline solution. D. Roll the vial gently between the palms.
D. Measure the client’s vital signs. 96.Which intervention should the nurse Trish use when
administering oxygen by face mask to a female client?
90.A 65 years old male client requests his medication at 9 p.m.
instead of 10 p.m. so that he can go to sleep earlier. Which type A. Secure the elastic band tightly around the client’s
of nursing intervention is required? head.
A. Independent B. Assist the client to the semi-Fowler position if
possible.
B. Dependent
C. Apply the face mask from the client’s chin up
C. Interdependent
over the nose.
D. Intradependent
D. Loosen the connectors between the oxygen
91.A female client is to be discharged from an acute care facility equipment and humidifier.
after treatment for right leg thrombophlebitis. The Nurse Betty
97.The maximum transfusion time for a unit of packed red
notes that the client’s leg is pain-free, without redness or edema.
blood cells (RBCs) is:
The nurse’s actions reflect which step of the nursing process?
A. 6 hours
A. Assessment
B. 4 hours
B. Diagnosis
C. 3 hours
C. Implementation
D. 2 hours
D. Evaluation
98.Nurse Monique is monitoring the effectiveness of a client’s
92.Nursing care for a female client includes removing elastic
drug therapy. When should the nurse Monique obtain a blood
stockings once per day. The Nurse Betty is aware that the
sample to measure the trough drug level?
rationale for this intervention?
A. 1 hour before administering the next dose.
A. To increase blood flow to the heart
B. Immediately before administering the next dose.
B. To observe the lower extremities
C. Immediately after administering the next dose.
C. To allow the leg muscles to stretch and relax
D. 30 minutes after administering the next dose.
99.Nurse May is aware that the main advantage of using a floor
stock system is:

A. The nurse can implement medication orders

quickly.

B. The nurse receives input from the pharmacist.

C. The system minimizes transcription errors.

D. The system reinforces accurate calculations.

100. Nurse Oliver is assessing a client’s abdomen. Which

finding should the nurse report as abnormal?

A. Dullness over the liver.

B. Bowel sounds occurring every 10 seconds.

C. Shifting dullness over the abdomen.

D. Vascular sounds heard over the renal arteries.

 particular disease or set of symptoms in special care areas
Foundation of Professional such as the coronary care unit. Facilities also may institute
medication protocols that specifically designate drugs that a
Nursing Practice nurse may not give.

1. Answer: (D) The actions of a reasonably prudent nurse with 14. Answer: (D) Liquid or semi-liquid stools. Passage of liquid
similar education and experience. The standard of care is or semi-liquid stools results from seepage of unformed bowel
determined by the average degree of skill, care, and diligence contents around the impacted stool in the rectum. Clients
by nurses in similar circumstances. with fecal impaction don’t pass hard, brown, formed stools
because the feces can’t move past the impaction. These
2. Answer: (B) I.M. With a platelet count of 22,000/μl, the clients typically report the urge to defecate (although they
clients tends to bleed easily. Therefore, the nurse should can’t pass stool) and a decreased appetite.
avoid using the I.M. route because the area is a highly
vascular and can bleed readily when penetrated by a needle. 15. Answer: (C) Pulling the helix up and back. To perform an
The bleeding can be difficult to stop. otoscopic examination on an adult, the nurse grasps the helix
of the ear and pulls it up and back to straighten the ear canal.
3. Answer: (C) “Digoxin 0.125 mg P.O. once daily” The nurse For a child, the nurse grasps the helix and pulls it down to
should always place a zero before a decimal point so that no straighten the ear canal. Pulling the lobule in any direction
one misreads the figure, which could result in a dosage error. wouldn’t straighten the ear canal for visualization.
The nurse should never insert a zero at the end of a dosage
that includes a decimal point because this could be misread, 16. Answer: (A) Protect the irritated skin from sunlight.
possibly leading to a tenfold increase in the dosage. Irradiated skin is very sensitive and must be protected with
clothing or sunblock. The priority approach is the avoidance
4. Answer: (A) Ineffective peripheral tissue perfusion related to of strong sunlight.
venous congestion. Ineffective peripheral tissue perfusion
related to venous congestion takes the highest priority 17. Answer: (C) Assist the client in removing dentures and nail
because venous inflammation and clot formation impede polish. Dentures, hairpins, and combs must be removed. Nail
blood flow in a client with deep vein thrombosis. polish must be removed so that cyanosis can be easily
monitored by observing the nail beds.
5. Answer: (B) A 44 year-old myocardial infarction (MI) client
who is complaining of nausea. Nausea is a symptom of 18. Answer: (D) Sudden onset of continuous epigastric and back
impending myocardial infarction (MI) and should be pain. The autodigestion of tissue by the pancreatic enzymes
assessed immediately so that treatment can be instituted and results in pain from inflammation, edema, and possible
further damage to the heart is avoided. hemorrhage. Continuous, unrelieved epigastric or back pain
reflects the inflammatory process in the pancreas.
6. Answer: (C) Check circulation every 15-30 minutes.
Restraints encircle the limbs, which place the client at risk 19. Answer: (B) Provide high-protein, high-carbohydrate diet. A
for circulation being restricted to the distal areas of the positive nitrogen balance is important for meeting metabolic
extremities. Checking the client’s circulation every 15-30 needs, tissue repair, and resistance to infection. Caloric goals
minutes will allow the nurse to adjust the restraints before may be as high as 5000 calories per day.
injury from decreased blood flow occurs.
20. Answer: (A) Blood pressure and pulse rate. The baseline
7. Answer: (A) Prevent stress ulcer. Curling’s ulcer occurs as a must be established to recognize the signs of an anaphylactic
generalized stress response in burn patients. This results in a or hemolytic reaction to the transfusion.
decreased production of mucus and increased secretion of
gastric acid. The best treatment for this prophylactic use of 21. Answer: (D) Immobilize the leg before moving the client. If
antacids and H2 receptor blockers. the nurse suspects a fracture, splinting the area before
moving the client is imperative. The nurse should call for
8. Answer: (D) Continue to monitor and record hourly urine emergency help if the client is not hospitalized and call for a
output. Normal urine output for an adult is approximately 1 physician for the hospitalized client.
ml/minute (60 ml/hour). Therefore, this client’s output is
normal. Beyond continued evaluation, no nursing action is 22. Answer: (B) Admit the client into a private room. The client
warranted. who has a radiation implant is placed in a private room and
has a limited number of visitors. This reduces the exposure
9. Answer: (A) “My ankle looks less swollen now”. Ice of others to the radiation.
application decreases pain and swelling. Continued or
increased pain, redness, and increased warmth are signs of 23. Answer: (C) Risk for infection. Agranulocytosis is
inflammation that shouldn’t occur after ice application characterized by a reduced number of leukocytes
(leucopenia) and neutrophils (neutropenia) in the blood. The
10. Answer: (B) Hyperkalemia. A loop diuretic removes water client is at high risk for infection because of the decreased
and, along with it, sodium and potassium. This may result in body defenses against microorganisms. Deficient knowledge
hypokalemia, hypovolemia, and hyponatremia. related to the nature of the disorder may be appropriate
diagnosis but is not the priority.
11. Answer:(A) Have condescending trust and confidence in
their subordinates. Benevolent-authoritative managers 24. Answer: (B) Place the client on the left side in the
pretentiously show their trust and confidence to their Trendelenburg position. Lying on the left side may prevent
followers. air from flowing into the pulmonary veins. The
Trendelenburg position increases intrathoracic pressure,
12. Answer: (A) Provides continuous, coordinated and which decreases the amount of blood pulled into the vena
comprehensive nursing services. Functional nursing is cava during aspiration.
focused on tasks and activities and not on the care of the
patients. 25. Answer: (A) Autocratic. The autocratic style of leadership is
a task-oriented and directive.
13. Answer: (B) Standard written order. This is a standard
written order. Prescribers write a single order for medications 26. Answer: (D) 2.5 cc. 2.5 cc is to be added, because only a 500
given only once. A stat order is written for medications given cc bag of solution is being medicated instead of a 1 liter.
immediately for an urgent client problem. A standing order,
also known as a protocol, establishes guidelines for treating a 27. Answer: (A) 50 cc/ hour. A rate of 50 cc/hr. The child is to
 receive 400 cc over a period of 8 hours = 50 cc/hr. 41. Answer: (A) Checking and taping all connections. Air leaks
commonly occur if the system isn’t secure. Checking all
28. Answer: (B) Assess the client for presence of pain. Assessing connections and taping them will prevent air leaks. The chest
the client for pain is a very important measure. Postoperative drainage system is kept lower to promote drainage – not to
pain is an indication of complication. The nurse should also prevent leaks.
assess the client for pain to provide for the client’s comfort.
42. Answer: (A) Check the client’s identification band. Checking
29. Answer: (A) BP – 80/60, Pulse – 110 irregular. The classic the client’s identification band is the safest way to verify a
signs of cardiogenic shock are low blood pressure, rapid and client’s identity because the band is assigned on admission
weak irregular pulse, cold, clammy skin, decreased urinary and isn’t be removed at any time. (If it is removed, it must be
output, and cerebral hypoxia. replaced). Asking the client’s name or having the client
repeated his name would be appropriate only for a client
30. Answer: (A) Take the proper equipment, place the client in a who’s alert, oriented, and able to understand what is being
comfortable position, and record the appropriate information said, but isn’t the safe standard of practice. Names on bed
in the client’s chart. It is a general or comprehensive aren’t always reliable
statement about the correct procedure, and it includes the
basic ideas which are found in the other options 43. Answer: (B) 32 drops/minute. Giving 1,000 ml over 8 hours
is the same as giving 125 ml over 1 hour (60 minutes). Find
31. Answer: (B) Evaluation. Evaluation includes observing the the number of milliliters per minute as follows:
person, asking questions, and comparing the patient’s
behavioral responses with the expected outcomes. ■ 125/60 minutes = X/1 minute
32. Answer: (C) History of present illness. The history of present ■ 60X = 125 = 2.1 ml/minute
illness is the single most important factor in assisting the
health professional in arriving at a diagnosis or determining ■ To find the number of drops per minute:
the person’s needs.
■ 2.1 ml/X gtt = 1 ml/ 15 gtt
33. Answer: (A) Trochanter roll extending from the crest of the
ileum to the mid-thigh. A trochanter roll, properly placed, ■ X = 32 gtt/minute, or 32 drops/minute
provides resistance to the external rotation of the hip.
44. Answer: (A) Clamp the catheter. If a central venous catheter
34. Answer: (C) Stage III. Clinically, a deep crater or without becomes disconnected, the nurse should immediately apply a
undermining of adjacent tissue is noted. catheter clamp, if available. If a clamp isn’t available, the
nurse can place a sterile syringe or catheter plug in the
35. Answer: (A) Second intention healing. When wounds catheter hub. After cleaning the hub with alcohol or
dehisce, they will allowed to heal by secondary intention povidone-iodine solution, the nurse must replace the I.V.
extension and restart the infusion.
36. Answer: (D) Tachycardia. With an extracellular fluid or
plasma volume deficit, compensatory mechanisms stimulate 45. Answer: (D) Auscultation, percussion, and palpation.The
the heart, causing an increase in heart rate. correct order of assessment for examining the abdomen is
inspection, auscultation, percussion, and palpation. The
37. Answer: (A) 0.75. To determine the number of milliliters the reason for this approach is that the less intrusive techniques
client should receive, the nurse uses the fraction method in should be performed before the more intrusive techniques.
the following equation. Percussion and palpation can alter natural findings during
auscultation.
■ 75 mg/X ml = 100 mg/1 ml
46. Answer: (D) Ulnar surface of the hand. The nurse uses the
■ To solve for X, cross-multiply: ulnar surface, or ball, of the hand to asses tactile fremitus,
thrills, and vocal vibrations through the chest wall. The
■ 75 mg x 1 ml = X ml x 100 mg fingertips and finger pads best distinguish texture and shape.
The dorsal surface best feels warmth.
■ 75 = 100X
47. Answer: (C) Formative. Formative (or concurrent)
■ 75/100 = X
evaluation occurs continuously throughout the teaching and
■ 0.75 ml (or ¾ ml) = X learning process. One benefit is that the nurse can adjust
teaching strategies as necessary to enhance learning.
38. Answer: (D) It’s a measure of effect, not a standard measure Summative, or retrospective, evaluation occurs at the
of weight or quantity. An insulin unit is a measure of effect, conclusion of the teaching and learning session. Informative
not a standard measure of weight or quantity. Different drugs is not a type of evaluation.
measured in units may have no relationship to one another in
quality or quantity. 48. Answer: (B) Once per year. Yearly mammograms should
begin at age 40 and continue for as long as the woman is in
39. Answer: (B) 38.9 °C. To convert Fahrenheit degreed to good health. If health risks, such as family history, genetic
Centigrade, use this formula tendency, or past breast cancer, exist, more frequent
examinations may be necessary.
■ °C = (°F – 32) ÷ 1.8
49. Answer: (A) Respiratory acidosis. The client has a
■ °C = (102 – 32) ÷ 1.8 below-normal (acidic) blood pH value and an above-normal
partial pressure of arterial carbon dioxide (Paco2) value,
■ °C = 70 ÷ 1.8 indicating respiratory acidosis. In respiratory alkalosis, the
pH value is above normal and in the Paco2 value is below
■ °C = 38.9 normal. In metabolic acidosis, the pH and bicarbonate
(Hco3) values are below normal. In metabolic alkalosis, the
40. Answer: (C) Failing eyesight, especially close vision. Failing pH and Hco3 values are above normal.
eyesight, especially close vision, is one of the first signs of
aging in middle life (ages 46 to 64). More frequent aches and 50. Answer: (B) To provide support for the client and family in
pains begin in the early late years (ages 65 to 79). Increase in coping with terminal illness. Hospices provide supportive
loss of muscle tone occurs in later years (age 80 and older). care for terminally ill clients and their families. Hospice care
 doesn’t focus on counseling regarding health care costs. 61. Answer: (A) Puts all the four points of the walker flat on the
Most client referred to hospices have been treated for their floor, puts weight on the hand pieces, and then walks into it.
disease without success and will receive only palliative care When the client uses a walker, the nurse stands adjacent to
in the hospice. the affected side. The client is instructed to put all four points
of the walker 2 feet forward flat on the floor before putting
51. Answer: (C) Using normal saline solution to clean the ulcer weight on hand pieces. This will ensure client safety and
and applying a protective dressing as necessary. Washing the prevent stress cracks in the walker. The client is then
area with normal saline solution and applying a protective instructed to move the walker forward and walk into it.
dressing are within the nurse’s realm of interventions and
will protect the area. Using a povidone-iodine wash and an 62. Answer: (C) Draws one line to cross out the incorrect
antibiotic cream require a physician’s order. Massaging with information and then initials the change. To correct an error
an astringent can further damage the skin. documented in a medical record, the nurse draws one line
through the incorrect information and then initials the error.
52. Answer: (D) Foot. An elastic bandage should be applied An error is never erased and correction fluid is never used in
form the distal area to the proximal area. This method the medical record.
promotes venous return. In this case, the nurse should begin
applying the bandage at the client’s foot. Beginning at the 63. Answer: (C) Secures the client safety belts after transferring
ankle, lower thigh, or knee does not promote venous return. to the stretcher. During the transfer of the client after the
surgical procedure is complete, the nurse should avoid
53. Answer: (B) Hypokalemia. Insulin administration causes exposure of the client because of the risk for potential heat
glucose and potassium to move into the cells, causing loss. Hurried movements and rapid changes in the position
hypokalemia. should be avoided because these predispose the client to
hypotension. At the time of the transfer from the surgery
54. Answer: (A) Throbbing headache or dizziness. Headache and table to the stretcher, the client is still affected by the effects
dizziness often occur when nitroglycerin is taken at the of the anesthesia; therefore, the client should not move self.
beginning of therapy. However, the client usually develops Safety belts can prevent the client from falling off the
tolerance stretcher.
55. Answer: (D) Check the client’s level of consciousness. 64. Answer: (B) Gown and gloves. Contact precautions require
Determining unresponsiveness is the first step assessment the use of gloves and a gown if direct client contact is
action to take. When a client is in ventricular tachycardia, anticipated. Goggles are not necessary unless the nurse
there is a significant decrease in cardiac output. However, anticipates the splashes of blood, body fluids, secretions, or
checking the unresponsiveness ensures whether the client is excretions may occur. Shoe protectors are not necessary.
affected by the decreased cardiac output.
65. Answer: (C) Quad cane. Crutches and a walker can be
56. Answer: (B) On the affected side of the client.When walking difficult to maneuver for a client with weakness on one side.
with clients, the nurse should stand on the affected side and A cane is better suited for client with weakness of the arm
grasp the security belt in the midspine area of the small of and leg on one side. However, the quad cane would provide
the back. The nurse should position the free hand at the the most stability because of the structure of the cane and
shoulder area so that the client can be pulled toward the because a quad cane has four legs.
nurse in the event that there is a forward fall. The client is
instructed to look up and outward rather than at his or her 66. Answer: (D) Left side-lying with the head of the bed
feet. elevated 45 degrees. To facilitate removal of fluid from the
chest wall, the client is positioned sitting at the edge of the
57. Answer: (A) Urine output: 45 ml/hr. Adequate perfusion bed leaning over the bedside table with the feet supported on
must be maintained to all vital organs in order for the client a stool. If the client is unable to sit up, the client is positioned
to remain visible as an organ donor. A urine output of 45 ml lying in bed on the unaffected side with the head of the bed
per hour indicates adequate renal perfusion. Low blood elevated 30 to 45 degrees.
pressure and delayed capillary refill time are circulatory
system indicators of inadequate perfusion. A serum pH of 67. Answer: (D) Reliability Reliability is consistency of the
7.32 is acidotic, which adversely affects all body tissues. research instrument. It refers to the repeatability of the
instrument in extracting the same responses upon its repeated
58. Answer: (D ) Obtaining the specimen from the urinary administration.
drainage bag. A urine specimen is not taken from the urinary
drainage bag. Urine undergoes chemical changes while 68. Answer: (A) Keep the identities of the subject secret.
sitting in the bag and does not necessarily reflect the current Keeping the identities of the research subject secret will
client status. In addition, it may become contaminated with ensure anonymity because this will hinder providing link
bacteria from opening the system. between the information given to whoever is its source.

59. Answer: (B) Cover the client, place the call light within 69. Answer: (A) Descriptive- correlational. Descriptive-
reach, and answer the phone call. Because telephone call is correlational study is the most appropriate for this study
an emergency, the nurse may need to answer it. The other because it studies the variables that could be the antecedents
appropriate action is to ask another nurse to accept the call. of the increased incidence of nosocomial infection.
However, is not one of the options. To maintain privacy and
safety, the nurse covers the client and places the call light 70. Answer: (C) Use of laboratory data. Incidence of nosocomial
within the client’s reach. Additionally, the client’s door infection is best collected through the use of biophysiologic
should be closed or the room curtains pulled around the measures, particularly in vitro measurements, hence
bathing area. laboratory data is essential.

60. Answer: (C) Use a sterile plastic container for obtaining the 71. Answer: (B) Quasi-experiment. Quasi-experiment is done
specimen. Sputum specimens for culture and sensitivity when randomization and control of the variables are not
testing need to be obtained using sterile techniques because possible.
the test is done to determine the presence of organisms. If the
procedure for obtaining the specimen is not sterile, then the 72. Answer: (C) Primary source. This refers to a primary source
specimen is not sterile, then the specimen would be which is a direct account of the investigation done by the
contaminated and the results of the test would be invalid. investigator. In contrast to this is a secondary source, which
is written by someone other than the original researcher.
73. Answer: (A) Non-maleficence. Non-maleficence means do 87. Answer: (D) Ground beef patties. Meat is an excellent source
not cause harm or do any action that will cause any harm to of complete protein, which this client needs to repair the
the patient/client. To do good is referred as beneficence. tissue breakdown caused by pressure ulcers. Oranges and
broccoli supply vitamin C but not protein. Ice cream supplies
74. Answer: (C) Res ipsa loquitor. Res ipsa loquitor literally only some incomplete protein, making it less helpful in tissue
means the thing speaks for itself. This means in operational repair.
terms that the injury caused is the proof that there was a
negligent act. 88. Answer: (D) Sims’ left lateral. The Sims’ left lateral position
is the most common position used to administer a cleansing
75. Answer: (B) The Board can investigate violations of the enema because it allows gravity to aid the flow of fluid along
nursing law and code of ethics. Quasi-judicial power means the curve of the sigmoid colon. If the client can’t assume this
that the Board of Nursing has the authority to investigate position nor has poor sphincter control, the dorsal recumbent
violations of the nursing law and can issue summons, or right lateral position may be used. The supine and prone
subpoena or subpoena duces tecum as needed. positions are inappropriate and uncomfortable for the client.

76. Answer: (C) May apply for re-issuance of his/her license 89. Answer: (A) Arrange for typing and cross matching of the
based on certain conditions stipulated in RA 9173. RA 9173 client’s blood. The nurse first arranges for typing and cross
sec. 24 states that for equity and justice, a revoked license matching of the client’s blood to ensure compatibility with
maybe re-issued provided that the following conditions are donor blood. The other options,although appropriate when
met: a) the cause for revocation of license has already been preparing to administer a blood transfusion, come later.
corrected or removed; and, b) at least four years has elapsed
since the license has been revoked. 90. Answer: (A) Independent. Nursing interventions are
classified as independent, interdependent, or dependent.
77. Answer: (B) Review related literature. After formulating and Altering the drug schedule to coincide with the client’s daily
delimiting the research problem, the researcher conducts a routine represents an independent intervention, whereas
review of related literature to determine the extent of what consulting with the physician and pharmacist to change a
has been done on the study by previous researchers. client’s medication because of adverse reactions represents
an interdependent intervention. Administering an
78. Answer: (B) Hawthorne effect. Hawthorne effect is based on already-prescribed drug on time is a dependent intervention.
the study of Elton Mayo and company about the effect of an An intradependent nursing intervention doesn’t exist.
intervention done to improve the working conditions of the
workers on their productivity. It resulted to an increased 91. Answer: (D) Evaluation. The nursing actions described
productivity but not due to the intervention but due to the constitute evaluation of the expected outcomes. The findings
psychological effects of being observed. They performed show that the expected outcomes have been achieved.
differently because they were under observation. Assessment consists of the client’s history, physical
examination, and laboratory studies. Analysis consists of
79. Answer: (B) Determines the different nationality of patients considering assessment information to derive the appropriate
frequently admitted and decides to get representations nursing diagnosis. Implementation is the phase of the nursing
samples from each. Judgment sampling involves including process where the nurse puts the plan of care into action.
samples according to the knowledge of the investigator about
the participants in the study. 92. Answer: (B) To observe the lower extremities. Elastic
stockings are used to promote venous return. The nurse
80. Answer: (B) Madeleine Leininger. Madeleine Leininger needs to remove them once per day to observe the condition
developed the theory on transcultural theory based on her of the skin underneath the stockings. Applying the stockings
observations on the behavior of selected people within a increases blood flow to the heart. When the stockings are in
culture. place, the leg muscles can still stretch and relax, and the
veins can fill with blood.
81. Answer: (A) Random. Random sampling gives equal chance
for all the elements in the population to be picked as part of 93. Answer:(A) Instructing the client to report any itching,
the sample. swelling, or dyspnea. Because administration of blood or
blood products may cause serious adverse effects such as
82. Answer: (A) Degree of agreement and disagreement. Likert allergic reactions, the nurse must monitor the client for these
scale is a 5-point summated scale used to determine the effects. Signs and symptoms of life-threatening allergic
degree of agreement or disagreement of the respondents to a reactions include itching, swelling, and dyspnea. Although
statement in a study the nurse should inform the client of the duration of the
transfusion and should document its administration, these
83. Answer: (B) Sr. Callista Roy. Sr. Callista Roy developed the
actions are less critical to the client’s immediate health. The
Adaptation Model which involves the physiologic mode,
nurse should assess vital signs at least hourly during the
self-concept mode, role function mode and dependence
transfusion.
mode.
94. Answer: (B) Decrease the rate of feedings and the
84. Answer: (A) Span of control. Span of control refers to the
concentration of the formula. Complaints of abdominal
number of workers who report directly to a manager.
discomfort and nausea are common in clients receiving tube
85. Answer: (B) Autonomy. Informed consent means that the feedings. Decreasing the rate of the feeding and the
patient fully understands about the surgery, including the concentration of the formula should decrease the client’s
risks involved and the alternative solutions. In giving consent discomfort. Feedings are normally given at room temperature
it is done with full knowledge and is given freely. The action to minimize abdominal cramping. To prevent aspiration
of allowing the patient to decide whether a surgery is to be during feeding, the head of the client’s bed should be
done or not exemplifies the bioethical principle of autonomy. elevated at least 30 degrees. Also, to prevent bacterial
growth, feeding containers should be routinely changed
86. Answer: (C) Avoid wearing canvas shoes. The client should every 8 to 12 hours.
be instructed to avoid wearing canvas shoes. Canvas shoes
cause the feet to perspire, which may, in turn, cause skin 95. Answer: (D) Roll the vial gently between the palms. Rolling
irritation and breakdown. Both cotton and cornstarch absorb the vial gently between the palms produces heat, which helps
perspiration. The client should be instructed to cut toenails dissolve the medication. Doing nothing or inverting the vial
straight across with nail clippers. wouldn’t help dissolve the medication. Shaking the vial
vigorously could cause the medication to break down,
 altering its action.

96. Answer: (B) Assist the client to the semi-Fowler position if

possible. By assisting the client to the semi-Fowler position,
the nurse promotes easier chest expansion, breathing, and
oxygen intake. The nurse should secure the elastic band so
that the face mask fits comfortably and snugly rather than
tightly, which could lead to irritation. The nurse should apply
the face mask from the client’s nose down to the chin — not
vice versa. The nurse should check the connectors between
the oxygen equipment and humidifier to ensure that they’re
airtight; loosened connectors can cause loss of oxygen.

97. Answer: (B) 4 hours. A unit of packed RBCs may be given

over a period of between 1 and 4 hours. It shouldn’t infuse
for longer than 4 hours because the risk of contamination and
sepsis increases after that time. Discard or return to the blood
bank any blood not given within this time, according to
facility policy.

98. Answer: (B) Immediately before administering the next dose.

Measuring the blood drug concentration helps determine
whether the dosing has achieved the therapeutic goal. For
measurement of the trough, or lowest, blood level of a drug,
the nurse draws a blood sample immediately before
administering the next dose. Depending on the drug’s
duration of action and half-life, peak blood drug levels
typically are drawn after administering the next dose.

99. Answer: (A) The nurse can implement medication orders

quickly. A floor stock system enables the nurse to implement
medication orders quickly. It doesn’t allow for pharmacist
input, nor does it minimize transcription errors or reinforce
accurate calculations.

100.Answer: (C) Shifting dullness over the abdomen. Shifting

dullness over the abdomen indicates ascites, an abnormal
finding. The other options are normal abdominal findings.
 A. Urinary output 90 cc in 2 hours.
Community Health Nursing
B. Absent patellar reflexes.
and Care of the Mother and
C. Rapid respiratory rate above 40/min.
Child D. Rapid rise in blood pressure.
1. May arrives at the health care clinic and tells the nurse that
her last menstrual period was 9 weeks ago. She also tells the 7. During vaginal examination of Janah who is in labor, the
nurse that a home pregnancy test was positive but she began to presenting part is at station plus two. Nurse, correctly interprets
have mild cramps and is now having moderate vaginal bleeding. it as:
During the physical examination of the client, the nurse notes
A. Presenting part is 2 cm above the plane of the
that May has a dilated cervix. The nurse determines that May is
ischial spines.
experiencing which type of abortion?
B. Biparietal diameter is at the level of the ischial
A. Inevitable
spines.
B. Incomplete
C. Presenting part in 2 cm below the plane of the
C. Threatened ischial spines.

D. Septic D. Biparietal diameter is 2 cm above the ischial

spines.
2. Nurse Reese is reviewing the record of a pregnant client for
her first prenatal visit. Which of the following data, if noted on 8. A pregnant client is receiving oxytocin (Pitocin) for induction
the client’s record, would alert the nurse that the client is at risk of labor. A condition that warrant the nurse in-charge to
for a spontaneous abortion? discontinue I.V. infusion of Pitocin is:

A. Age 36 years A. Contractions every 1 ½ minutes lasting 70-80

seconds.
B. History of syphilis
B. Maternal temperature 101.2
C. History of genital herpes
C. Early decelerations in the fetal heart rate.
D. History of diabetes mellitus
D. Fetal heart rate baseline 140-160 bpm.
3. Nurse Hazel is preparing to care for a client who is newly
admitted to the hospital with a possible diagnosis of ectopic 9. Calcium gluconate is being administered to a client with
pregnancy. Nurse Hazel develops a plan of care for the client pregnancy induced hypertension (PIH). A nursing action that
and determines that which of the following nursing actions is the must be initiated as the plan of care throughout injection of the
priority? drug is:

A. Monitoring weight A. Ventilator assistance

B. Assessing for edema B. CVP readings

C. Monitoring apical pulse C. EKG tracings

D. Monitoring temperature D. Continuous CPR

4. Nurse Oliver is teaching a diabetic pregnant client about 10. A trial for vaginal delivery after an earlier caesareans, would
nutrition and insulin needs during pregnancy. The nurse likely to be given to a gravida, who had:
determines that the client understands dietary and insulin needs
A. First low transverse cesarean was for active
if the client states that the second half of pregnancy require:
herpes type 2 infections; vaginal culture at 39
A. Decreased caloric intake weeks pregnancy was positive.

B. Increased caloric intake B. First and second caesareans were for

cephalopelvic disproportion.
C. Decreased Insulin
C. First caesarean through a classic incision as a
D. Increase Insulin result of severe fetal distress.

5. Nurse Michelle is assessing a 24 year old client with a D. First low transverse caesarean was for breech
diagnosis of hydatidiform mole. She is aware that one of the position. Fetus in this pregnancy is in a vertex
following is unassociated with this condition? presentation.

A. Excessive fetal activity. 11.Nurse Ryan is aware that the best initial approach when
trying to take a crying toddler’s temperature is:
B. Larger than normal uterus for gestational age.
A. Talk to the mother first and then to the toddler.
C. Vaginal bleeding
B. Bring extra help so it can be done quickly.
D. Elevated levels of human chorionic gonadotropin.
C. Encourage the mother to hold the child.
6. A pregnant client is receiving magnesium sulfate for severe
pregnancy induced hypertension (PIH). The clinical findings D. Ignore the crying and screaming.
that would warrant use of the antidote , calcium gluconate is:
12.Baby Tina a 3 month old infant just had a cleft lip and palate
repair. What should the nurse do to prevent trauma to operative
site? C. Regional Health Office

A. Avoid touching the suture line, even when D. Rural Health Unit
cleaning.
19.Tony is aware the Chairman of the Municipal Health Board
B. Place the baby in prone position. is:

C. Give the baby a pacifier. A. Mayor

D. Place the infant’s arms in soft elbow restraints. B. Municipal Health Officer

13. Which action should nurse Marian include in the care plan C. Public Health Nurse
for a 2 month old with heart failure?
D. Any qualified physician
A. Feed the infant when he cries.
20.Myra is the public health nurse in a municipality with a total
B. Allow the infant to rest before feeding. population of about 20,000. There are 3 rural health midwives
among the RHU personnel. How many more midwife items will
C. Bathe the infant and administer medications the RHU need?
before feeding.
A. 1
D. Weigh and bathe the infant before feeding.
B. 2
14.Nurse Hazel is teaching a mother who plans to discontinue
breast feeding after 5 months. The nurse should advise her to C. 3
include which foods in her infant’s diet?
D. The RHU does not need any more midwife item.
A. Skim milk and baby food.
21.According to Freeman and Heinrich, community health
B. Whole milk and baby food. nursing is a developmental service. Which of the following best
illustrates this statement?
C. Iron-rich formula only.
A. The community health nurse continuously
D. Iron-rich formula and baby food. develops himself personally and professionally.

15.Mommy Linda is playing with her infant, who is sitting B. Health education and community organizing are
securely alone on the floor of the clinic. The mother hides a toy necessary in providing community health
behind her back and the infant looks for it. The nurse is aware services.
that estimated age of the infant would be:
C. Community health nursing is intended primarily
A. 6 months for health promotion and prevention and treatment
of disease.
B. 4 months
D. The goal of community health nursing is to
C. 8 months provide nursing services to people in their own
places of residence.
D. 10 months
22.Nurse Tina is aware that the disease declared through
16.Which of the following is the most prominent feature of Presidential Proclamation No. 4 as a target for eradication in the
public health nursing? Philippines is?
A. It involves providing home care to sick people A. Poliomyelitis
who are not confined in the hospital.
B. Measles
B. Services are provided free of charge to people
within the catchments area. C. Rabies
C. The public health nurse functions as part of a team D. Neonatal tetanus
providing a public health nursing services.
23.May knows that the step in community organizing that
D. Public health nursing focuses on preventive, not involves training of potential leaders in the community is:
curative, services.
A. Integration
17.When the nurse determines whether resources were
maximized in implementing Ligtas Tigdas, she is evaluating B. Community organization
A. Effectiveness C. Community study

B. Efficiency D. Core group formation

C. Adequacy 24.Beth a public health nurse takes an active role in community

participation. What is the primary goal of community
D. Appropriateness organizing?
18.Vangie is a new B.S.N. graduate. She wants to become a A. To educate the people regarding community
Public Health Nurse. Where should she apply? health problems
A. Department of Health B. To mobilize the people to resolve community
health problems
B. Provincial Health Office
 C. To maximize the community’s resources in A. Menorrhagia
dealing with health problems.
B. Metrorrhagia
D. To maximize the community’s resources in
dealing with health problems. C. Dyspareunia

25.Tertiary prevention is needed in which stage of the natural D. Amenorrhea

history of disease?
32. Jannah is admitted to the labor and delivery unit. The critical
A. Pre-pathogenesis laboratory result for this client would be:

B. Pathogenesis A. Oxygen saturation

C. Prodromal B. Iron binding capacity

D. Terminal C. Blood typing

26.The nurse is caring for a primigravid client in the labor and D. Serum Calcium
delivery area. Which condition would place the client at risk for
disseminated intravascular coagulation (DIC)? 33.Nurse Gina is aware that the most common condition found
during the second-trimester of pregnancy is:
A. Intrauterine fetal death.
A. Metabolic alkalosis
B. Placenta accreta.
B. Respiratory acidosis
C. Dysfunctional labor.
C. Mastitis
D. Premature rupture of the membranes.
D. Physiologic anemia
27.A fullterm client is in labor. Nurse Betty is aware that the
fetal heart rate would be: 34.Nurse Lynette is working in the triage area of an emergency
department. She sees that several pediatric clients arrive
A. 80 to 100 beats/minute simultaneously. The client who needs to be treated first is:

B. 100 to 120 beats/minute A. A crying 5 year old child with a laceration on his
scalp.
C. 120 to 160 beats/minute
B. A 4 year old child with a barking coughs and
D. 160 to 180 beats/minute flushed appearance.

28.The skin in the diaper area of a 7 month old infant is C. A 3 year old child with Down syndrome who is
excoriated and red. Nurse Hazel should instruct the mother to: pale and asleep in his mother’s arms.

A. Change the diaper more often. D. A 2 year old infant with stridorous breath
sounds, sitting up in his mother’s arms and
B. Apply talc powder with diaper changes. drooling.

C. Wash the area vigorously with each diaper 35.Maureen in her third trimester arrives at the emergency room
change. with painless vaginal bleeding. Which of the following
conditions is suspected?
D. Decrease the infant’s fluid intake to decrease
saturating diapers. A. Placenta previa

29.Nurse Carla knows that the common cardiac anomalies in B. Abruptio placentae
children with Down Syndrome (tri-somy 21) is:
C. Premature labor
A. Atrial septal defect
D. Sexually transmitted disease
B. Pulmonic stenosis
36.A young child named Richard is suspected of having
C. Ventricular septal defect pinworms. The community nurse collects a stool specimen to
confirm the diagnosis. The nurse should schedule the collection
D. Endocardial cushion defect of this specimen for:
30.Malou was diagnosed with severe preeclampsia is now A. Just before bedtime
receiving I.V. magnesium sulfate. The adverse effects associated
with magnesium sulfate is: B. After the child has been bathe

A. Anemia C. Any time during the day

B. Decreased urine output D. Early in the morning

C. Hyperreflexia 37.In doing a child’s admission assessment, Nurse Betty should
be alert to note which signs or symptoms of chronic lead
D. Increased respiratory rate poisoning?
31.A 23 year old client is having her menstrual period every 2 A. Irritability and seizures
weeks that last for 1 week. This type of menstrual pattern is bets
defined by: B. Dehydration and diarrhea
 C. Bradycardia and hypotension B. Patant fontanelles

D. Petechiae and hematuria C. Moro’s reflex

38.To evaluate a woman’s understanding about the use of D. Voided

diaphragm for family planning, Nurse Trish asks her to explain
how she will use the appliance. Which response indicates a need 44.Nurse Carla should know that the most common causative
for further health teaching? factor of dermatitis in infants and younger children is:

A. “I should check the diaphragm carefully for A. Baby oil

holes every time I use it”
B. Baby lotion
B. “I may need a different size of diaphragm if I
gain or lose weight more than 20 pounds” C. Laundry detergent

C. “The diaphragm must be left in place for atleast D. Powder with cornstarch
6 hours after intercourse”
45.During tube feeding, how far above an infant’s stomach
D. “I really need to use the diaphragm and jelly should the nurse hold the syringe with formula?
most during the middle of my menstrual cycle”.
A. 6 inches
39.Hypoxia is a common complication of
laryngotracheobronchitis. Nurse Oliver should frequently assess B. 12 inches
a child with laryngotracheobronchitis for:
C. 18 inches
A. Drooling
D. 24 inches
B. Muffled voice
46. In a mothers’ class, Nurse Lhynnete discussed childhood
C. Restlessness diseases such as chicken pox. Which of the following statements
about chicken pox is correct?
D. Low-grade fever
A. The older one gets, the more susceptible he
40.How should Nurse Michelle guide a child who is blind to becomes to the complications of chicken pox.
walk to the playroom?
B. A single attack of chicken pox will prevent future
A. Without touching the child, talk continuously as episodes, including conditions such as shingles.
the child walks down the hall.
C. To prevent an outbreak in the community,
B. Walk one step ahead, with the child’s hand on quarantine may be imposed by health authorities.
the nurse’s elbow.
D. Chicken pox vaccine is best given when there is
C. Walk slightly behind, gently guiding the child an impending outbreak in the community.
forward.
47.Barangay Pinoy had an outbreak of German measles. To
D. Walk next to the child, holding the child’s hand. prevent congenital rubella, what is the BEST advice that you
can give to women in the first trimester of pregnancy in the
41.When assessing a newborn diagnosed with ductus arteriosus, barangay Pinoy?
Nurse Olivia should expect that the child most likely would
have an: A. Advice them on the signs of German measles.

A. Loud, machinery-like murmur. B. Avoid crowded places, such as markets and

movie houses.
B. Bluish color to the lips.
C. Consult at the health center where rubella
C. Decreased BP reading in the upper extremities vaccine may be given.

D. Increased BP reading in the upper extremities. D. Consult a physician who may give them rubella
immunoglobulin.
42.The reason nurse May keeps the neonate in a neutral thermal
environment is that when a newborn becomes too cool, the 48.Myrna a public health nurse knows that to determine possible
neonate requires: sources of sexually transmitted infections, the BEST method
that may be undertaken is:
A. Less oxygen, and the newborn’s metabolic rate
increases. A. Contact tracing

B. More oxygen, and the newborn’s metabolic rate B. Community survey

decreases.
C. Mass screening tests
C. More oxygen, and the newborn’s metabolic rate
increases. D. Interview of suspects

D. Less oxygen, and the newborn’s metabolic rate 49.A 33-year old female client came for consultation at the
decreases. health center with the chief complaint of fever for a week.
Accompanying symptoms were muscle pains and body malaise.
43.Before adding potassium to an infant’s I.V. line, Nurse Ron A week after the start of fever, the client noted yellowish
must be sure to assess whether this infant has: discoloration of his sclera. History showed that he waded in
flood waters about 2 weeks before the onset of symptoms.
A. Stable blood pressure Based on her history, which disease condition will you suspect?
 A. Hepatitis A D. 65 infants

B. Hepatitis B 56.The community nurse is aware that the biological used in

Expanded Program on Immunization (EPI) should NOT be
C. Tetanus stored in the freezer?

D. Leptospirosis A. DPT

50.Mickey a 3-year old client was brought to the health center B. Oral polio vaccine
with the chief complaint of severe diarrhea and the passage of
“rice water” stools. The client is most probably suffering from C. Measles vaccine
which condition?
D. MMR
A. Giardiasis
57.It is the most effective way of controlling schistosomiasis in
B. Cholera an endemic area?

C. Amebiasis A. Use of molluscicides

D. Dysentery B. Building of foot bridges

51.The most prevalent form of meningitis among children aged C. Proper use of sanitary toilets
2 months to 3 years is caused by which microorganism?
D. Use of protective footwear, such as rubber boots
A. Hemophilus influenzae
58.Several clients is newly admitted and diagnosed with leprosy.
B. Morbillivirus Which of the following clients should be classified as a case of
multibacillary leprosy?
C. Steptococcus pneumoniae
A. 3 skin lesions, negative slit skin smear
D. Neisseria meningitidis
B. 3 skin lesions, positive slit skin smear
52.The student nurse is aware that the pathognomonic sign of
measles is Koplik’s spot and you may see Koplik’s spot by C. 5 skin lesions, negative slit skin smear
inspecting the:
D. 5 skin lesions, positive slit skin smear
A. Nasal mucosa
59.Nurses are aware that diagnosis of leprosy is highly
B. Buccal mucosa dependent on recognition of symptoms. Which of the following
is an early sign of leprosy?
C. Skin on the abdomen
A. Macular lesions
D. Skin on neck
B. Inability to close eyelids
53.Angel was diagnosed as having Dengue fever. You will say
that there is slow capillary refill when the color of the nailbed C. Thickened painful nerves
that you pressed does not return within how many seconds?
D. Sinking of the nosebridge
A. 3 seconds
60.Marie brought her 10 month old infant for consultation
B. 6 seconds because of fever, started 4 days prior to consultation. In
determining malaria risk, what will you do?
C. 9 seconds
A. Perform a tourniquet test.
D. 10 seconds
B. Ask where the family resides.
54.In Integrated Management of Childhood Illness, the nurse is
aware that the severe conditions generally require urgent referral C. Get a specimen for blood smear.
to a hospital. Which of the following severe conditions DOES
NOT always require urgent referral to a hospital? D. Ask if the fever is present everyday.

A. Mastoiditis 61.Susie brought her 4 years old daughter to the RHU because
of cough and colds. Following the IMCI assessment guide,
B. Severe dehydration which of the following is a danger sign that indicates the need
for urgent referral to a hospital?
C. Severe pneumonia
A. Inability to drink
D. Severe febrile disease
B. High grade fever
55.Myrna a public health nurse will conduct outreach
immunization in a barangay Masay with a population of about C. Signs of severe dehydration
1500. The estimated number of infants in the barangay would
be: D. Cough for more than 30 days

A. 45 infants 62.Jimmy a 2-year old child revealed “baggy pants”. As a nurse,

using the IMCI guidelines, how will you manage Jimmy?
B. 50 infants
A. Refer the child urgently to a hospital for
C. 55 infants confinement.
 B. Coordinate with the social worker to enroll the C. 1 year
child in a feeding program.
D. 2 years
C. Make a teaching plan for the mother, focusing on
menu planning for her child. 69.Nurse Ron is aware that the gestational age of a conceptus
that is considered viable (able to live outside the womb) is:
D. Assess and treat the child for health problems
like infections and intestinal parasitism. A. 8 weeks

63.Gina is using Oresol in the management of diarrhea of her B. 12 weeks

3-year old child. She asked you what to do if her child vomits.
As a nurse you will tell her to: C. 24 weeks

A. Bring the child to the nearest hospital for further D. 32 weeks

assessment.
70.When teaching parents of a neonate the proper position for
B. Bring the child to the health center for the neonate’s sleep, the nurse Patricia stresses the importance of
intravenous fluid therapy. placing the neonate on his back to reduce the risk of which of
the following?
C. Bring the child to the health center for
assessment by the physician. A. Aspiration

D. Let the child rest for 10 minutes then continue B. Sudden infant death syndrome (SIDS)
giving Oresol more slowly.
C. Suffocation
64.Nikki a 5-month old infant was brought by his mother to the
health center because of diarrhea for 4 to 5 times a day. Her skin D. Gastroesophageal reflux (GER)
goes back slowly after a skin pinch and her eyes are sunken.
71.Which finding might be seen in baby James a neonate
Using the IMCI guidelines, you will classify this infant in which
suspected of having an infection?
category?
A. Flushed cheeks
A. No signs of dehydration
B. Increased temperature
B. Some dehydration
C. Decreased temperature
C. Severe dehydration
D. Increased activity level
D. The data is insufficient.
72.Baby Jenny who is small-for-gestation is at increased risk
65.Chris a 4-month old infant was brought by her mother to the
during the transitional period for which complication?
health center because of cough. His respiratory rate is
42/minute. Using the Integrated Management of Child Illness A. Anemia probably due to chronic fetal hyposia
(IMCI) guidelines of assessment, his breathing is considered as:
B. Hyperthermia due to decreased glycogen stores
A. Fast
C. Hyperglycemia due to decreased glycogen stores
B. Slow
D. Polycythemia probably due to chronic fetal
C. Normal hypoxia
D. Insignificant 73.Marjorie has just given birth at 42 weeks’ gestation. When
the nurse assessing the neonate, which physical finding is
66.Maylene had just received her 4th dose of tetanus toxoid. She
expected?
is aware that her baby will have protection against tetanus for
A. A sleepy, lethargic baby
A. 1 year
B. Lanugo covering the body
B. 3 years
C. Desquamation of the epidermis
C. 5 years
D. Vernix caseosa covering the body
D. Lifetime
74.After reviewing the Myrna’s maternal history of magnesium
67.Nurse Ron is aware that unused BCG should be discarded
sulfate during labor, which condition would nurse Richard
after how many hours of reconstitution?
anticipate as a potential problem in the neonate?
A. 2 hours
A. Hypoglycemia
B. 4 hours
B. Jitteriness
C. 8 hours
C. Respiratory depression
D. At the end of the day
D. Tachycardia
68.The nurse explains to a breastfeeding mother that breast milk
75.Which symptom would indicate the Baby Alexandra was
is sufficient for all of the baby’s nutrient needs only up to:
adapting appropriately to extra-uterine life without difficulty?
A. 5 months
A. Nasal flaring
B. 6 months
 B. Light audible grunting A. “Do you have any chronic illnesses?”

C. Respiratory rate 40 to 60 breaths/minute B. “Do you have any allergies?”

D. Respiratory rate 60 to 80 breaths/minute C. “What is your expected due date?”

76. When teaching umbilical cord care for Jennifer a new D. “Who will be with you during labor?”
mother, the nurse Jenny would include which information?
82.A neonate begins to gag and turns a dusky color. What
A. Apply peroxide to the cord with each diaper should the nurse do first?
change
A. Calm the neonate.
B. Cover the cord with petroleum jelly after bathing
B. Notify the physician.
C. Keep the cord dry and open to air
C. Provide oxygen via face mask as ordered
D. Wash the cord with soap and water each day
during a tub bath. D. Aspirate the neonate’s nose and mouth with a bulb
syringe.
77.Nurse John is performing an assessment on a neonate. Which
of the following findings is considered common in the healthy 83. When a client states that her “water broke,” which of the
neonate? following actions would be inappropriate for the nurse to do?

A. Simian crease A. Observing the pooling of straw-colored fluid.

B. Conjunctival hemorrhage B. Checking vaginal discharge with nitrazine paper.

C. Cystic hygroma C. Conducting a bedside ultrasound for an amniotic

fluid index.
D. Bulging fontanelle
D. Observing for flakes of vernix in the vaginal
78.Dr. Esteves decides to artificially rupture the membranes of a discharge.
mother who is on labor. Following this procedure, the nurse
Hazel checks the fetal heart tones for which the following 84. A baby girl is born 8 weeks premature. At birth, she has no
reasons? spontaneous respirations but is successfully resuscitated. Within
several hours she develops respiratory grunting, cyanosis,
A. To determine fetal well-being. tachypnea, nasal flaring, and retractions. She’s diagnosed with
respiratory distress syndrome, intubated, and placed on a
B. To assess for prolapsed cord ventilator. Which nursing action should be included in the
baby’s plan of care to prevent retinopathy of prematurity?
C. To assess fetal position
A. Cover his eyes while receiving oxygen.
D. To prepare for an imminent delivery.
B. Keep her body temperature low.
79.Which of the following would be least likely to indicate
anticipated bonding behaviors by new parents? C. Monitor partial pressure of oxygen (Pao2) levels.

A. The parents’ willingness to touch and hold the D. Humidify the oxygen.
new born.
85. Which of the following is normal newborn calorie intake?
B. The parent’s expression of interest about the size
of the new born. A. 110 to 130 calories per kg.

C. The parents’ indication that they want to see the B. 30 to 40 calories per lb of body weight.
newborn.
C. At least 2 ml per feeding
D. The parents’ interactions with each other.
D. 90 to 100 calories per kg
80.Following a precipitous delivery, examination of the client’s
vagina reveals 86. Nurse John is knowledgeable that usually individual twins
will grow appropriately and at the same rate as singletons until
a fourth-degree laceration. Which of the following would be how many weeks?
contraindicated when caring for this client?
A. 16 to 18 weeks
A. Applying cold to limit edema during the first 12 to
24 hours. B. 18 to 22 weeks

B. Instructing the client to use two or more peripads C. 30 to 32 weeks

to cushion the area.
D. 38 to 40 weeks
C. Instructing the client on the use of sitz baths if
ordered. 87. Which of the following classifications applies to
monozygotic twins for whom the cleavage of the fertilized
D. Instructing the client about the importance of ovum occurs more than 13 days after fertilization?
perineal (kegel) exercises.
A. conjoined twins
81. A pregnant woman accompanied by her husband, seeks
admission to the labor and delivery area. She states that she’s in B. diamniotic dichorionic twins
labor and says she attended the facility clinic for prenatal care.
Which question should the nurse Oliver ask her first? C. diamniotic monochorionic twin
 D. monoamniotic monochorionic twins appears in 48 to 72 hours.

88. Tyra experienced painless vaginal bleeding has just been C. A flat circumcised area under 10 mm in diameter
diagnosed as having a placenta previa. Which of the following appears in 6 to 12 hours.
procedures is usually performed to diagnose placenta previa?
D. A flat circumcised area over 10 mm in diameter
A. Amniocentesis appears in 48 to 72 hours.

B. Digital or speculum examination 95. Dianne, 24 year-old is 27 weeks’ pregnant arrives at her
physician’s office with complaints of fever, nausea, vomiting,
C. External fetal monitoring malaise, unilateral flank pain, and costovertebral angle
tenderness. Which of the following diagnoses is most likely?
D. Ultrasound
A. Asymptomatic bacteriuria
89. Nurse Arnold knows that the following changes in
respiratory functioning during pregnancy is considered normal: B. Bacterial vaginosis

A. Increased tidal volume C. Pyelonephritis

B. Increased expiratory volume D. Urinary tract infection (UTI)

C. Decreased inspiratory capacity 96. Rh isoimmunization in a pregnant client develops during

which of the following conditions?
D. Decreased oxygen consumption
A. Rh-positive maternal blood crosses into fetal
90. Emily has gestational diabetes and it is usually managed by blood, stimulating fetal antibodies.
which of the following therapy?
B. Rh-positive fetal blood crosses into maternal
A. Diet blood, stimulating maternal antibodies.
B. Long-acting insulin C. Rh-negative fetal blood crosses into maternal
blood, stimulating maternal antibodies.
C. Oral hypoglycemic
D. Rh-negative maternal blood crosses into fetal
D. Oral hypoglycemic drug and insulin blood, stimulating fetal antibodies.
91. Magnesium sulfate is given to Jemma with preeclampsia to 97. To promote comfort during labor, the nurse John advises a
prevent which of the following condition? client to assume certain positions and avoid others. Which
position may cause maternal hypotension and fetal hypoxia?
A. Hemorrhage
A. Lateral position
B. Hypertension
B. Squatting position
C. Hypomagnesemia
C. Supine position
D. Seizure
D. Standing position
92. Cammile with sickle cell anemia has an increased risk for
having a sickle cell crisis during pregnancy. Aggressive 98. Celeste who used heroin during her pregnancy delivers a
management of a sickle cell crisis includes which of the neonate. When assessing the neonate, the nurse Lhynnette
following measures? expects to find:
A. Antihypertensive agents A. Lethargy 2 days after birth.
B. Diuretic agents B. Irritability and poor sucking.
C. I.V. fluids C. A flattened nose, small eyes, and thin lips.
D. Acetaminophen (Tylenol) for pain D. Congenital defects such as limb anomalies.
93. Which of the following drugs is the antidote for magnesium 99. The uterus returns to the pelvic cavity in which of the
toxicity? following time frames?
A. Calcium gluconate (Kalcinate) A. 7th to 9th day postpartum.
B. Hydralazine (Apresoline) B. 2 weeks postpartum.
C. Naloxone (Narcan) C. End of 6th week postpartum.
D. Rho (D) immune globulin (RhoGAM) D. When the lochia changes to alba.
94. Marlyn is screened for tuberculosis during her first prenatal 100. Maureen, a primigravida client, age 20, has just completed
visit. An intradermal injection of purified protein derivative a difficult, forceps-assisted delivery of twins. Her labor was
(PPD) of the tuberculin bacilli is given. She is considered to unusually long and required oxytocin (Pitocin) augmentation.
have a positive test for which of the following results? The nurse who’s caring for her should stay alert for:
A. An indurated wheal under 10 mm in diameter A. Uterine inversion
appears in 6 to 12 hours.
B. Uterine atony
B. An indurated wheal over 10 mm in diameter
C. Uterine involution

D. Uterine discomfort
 should be cleaned gently to prevent infection, which could
Community Health Nursing interfere with healing and damage the cosmetic appearance
of the repair.
and Care of the Mother and
13. Answer: (B) Allow the infant to rest before feeding. Because
Child feeding requires so much energy, an infant with heart failure
should rest before feeding.
1. Answer: (A) Inevitable. An inevitable abortion is termination
of pregnancy that cannot be prevented. Moderate to severe 14. Answer: (C) Iron-rich formula only. The infants at age 5
bleeding with mild cramping and cervical dilation would be months should receive iron-rich formula and that they
noted in this type of abortion. shouldn’t receive solid food, even baby food until age 6
months.
2. Answer: (B) History of syphilis. Maternal infections such as
syphilis, toxoplasmosis, and rubella are causes of 15. Answer: (D) 10 months. A 10 month old infant can sit alone
spontaneous abortion. and understands object permanence, so he would look for the
hidden toy. At age 4 to 6 months, infants can’t sit securely
3. Answer: (C) Monitoring apical pulse. Nursing care for the alone. At age 8 months, infants can sit securely alone but
client with a possible ectopic pregnancy is focused on cannot understand the permanence of objects.
preventing or identifying hypovolemic shock and controlling
pain. An elevated pulse rate is an indicator of shock. 16. Answer: (D) Public health nursing focuses on preventive, not
curative, services. The catchments area in PHN consists of a
4. Answer: (B) Increased caloric intake. Glucose crosses the residential community, many of whom are well individuals
placenta, but insulin does not. High fetal demands for who have greater need for preventive rather than curative
glucose, combined with the insulin resistance caused by services.
hormonal changes in the last half of pregnancy can result in
elevation of maternal blood glucose levels. This increases the 17. Answer: (B) Efficiency. Efficiency is determining whether
mother’s demand for insulin and is referred to as the the goals were attained at the least possible cost.
diabetogenic effect of pregnancy.
18. Answer: (D) Rural Health Unit. R.A. 7160 devolved basic
5. Answer: (A) Excessive fetal activity. The most common health services to local government units (LGU’s ). The
signs and symptoms of hydatidiform mole includes elevated public health nurse is an employee of the LGU.
levels of human chorionic gonadotropin, vaginal bleeding,
larger than normal uterus for gestational age, failure to detect 19. Answer: (A) Mayor. The local executive serves as the
fetal heart activity even with sensitive instruments, excessive chairman of the Municipal Health Board.
nausea and vomiting, and early development of
pregnancy-induced hypertension. Fetal activity would not be 20. Answer: (A) 1. Each rural health midwife is given a
noted. population assignment of about 5,000.

6. Answer: (B) Absent patellar reflexes. Absence of patellar 21. Answer: (B) Health education and community organizing are
reflexes is an indicator of hypermagnesemia, which requires necessary in providing community health services. The
administration of calcium gluconate. community health nurse develops the health capability of
people through health education and community organizing
7. Answer: (C) Presenting part in 2 cm below the plane of the activities.
ischial spines. Fetus at station plus two indicates that the
presenting part is 2 cm below the plane of the ischial spines. 22. Answer: (B) Measles. Presidential Proclamation No. 4 is on
the Ligtas Tigdas Program.
8. Answer: (A) Contractions every 1 ½ minutes lasting 70-80
seconds. Contractions every 1 ½ minutes lasting 70-80 23. Answer: (D) Core group formation. In core group formation,
seconds, is indicative of hyperstimulation of the uterus, the nurse is able to transfer the technology of community
which could result in injury to the mother and the fetus if organizing to the potential or informal community leaders
Pitocin is not discontinued. through a training program.

9. Answer: (C) EKG tracings. A potential side effect of calcium 24. Answer: (D) To maximize the community’s resources in
gluconate administration is cardiac arrest. Continuous dealing with health problems. Community organizing is a
monitoring of cardiac activity (EKG) throught administration developmental service, with the goal of developing the
of calcium gluconate is an essential part of care. people’s self-reliance in dealing with community health
problems. A, B and C are objectives of contributory
10. Answer: (D) First low transverse caesarean was for breech objectives to this goal.
position. Fetus in this pregnancy is in a vertex presentation.
This type of client has no obstetrical indication for a 25. Answer: (D) Terminal. Tertiary prevention involves
caesarean section as she did with her first caesarean delivery. rehabilitation, prevention of permanent disability and
disability limitation appropriate for convalescents, the
11. Answer: (A) Talk to the mother first and then to the toddler. disabled, complicated cases and the terminally ill (those in
When dealing with a crying toddler, the best approach is to the terminal stage of a disease).
talk to the mother and ignore the toddler first. This approach
helps the toddler get used to the nurse before she attempts 26. Answer: (A) Intrauterine fetal death. Intrauterine fetal death,
any procedures. It also gives the toddler an opportunity to abruptio placentae, septic shock, and amniotic fluid
see that the mother trusts the nurse. embolism may trigger normal clotting mechanisms; if
clotting factors are depleted, DIC may occur. Placenta
12. Answer: (D) Place the infant’s arms in soft elbow restraints. accreta, dysfunctional labor, and premature rupture of the
Soft restraints from the upper arm to the wrist prevent the membranes aren’t associated with DIC.
infant from touching her lip but allow him to hold a favorite
item such as a blanket. Because they could damage the 27. Answer: (C) 120 to 160 beats/minute. A rate of 120 to 160
operative site, such as objects as pacifiers, suction catheters, beats/minute in the fetal heart appropriate for filling the heart
and small spoons shouldn’t be placed in a baby’s mouth after with blood and pumping it out to the system.
cleft repair. A baby in a prone position may rub her face on
28. Answer: (A) Change the diaper more often. Decreasing the
the sheets and traumatize the operative site. The suture line
amount of time the skin comes contact with wet soiled
 diapers will help heal the irritation. not voiding, the nurse should withhold the potassium and
notify the physician.
29. Answer: (D) Endocardial cushion defect. Endocardial
cushion defects are seen most in children with Down 44. Answer: (C) Laundry detergent. Eczema or dermatitis is an
syndrome, asplenia, or polysplenia. allergic skin reaction caused by an offending allergen. The
topical allergen that is the most common causative factor is
30. Answer: (B) Decreased urine output. Decreased urine output laundry detergent.
may occur in clients receiving I.V. magnesium and should be
monitored closely to keep urine output at greater than 30 45. Answer: (A) 6 inches. This distance allows for easy flow of
ml/hour, because magnesium is excreted through the kidneys the formula by gravity, but the flow will be slow enough not
and can easily accumulate to toxic levels. to overload the stomach too rapidly.

31. Answer: (A) Menorrhagia. Menorrhagia is an excessive 46. Answer: (A) The older one gets, the more susceptible he
menstrual period. becomes to the complications of chicken pox. Chicken pox is
usually more severe in adults than in children.
32. Answer: (C) Blood typing. Blood type would be a critical Complications, such as pneumonia, are higher in incidence in
value to have because the risk of blood loss is always a adults.
potential complication during the labor and delivery process.
Approximately 40% of a woman’s cardiac output is delivered 47. Answer: (D) Consult a physician who may give them rubella
to the uterus, therefore, blood loss can occur quite rapidly in immunoglobulin. Rubella vaccine is made up of attenuated
the event of uncontrolled bleeding. German measles viruses. This is contraindicated in
pregnancy. Immune globulin, a specific prophylactic against
33. Answer: (D) Physiologic anemia. Hemoglobin values and German measles, may be given to pregnant women.
hematocrit decrease during pregnancy as the increase in
plasma volume exceeds the increase in red blood cell 48. Answer: (A) Contact tracing. Contact tracing is the most
production. practical and reliable method of finding possible sources of
person-to-person transmitted infections, such as sexually
34. Answer: (D) A 2 year old infant with stridorous breath transmitted diseases.
sounds, sitting up in his mother’s arms and drooling. The
infant with the airway emergency should be treated first, 49. Answer: (D) Leptospirosis. Leptospirosis is transmitted
because of the risk of epiglottitis. through contact with the skin or mucous membrane with
water or moist soil contaminated with urine of infected
35. Answer: (A) Placenta previa. Placenta previa with painless animals, like rats.
vaginal bleeding.
50. Answer: (B) Cholera. Passage of profuse watery stools is the
36. Answer: (D) Early in the morning. Based on the nurse’s major symptom of cholera. Both amebic and bacillary
knowledge of microbiology, the specimen should be dysentery are characterized by the presence of blood and/or
collected early in the morning. The rationale for this timing mucus in the stools. Giardiasis is characterized by fat
is that, because the female worm lays eggs at night around malabsorption and, therefore, steatorrhea.
the perineal area, the first bowel movement of the day will
yield the best results. The specific type of stool specimen 51. Answer: (A) Hemophilus influenzae. Hemophilus meningitis
used in the diagnosis of pinworms is called the tape test. is unusual over the age of 5 years. In developing countries,
the peak incidence is in children less than 6 months of age.
37. Answer: (A) Irritability and seizures. Lead poisoning Morbillivirus is the etiology of measles. Streptococcus
primarily affects the CNS, causing increased intracranial pneumoniae and Neisseria meningitidis may cause
pressure. This condition results in irritability and changes in meningitis, but age distribution is not specific in young
level of consciousness, as well as seizure disorders, children.
hyperactivity, and learning disabilities.
52. Answer: (B) Buccal mucosa. Koplik’s spot may be seen on
38. Answer: (D) “I really need to use the diaphragm and jelly the mucosa of the mouth or the throat.
most during the middle of my menstrual cycle”. The woman
must understand that, although the “fertile” period is 53. Answer: (A) 3 seconds. Adequate blood supply to the area
approximately mid-cycle, hormonal variations do occur and allows the return of the color of the nailbed within 3 seconds.
can result in early or late ovulation. To be effective, the
diaphragm should be inserted before every intercourse. 54. Answer: (B) Severe dehydration. The order of priority in the
management of severe dehydration is as follows: intravenous
39. Answer: (C) Restlessness. In a child, restlessness is the fluid therapy, referral to a facility where IV fluids can be
earliest sign of hypoxia. Late signs of hypoxia in a child are initiated within 30 minutes, Oresol or nasogastric tube. When
associated with a change in color, such as pallor or cyanosis. the foregoing measures are not possible or effective, then
urgent referral to the hospital is done.
40. Answer: (B) Walk one step ahead, with the child’s hand on
the nurse’s elbow. This procedure is generally recommended 55. Answer: (A) 45 infants. To estimate the number of infants,
to follow in guiding a person who is blind. multiply total population by 3%.

41. Answer: (A) Loud, machinery-like murmur. A loud, 56. Answer: (A) DPT. DPT is sensitive to freezing. The
machinery-like murmur is a characteristic finding associated appropriate storage temperature of DPT is 2 to 8° C only.
with patent ductus arteriosus. OPV and measles vaccine are highly sensitive to heat and
require freezing. MMR is not an immunization in the
42. Answer: (C) More oxygen, and the newborn’s metabolic rate Expanded Program on Immunization.
increases. When cold, the infant requires more oxygen and
there is an increase in metabolic rate. Non-shievering 57. Answer: (C) Proper use of sanitary toilets. The ova of the
thermogenesis is a complex process that increases the parasite get out of the human body together with feces.
metabolic rate and rate of oxygen consumption, therefore, Cutting the cycle at this stage is the most effective way of
the newborn increase heat production. preventing the spread of the disease to susceptible hosts.

43. Answer: (D) Voided. Before administering potassium I.V. to 58. Answer: (D) 5 skin lesions, positive slit skin smear. A
any client, the nurse must first check that the client’s kidneys multibacillary leprosy case is one who has a positive slit skin
are functioning and that the client is voiding. If the client is smear and at least 5 skin lesions.
59. Answer: (C) Thickened painful nerves. The lesion of leprosy 72. Answer: (D) Polycythemia probably due to chronic fetal
is not macular. It is characterized by a change in skin color hypoxia. The small-for-gestation neonate is at risk for
(either reddish or whitish) and loss of sensation, sweating developing polycythemia during the transitional period in an
and hair growth over the lesion. Inability to close the eyelids attempt to decreasehypoxia. The neonates are also at
(lagophthalmos) and sinking of the nosebridge are late increased risk for developing hypoglycemia and hypothermia
symptoms. due to decreased glycogen stores.

60. Answer: (B) Ask where the family resides. Because malaria 73. Answer: (C) Desquamation of the epidermis. Postdate
is endemic, the first question to determine malaria risk is fetuses lose the vernix caseosa, and the epidermis may
where the client’s family resides. If the area of residence is become desquamated. These neonates are usually very alert.
not a known endemic area, ask if the child had traveled Lanugo is missing in the postdate neonate.
within the past 6 months, where she was brought and
whether she stayed overnight in that area. 74. Answer: (C) Respiratory depression. Magnesium sulfate
crosses the placenta and adverse neonatal effects are
61. Answer: (A) Inability to drink. A sick child aged 2 months to respiratory depression, hypotonia, and bradycardia. The
5 years must be referred urgently to a hospital if he/she has serum blood sugar isn’t affected by magnesium sulfate. The
one or more of the following signs: not able to feed or drink, neonate would be floppy, not jittery.
vomits everything, convulsions, abnormally sleepy or
difficult to awaken. 75. Answer: (C) Respiratory rate 40 to 60 breaths/minute. A
respiratory rate 40 to 60 breaths/minute is normal for a
62. Answer: (A) Refer the child urgently to a hospital for neonate during the transitional period. Nasal flaring,
confinement. “Baggy pants” is a sign of severe marasmus. respiratory rate more than 60 breaths/minute, and audible
The best management is urgent referral to a hospital. grunting are signs of respiratory distress.

63. Answer: (D) Let the child rest for 10 minutes then continue 76. Answer: (C) Keep the cord dry and open to air. Keeping the
giving Oresol more slowly. If the child vomits persistently, cord dry and open to air helps reduce infection and hastens
that is, he vomits everything that he takes in, he has to be drying. Infants aren’t given tub bath but are sponged off until
referred urgently to a hospital. Otherwise, vomiting is the cord falls off. Petroleum jelly prevents the cord from
managed by letting the child rest for 10 minutes and then drying and encourages infection. Peroxide could be painful
continuing with Oresol administration. Teach the mother to and isn’t recommended.
give Oresol more slowly.
77. Answer: (B) Conjunctival hemorrhage. Conjunctival
64. Answer: (B) Some dehydration. Using the assessment hemorrhages are commonly seen in neonates secondary to
guidelines of IMCI, a child (2 months to 5 years old) with the cranial pressure applied during the birth process. Bulging
diarrhea is classified as having SOME DEHYDRATION if fontanelles are a sign of intracranial pressure. Simian creases
he shows 2 or more of the following signs: restless or are present in 40% of the neonates with trisomy 21. Cystic
irritable, sunken eyes, the skin goes back slow after a skin hygroma is a neck mass that can affect the airway.
pinch.
78. Answer: (B) To assess for prolapsed cord. After a client has
65. Answer: (C) Normal. In IMCI, a respiratory rate of an amniotomy, the nurse should assure that the cord isn’t
50/minute or more is fast breathing for an infant aged 2 to 12 prolapsed and that the baby tolerated the procedure well. The
months. most effective way to do this is to check the fetal heart rate.
Fetal well-being is assessed via a nonstress test. Fetal
66. Answer: (A) 1 year. The baby will have passive natural position is determined by vaginal examination. Artificial
immunity by placental transfer of antibodies. The mother rupture of membranes doesn’t indicate an imminent delivery.
will have active artificial immunity lasting for about 10
years. 5 doses will give the mother lifetime protection. 79. Answer: (D) The parents’ interactions with each other.
Parental interaction will provide the nurse with a good
67. Answer: (B) 4 hours. While the unused portion of other assessment of the stability of the family’s home life but it has
biologicals in EPI may be given until the end of the day, only no indication for parental bonding. Willingness to touch and
BCG is discarded 4 hours after reconstitution. This is why hold the newborn, expressing interest about the newborn’s
BCG immunization is scheduled only in the morning. size, and indicating a desire to see the newborn are behaviors
indicating parental bonding.
68. Answer: (B) 6 months. After 6 months, the baby’s nutrient
needs, especially the baby’s iron requirement, can no longer 80. Answer: (B) Instructing the client to use two or more
be provided by mother’s milk alone. peripads to cushion the area. Using two or more peripads
would do little to reduce the pain or promote perineal
69. Answer: (C) 24 weeks. At approximately 23 to 24 weeks’ healing. Cold applications, sitz baths, and Kegel exercises
gestation, the lungs are developed enough to sometimes are important measures when the client has a fourth-degree
maintain extrauterine life. The lungs are the most immature laceration.
system during the gestation period. Medical care for
premature labor begins much earlier (aggressively at 21 81. Answer: (C) “What is your expected due date?” When
weeks’ gestation) obtaining the history of a client who may be in labor, the
nurse’s highest priority is to determine her current status,
70. Answer: (B) Sudden infant death syndrome (SIDS). Supine particularly her due date, gravidity, and parity. Gravidity and
positioning is recommended to reduce the risk of SIDS in parity affect the duration of labor and the potential for labor
infancy. The risk of aspiration is slightly increased with the complications. Later, the nurse should ask about chronic
supine position. Suffocation would be less likely with an illnesses, allergies, and support persons.
infant supine than prone and the position for GER requires
the head of the bed to be elevated. 82. Answer: (D) Aspirate the neonate’s nose and mouth with a
bulb syringe. The nurse’s first action should be to clear the
71. Answer: (C) Decreased temperature. Temperature instability, neonate’s airway with a bulb syringe. After the airway is
especially when it results in a low temperature in the clear and the neonate’s color improves, the nurse should
neonate, may be a sign of infection. The neonate’s color comfort and calm the neonate. If the problem recurs or the
often changes with an infection process but generally neonate’s color doesn’t improve readily, the nurse should
becomes ashen or mottled. The neonate with an infection notify the physician. Administering oxygen when the airway
will usually show a decrease in activity level or lethargy. isn’t clear would be ineffective.
83. Answer: (C) Conducting a bedside ultrasound for an 92. Answer: (C) I.V. fluids. A sickle cell crisis during pregnancy
amniotic fluid index. It isn’t within a nurse’s scope of is usually managed by exchange transfusion oxygen, and
practice to perform and interpret a bedside ultrasound under L.V. Fluids. The client usually needs a stronger analgesic
these conditions and without specialized training. Observing than acetaminophen to control the pain of a crisis.
for pooling of straw-colored fluid, checking vaginal Antihypertensive drugs usually aren’t necessary. Diuretic
discharge with nitrazine paper, and observing for flakes of wouldn’t be used unless fluid overload resulted.
vernix are appropriate assessments for determining whether a
client has ruptured membranes. 93. Answer: (A) Calcium gluconate (Kalcinate). Calcium
gluconate is the antidote for magnesium toxicity. Ten
84. Answer: (C) Monitor partial pressure of oxygen (Pao2) milliliters of 10% calcium gluconate is given L.V. push over
levels. Monitoring PaO2 levels and reducing the oxygen 3 to 5 minutes. Hydralazine is given for sustained elevated
concentration to keep PaO2 within normal limits reduces the blood pressure in preeclamptic clients. Rho (D) immune
risk of retinopathy of prematurity in a premature infant globulin is given to women with Rh-negative blood to
receiving oxygen. Covering the infant’s eyes and prevent antibody formation from RH-positive conceptions.
humidifying the oxygen don’t reduce the risk of retinopathy Naloxone is used to correct narcotic toxicity.
of prematurity. Because cooling increases the risk of
acidosis, the infant should be kept warm so that his 94. Answer: (B) An indurated wheal over 10 mm in diameter
respiratory distress isn’t aggravated. appears in 48 to 72 hours. A positive PPD result would be an
indurated wheal over 10 mm in diameter that appears in 48
85. Answer: (A) 110 to 130 calories per kg. Calories per kg is to 72 hours. The area must be a raised wheal, not a flat
the accepted way of determined appropriate nutritional circumcised area to be considered positive.
intake for a newborn. The recommended calorie requirement
is 110 to 130 calories per kg of newborn body weight. This 95. Answer: (C) Pyelonephritis. The symptoms indicate acute
level will maintain a consistent blood glucose level and pyelonephritis, a serious condition in a pregnant client. UTI
provide enough calories for continued growth and symptoms include dysuria, urgency, frequency, and
development. suprapubic tenderness. Asymptomatic bacteriuria doesn’t
cause symptoms. Bacterial vaginosis causes milky white
86. Answer: (C) 30 to 32 weeks. Individual twins usually grow vaginal discharge but no systemic symptoms.
at the same rate as singletons until 30 to 32 weeks’ gestation,
then twins don’t’ gain weight as rapidly as singletons of the 96. Answer: (B) Rh-positive fetal blood crosses into maternal
same gestational age. The placenta can no longer keep pace blood, stimulating maternal antibodies. Rh isoimmunization
with the nutritional requirements of both fetuses after 32 occurs when Rh-positive fetal blood cells cross into the
weeks, so there’s some growth retardation in twins if they maternal circulation and stimulate maternal antibody
remain in utero at 38 to 40 weeks. production. In subsequent pregnancies with Rh-positive
fetuses, maternal antibodies may cross back into the fetal
87. Answer: (A) conjoined twins. The type of placenta that circulation and destroy the fetal blood cells.
develops in monozygotic twins depends on the time at which
cleavage of the ovum occurs. Cleavage in conjoined twins 97. Answer: (C) Supine position. The supine position causes
occurs more than 13 days after fertilization. Cleavage that compression of the client’s aorta and inferior vena cava by
occurs less than 3 day after fertilization results in diamniotic the fetus. This, in turn, inhibits maternal circulation, leading
dicchorionic twins. Cleavage that occurs between days 3 and to maternal hypotension and, ultimately, fetal hypoxia. The
8 results in diamniotic monochorionic twins. Cleavage that other positions promote comfort and aid labor progress. For
occurs between days 8 to 13 result in monoamniotic instance, the lateral, or side-lying, position improves
monochorionic twins. maternal and fetal circulation, enhances comfort, increases
maternal relaxation, reduces muscle tension, and eliminates
88. Answer: (D) Ultrasound. Once the mother and the fetus are pressure points. The squatting position promotes comfort by
stabilized, ultrasound evaluation of the placenta should be taking advantage of gravity. The standing position also takes
done to determine the cause of the bleeding. Amniocentesis advantage of gravity and aligns the fetus with the pelvic
is contraindicated in placenta previa. A digital or speculum angle.
examination shouldn’t be done as this may lead to severe
bleeding or hemorrhage. External fetal monitoring won’t 98. Answer: (B) Irritability and poor sucking. Neonates of
detect a placenta previa, although it will detect fetal distress, heroin-addicted mothers are physically dependent on the
which may result from blood loss or placenta separation. drug and experience withdrawal when the drug is no longer
supplied. Signs of heroin withdrawal include irritability, poor
89. Answer: (A) Increased tidal volume. A pregnant client sucking, and restlessness. Lethargy isn’t associated with
breathes deeper, which increases the tidal volume of gas neonatal heroin addiction. A flattened nose, small eyes, and
moved in and out of the respiratory tract with each breath. thin lips are seen in infants with fetal alcohol syndrome.
The expiratory volume and residual volume decrease as the Heroin use during pregnancy hasn’t been linked to specific
pregnancy progresses. The inspiratory capacity increases congenital anomalies.
during pregnancy. The increased oxygen consumption in the
pregnant client is 15% to 20% greater than in the 99. Answer: (A) 7th to 9th day postpartum. The normal
nonpregnant state. involutional process returns the uterus to the pelvic cavity in
7 to 9 days. A significant involutional complication is the
90. Answer: (A) Diet. Clients with gestational diabetes are failure of the uterus to return to the pelvic cavity within the
usually managed by diet alone to control their glucose prescribed time period. This is known as subinvolution.
intolerance. Oral hypoglycemic drugs are contraindicated in
pregnancy. Long-acting insulin usually isn’t needed for 100.Answer: (B) Uterine atony. Multiple fetuses, extended labor
blood glucose control in the client with gestational diabetes. stimulation with oxytocin, and traumatic delivery commonly
are associated with uterine atony, which may lead to
91. Answer: (D) Seizure. The anticonvulsant mechanism of postpartum hemorrhage. Uterine inversion may precede or
magnesium is believes to depress seizure foci in the brain follow delivery and commonly results from apparent
and peripheral neuromuscular blockade. Hypomagnesemia excessive traction on the umbilical cord and attempts to
isn’t a complication of preeclampsia. Antihypertensive drug deliver the placenta manually. Uterine involution and some
other than magnesium are preferred for sustained uterine discomfort are normal after delivery.
hypertension. Magnesium doesn’t help prevent hemorrhage
in preeclamptic clients.
 D. Provide milk every 2 to 3 hours.
Care of Clients with
7. A male client was on warfarin (Coumadin) before admission,
Physiologic and Psychosocial and has been receiving heparin I.V. for 2 days. The partial
thromboplastin time (PTT) is 68 seconds. What should Nurse
Alterations (Part 1) Carla do?

1. Nurse Michelle should know that the drainage is normal 4 A. Stop the I.V. infusion of heparin and notify the
days after a sigmoid colostomy when the stool is: physician.

A. Green liquid B. Continue treatment as ordered.

B. Solid formed C. Expect the warfarin to increase the PTT.

C. Loose, bloody D. Increase the dosage, because the level is lower

than normal.
D. Semiformed
8. A client undergone ileostomy, when should the drainage
2. Where would nurse Kristine place the call light for a male appliance be applied to the stoma?
client with a right-sided brain attack and left homonymous
hemianopsia? A. 24 hours later, when edema has subsided.

A. On the client’s right side B. In the operating room.

B. On the client’s left side C. After the ileostomy begin to function.

C. Directly in front of the client D. When the client is able to begin self-care
procedures.
D. Where the client like
9. A client undergone spinal anesthetic, it will be important that
3. A male client is admitted to the emergency department the nurse immediately position the client in:
following an accident. What are the first nursing actions of the
nurse? A. On the side, to prevent obstruction of airway by
tongue.
A. Check respiration, circulation, neurological
response. B. Flat on back.

B. Align the spine, check pupils, and check for C. On the back, with knees flexed 15 degrees.
hemorrhage.
D. Flat on the stomach, with the head turned to the
C. Check respirations, stabilize spine, and check side.
circulation.
10.While monitoring a male client several hours after a motor
D. Assess level of consciousness and circulation. vehicle accident, which assessment data suggest increasing
intracranial pressure?
4. In evaluating the effect of nitroglycerin, Nurse Arthur should
know that it reduces preload and relieves angina by: A. Blood pressure is decreased from 160/90 to
110/70.
A. Increasing contractility and slowing heart rate.
B. Pulse is increased from 87 to 95, with an
B. Increasing AV conduction and heart rate. occasional skipped beat.

C. Decreasing contractility and oxygen consumption. C. The client is oriented when aroused from sleep,
and goes back to sleep immediately.
D. Decreasing venous return through vasodilation.
D. The client refuses dinner because of anorexia.
5. Nurse Patricia finds a female client who is post-myocardial
infarction (MI) slumped on the side rails of the bed and 11.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which
unresponsive to shaking or shouting. Which is the nurse next of the following symptoms may appear first?
action?
A. Altered mental status and dehydration
A. Call for help and note the time.
B. Fever and chills
B. Clear the airway
C. Hemoptysis and Dyspnea
C. Give two sharp thumps to the precordium, and
check the pulse. D. Pleuritic chest pain and cough

D. Administer two quick blows. 12. A male client has active tuberculosis (TB). Which of the
following symptoms will be exhibit?
6. Nurse Monett is caring for a client recovering from
gastro-intestinal bleeding. The nurse should: A. Chest and lower back pain

A. Plan care so the client can receive 8 hours of B. Chills, fever, night sweats, and hemoptysis
uninterrupted sleep each night.
C. Fever of more than 104°F (40°C) and nausea
B. Monitor vital signs every 2 hours.
D. Headache and photophobia
C. Make sure that the client takes food and
medications at prescribed intervals. 13. Mark, a 7-year-old client is brought to the emergency
department. He’s tachypneic and afebrile and has a respiratory A. Bone fracture
rate of 36 breaths/minute and has a nonproductive cough. He
recently had a cold. Form this history; the client may have B. Loss of estrogen
which of the following conditions?
C. Negative calcium balance
A. Acute asthma
D. Dowager’s hump
B. Bronchial pneumonia
20. Nurse Len is teaching a group of women to perform BSE.
C. Chronic obstructive pulmonary disease (COPD) The nurse should explain that the purpose of performing the
examination is to discover:
D. Emphysema
A. Cancerous lumps
14. Marichu was given morphine sulfate for pain. She is
sleeping and her respiratory rate is 4 breaths/minute. If action B. Areas of thickness or fullness
isn’t taken quickly, she might have which of the following
reactions? C. Changes from previous examinations.

A. Asthma attack D. Fibrocystic masses

B. Respiratory arrest 21. When caring for a female client who is being treated for
hyperthyroidism, it is important to:
C. Seizure
A. Provide extra blankets and clothing to keep the
D. Wake up on his own client warm.

15. A 77-year-old male client is admitted for elective knee B. Monitor the client for signs of restlessness,
surgery. Physical examination reveals shallow respirations but sweating, and excessive weight loss during
no sign of respiratory distress. Which of the following is a thyroid replacement therapy.
normal physiologic change related to aging?
C. Balance the client’s periods of activity and rest.
A. Increased elastic recoil of the lungs
D. Encourage the client to be active to prevent
B. Increased number of functional capillaries in the constipation.
alveoli
22. Nurse Kris is teaching a client with history of
C. Decreased residual volume atherosclerosis. To decrease the risk of atherosclerosis, the nurse
should encourage the client to:
D. Decreased vital capacity
A. Avoid focusing on his weight.
16. Nurse John is caring for a male client receiving lidocaine
I.V. Which factor is the most relevant to administration of this B. Increase his activity level.
medication?
C. Follow a regular diet.
A. Decrease in arterial oxygen saturation (SaO2)
when measured with a pulse oximeter. D. Continue leading a high-stress lifestyle.

B. Increase in systemic blood pressure. 23. Nurse Greta is working on a surgical floor. Nurse Greta must
logroll a client following a:
C. Presence of premature ventricular contractions
(PVCs) on a cardiac monitor. A. Laminectomy

D. Increase in intracranial pressure (ICP). B. Thoracotomy

17. Nurse Ron is caring for a male client taking an C. Hemorrhoidectomy

anticoagulant. The nurse should teach the client to:
D. Cystectomy.
A. Report incidents of diarrhea.
24. A 55-year old client underwent cataract removal with
B. Avoid foods high in vitamin K intraocular lens implant. Nurse Oliver is giving the client
discharge instructions. These instructions should include which
C. Use a straight razor when shaving. of the following?

D. Take aspirin to pain relief. A. Avoid lifting objects weighing more than 5 lb
(2.25 kg).
18. Nurse Lhynnette is preparing a site for the insertion of an
I.V. catheter. The nurse should treat excess hair at the site by: B. Lie on your abdomen when in bed

A. Leaving the hair intact C. Keep rooms brightly lit.

B. Shaving the area D. Avoiding straining during bowel movement or

bending at the waist.
C. Clipping the hair in the area
25. George should be taught about testicular examinations
D. Removing the hair with a depilatory. during:

19. Nurse Michelle is caring for an elderly female with A. when sexual activity starts
osteoporosis. When teaching the client, the nurse should include
information about which major complication: B. After age 69
 C. After age 40 A. Infection of the lung.

D. Before age 20. B. Kinked or obstructed chest tube

26. A male client undergone a colon resection. While turning C. Excessive water in the water-seal chamber
him, wound dehiscence with evisceration occurs. Nurse Trish
first response is to: D. Excessive chest tube drainage

A. Call the physician 32. Nurse Maureen is talking to a male client, the client begins
choking on his lunch. He’s coughing forcefully. The nurse
B. Place a saline-soaked sterile dressing on the should:
wound.
A. Stand him up and perform the abdominal thrust
C. Take a blood pressure and pulse. maneuver from behind.

D. Pull the dehiscence closed. B. Lay him down, straddle him, and perform the
abdominal thrust maneuver.
27. Nurse Audrey is caring for a client who has suffered a severe
cerebrovascular accident. During routine assessment, the nurse C. Leave him to get assistance
notices Cheyne- Strokes respirations. Cheyne-strokes
respirations are: D. Stay with him but not intervene at this time.

A. A progressively deeper breaths followed by 33. Nurse Ron is taking a health history of an 84 year old client.
shallower breaths with apneic periods. Which information will be most useful to the nurse for planning
care?
B. Rapid, deep breathing with abrupt pauses between
each breath. A. General health for the last 10 years.

C. Rapid, deep breathing and irregular breathing B. Current health promotion activities.
without pauses.
C. Family history of diseases.
D. Shallow breathing with an increased respiratory
rate. D. Marital status.

28. Nurse Bea is assessing a male client with heart failure. The 34. When performing oral care on a comatose client, Nurse
breath sounds commonly auscultated in clients with heart failure Krina should:
are:
A. Apply lemon glycerin to the client’s lips at least
A. Tracheal every 2 hours.

B. Fine crackles B. Brush the teeth with client lying supine.

C. Coarse crackles C. Place the client in a side lying position, with the
head of the bed lowered.
D. Friction rubs
D. Clean the client’s mouth with hydrogen peroxide.
29. The nurse is caring for Kenneth experiencing an acute
asthma attack. The client stops wheezing and breath sounds 35. A 77-year-old male client is admitted with a diagnosis of
aren’t audible. The reason for this change is that: dehydration and change in mental status. He’s being hydrated
with L.V. fluids. When the nurse takes his vital signs, she notes
A. The attack is over. he has a fever of 103°F (39.4°C) a cough producing yellow
sputum and pleuritic chest pain. The nurse suspects this client
B. The airways are so swollen that no air cannot get may have which of the following conditions?
through.
A. Adult respiratory distress syndrome (ARDS)
C. The swelling has decreased.
B. Myocardial infarction (MI)
D. Crackles have replaced wheezes.
C. Pneumonia
30. Mike with epilepsy is having a seizure. During the active
seizure phase, the nurse should: D. Tuberculosis

A. Place the client on his back remove dangerous 36. Nurse Oliver is working in a out patient clinic. He has been
objects, and insert a bite block. alerted that there is an outbreak of tuberculosis (TB). Which of
the following clients entering the clinic today most likely to
B. Place the client on his side, remove dangerous have TB?
objects, and insert a bite block.
A. A 16-year-old female high school student
C. Place the client o his back, remove dangerous
objects, and hold down his arms. B. A 33-year-old day-care worker

D. Place the client on his side, remove dangerous C. A 43-yesr-old homeless man with a history of
objects, and protect his head. alcoholism

31. After insertion of a cheat tube for a pneumothorax, a client D. A 54-year-old businessman
becomes hypotensive with neck vein distention, tracheal shift,
absent breath sounds, and diaphoresis. Nurse Amanda suspects a 37. Virgie with a positive Mantoux test result will be sent for a
tension pneumothorax has occurred. What cause of tension chest X-ray. The nurse is aware that which of the following
pneumothorax should the nurse check for? reasons this is done?
 A. To confirm the diagnosis 43. Diagnostic assessment of Francis would probably not reveal:

B. To determine if a repeat skin test is needed A. Predominance of lymhoblasts

C. To determine the extent of lesions B. Leukocytosis

D. To determine if this is a primary or secondary C. Abnormal blast cells in the bone marrow
infection
D. Elevated thrombocyte counts
38. Kennedy with acute asthma showing inspiratory and
expiratory wheezes and a decreased forced expiratory volume 44. Robert, a 57-year-old client with acute arterial occlusion of
should be treated with which of the following classes of the left leg undergoes an emergency embolectomy. Six hours
medication right away? later, the nurse isn’t able to obtain pulses in his left foot using
Doppler ultrasound. The nurse immediately notifies the
A. Beta-adrenergic blockers physician, and asks her to prepare the client for surgery. As the
nurse enters the client’s room to prepare him, he states that he
B. Bronchodilators won’t have any more surgery. Which of the following is the best
initial response by the nurse?
C. Inhaled steroids
A. Explain the risks of not having the surgery
D. Oral steroids
B. Notifying the physician immediately
39. Mr. Vasquez 56-year-old client with a 40-year history of
smoking one to two packs of cigarettes per day has a chronic C. Notifying the nursing supervisor
cough producing thick sputum, peripheral edema and cyanotic
nail beds. Based on this information, he most likely has which D. Recording the client’s refusal in the nurses’ notes
of the following conditions?
45. During the endorsement, which of the following clients
A. Adult respiratory distress syndrome (ARDS) should the on-duty nurse assess first?

B. Asthma A. The 58-year-old client who was admitted 2 days

ago with heart failure, blood pressure of 126/76
C. Chronic obstructive bronchitis mm Hg, and a respiratory rate of 22
breaths/minute.
D. Emphysema
B. The 89-year-old client with end-stage right-sided
Situation: Francis, age 46 is admitted to the hospital with heart failure, blood pressure of 78/50 mm Hg, and
diagnosis of Chronic Lymphocytic Leukemia. a “do not resuscitate” order
40. The treatment for patients with leukemia is bone marrow C. The 62-year-old client who was admitted 1 day
transplantation. Which statement about bone marrow ago with thrombophlebitis and is receiving L.V.
transplantation is not correct? heparin
A. The patient is under local anesthesia during the D. The 75-year-old client who was admitted 1 hour
procedure ago with new-onset atrial fibrillation and is
receiving L.V. dilitiazem (Cardizem)
B. The aspirated bone marrow is mixed with heparin.
46. Honey, a 23-year old client complains of substernal chest
C. The aspiration site is the posterior or anterior iliac pain and states that her heart feels like “it’s racing out of the
crest. chest”. She reports no history of cardiac disorders. The nurse
attaches her to a cardiac monitor and notes sinus tachycardia
D. The recipient receives cyclophosphamide
with a rate of 136beats/minutes. Breath sounds are clear and the
(Cytoxan) for 4 consecutive days before the
respiratory rate is 26 breaths/minutes. Which of the following
procedure.
drugs should the nurse question the client about using?
41. After several days of admission, Francis becomes
A. Barbiturates
disoriented and complains of frequent headaches. The nurse
in-charge first action would be: B. Opioids
A. Call the physician C. Cocaine
B. Document the patient’s status in his charts. D. Benzodiazepines
C. Prepare oxygen treatment 47. A 51-year-old female client tells the nurse in-charge that she
has found a painless lump in her right breast during her monthly
D. Raise the side rails
self-examination. Which assessment finding would strongly
42. During routine care, Francis asks the nurse, “How can I be suggest that this client’s lump is cancerous?
anemic if this disease causes increased my white blood cell
A. Eversion of the right nipple and mobile mass
production?” The nurse in-charge best response would be that
the increased number of white blood cells (WBC) is: B. Nonmobile mass with irregular edges
A. Crowd red blood cells C. Mobile mass that is soft and easily delineated
B. Are not responsible for the anemia. D. Nonpalpable right axillary lymph nodes
C. Uses nutrients from other cells 48. A 35-year-old client with vaginal cancer asks the nurse,
“What is the usual treatment for this type of cancer?” Which
D. Have an abnormally short life span of cells.
treatment should the nurse name?
 A. Surgery D. Papanicolaou-specific antigen, which is used to
screen for cervical cancer.
B. Chemotherapy
54. What is the most important postoperative instruction that
C. Radiation nurse Kate must give a client who has just returned from the
operating room after receiving a subarachnoid block?
D. Immunotherapy
A. “Avoid drinking liquids until the gag reflex
49. Cristina undergoes a biopsy of a suspicious lesion. The returns.”
biopsy report classifies the lesion according to the TNM staging
system as follows: TIS, N0, M0. What does this classification B. “Avoid eating milk products for 24 hours.”
mean?
C. “Notify a nurse if you experience blood in your
A. No evidence of primary tumor, no abnormal urine.”
regional lymph nodes, and no evidence of distant
metastasis D. “Remain supine for the time specified by the
physician.”
B. Carcinoma in situ, no abnormal regional lymph
nodes, and no evidence of distant metastasis 55. A male client suspected of having colorectal cancer will
require which diagnostic study to confirm the diagnosis?
C. Can’t assess tumor or regional lymph nodes and
no evidence of metastasis A. Stool Hematest

D. Carcinoma in situ, no demonstrable metastasis of B. Carcinoembryonic antigen (CEA)

the regional lymph nodes, and ascending degrees
of distant metastasis C. Sigmoidoscopy

50. Lydia undergoes a laryngectomy to treat laryngeal cancer. D. Abdominal computed tomography (CT) scan
When teaching the client how to care for the neck stoma, the
nurse should include which instruction? 56. During a breast examination, which finding most strongly
suggests that the Luz has breast cancer?
A. “Keep the stoma uncovered.”
A. Slight asymmetry of the breasts.
B. “Keep the stoma dry.”
B. A fixed nodular mass with dimpling of the
C. “Have a family member perform stoma care overlying skin
initially until you get used to the procedure.”
C. Bloody discharge from the nipple
D. “Keep the stoma moist.”
D. Multiple firm, round, freely movable masses that
51. A 37-year-old client with uterine cancer asks the nurse, change with the menstrual cycle
“Which is the most common type of cancer in women?” The
nurse replies that it’s breast cancer. Which type of cancer causes 57. A female client with cancer is being evaluated for possible
the most deaths in women? metastasis. Which of the following is one of the most common
metastasis sites for cancer cells?
A. Breast cancer
A. Liver
B. Lung cancer
B. Colon
C. Brain cancer
C. Reproductive tract
D. Colon and rectal cancer
D. White blood cells (WBCs)
52. Antonio with lung cancer develops Horner’s syndrome when
the tumor invades the ribs and affects the sympathetic nerve 58. Nurse Mandy is preparing a client for magnetic resonance
ganglia. When assessing for signs and symptoms of this imaging (MRI) to confirm or rule out a spinal cord lesion.
syndrome, the nurse should note: During the MRI scan, which of the following would pose a
threat to the client?
A. miosis, partial eyelid ptosis, and anhidrosis on the
affected side of the face. A. The client lies still.

B. chest pain, dyspnea, cough, weight loss, and fever. B. The client asks questions.

C. arm and shoulder pain and atrophy of arm and C. The client hears thumping sounds.
hand muscles, both on the affected side.
D. The client wears a watch and wedding band.
D. hoarseness and dysphagia.
59. Nurse Cecile is teaching a female client about preventing
53. Vic asks the nurse what PSA is. The nurse should reply that osteoporosis. Which of the following teaching points is correct?
it stands for:
A. Obtaining an X-ray of the bones every 3 years is
A. prostate-specific antigen, which is used to screen recommended to detect bone loss.
for prostate cancer.
B. To avoid fractures, the client should avoid
B. protein serum antigen, which is used to determine strenuous exercise.
protein levels.
C. The recommended daily allowance of calcium
C. pneumococcal strep antigen, which is a bacteria may be found in a wide variety of foods.
that causes pneumonia.
D. Obtaining the recommended daily allowance of
 calcium requires taking a calcium supplement. D. Osteoarthritis has dislocations and subluxations,
rheumatoid arthritis doesn’t
60. Before Jacob undergoes arthroscopy, the nurse reviews the
assessment findings for contraindications for this procedure. 66. Mrs. Cruz uses a cane for assistance in walking. Which of
Which finding is a contraindication? the following statements is true about a cane or other assistive
devices?
A. Joint pain
A. A walker is a better choice than a cane.
B. Joint deformity
B. The cane should be used on the affected side
C. Joint flexion of less than 50%
C. The cane should be used on the unaffected side
D. Joint stiffness
D. A client with osteoarthritis should be encouraged
61. Mr. Rodriguez is admitted with severe pain in the knees. to ambulate without the cane
Which form of arthritis is characterized by urate deposits and
joint pain, usually in the feet and legs, and occurs primarily in 67. A male client with type 1 diabetes is scheduled to receive 30
men over age 30? U of 70/30 insulin. There is no 70/30 insulin available. As a
substitution, the nurse may give the client:
A. Septic arthritis
A. 9 U regular insulin and 21 U neutral protamine
B. Traumatic arthritis Hagedorn (NPH).
C. Intermittent arthritis B. 21 U regular insulin and 9 U NPH.

D. Gouty arthritis C. 10 U regular insulin and 20 U NPH.

62. A heparin infusion at 1,500 unit/hour is ordered for a D. 20 U regular insulin and 10 U NPH.
64-year-old client with stroke in evolution. The infusion
contains 25,000 units of heparin in 500 ml of saline solution. 68. Nurse Len should expect to administer which medication to
How many milliliters per hour should be given? a client with gout?

A. 15 ml/hour A. aspirin

B. 30 ml/hour B. furosemide (Lasix)

C. 45 ml/hour C. colchicines

D. 50 ml/hour D. calcium gluconate (Kalcinate)

63. A 76-year-old male client had a thromboembolic right 69. Mr. Domingo with a history of hypertension is diagnosed
stroke; his left arm is swollen. Which of the following with primary hyperaldosteronism. This diagnosis indicates that
conditions may cause swelling after a stroke? the client’s hypertension is caused by excessive hormone
secretion from which of the following glands?
A. Elbow contracture secondary to spasticity
A. Adrenal cortex
B. Loss of muscle contraction decreasing venous
return B. Pancreas

C. Deep vein thrombosis (DVT) due to immobility of C. Adrenal medulla

the ipsilateral side
D. Parathyroid
D. Hypoalbuminemia due to protein escaping from
an inflamed glomerulus 70. For a diabetic male client with a foot ulcer, the doctor orders
bed rest, a wetto- dry dressing change every shift, and blood
64. Heberden’s nodes are a common sign of osteoarthritis. glucose monitoring before meals and bedtime. Why are
Which of the following statement is correct about this wet-to-dry dressings used for this client?
deformity?
A. They contain exudate and provide a moist wound
A. It appears only in men environment.

B. It appears on the distal interphalangeal joint B. They protect the wound from mechanical trauma
and promote healing.
C. It appears on the proximal interphalangeal joint
C. They debride the wound and promote healing by
D. It appears on the dorsolateral aspect of the secondary intention.
interphalangeal joint.
D. They prevent the entrance of microorganisms and
65. Which of the following statements explains the main minimize wound discomfort.
difference between rheumatoid arthritis and osteoarthritis?
71. Nurse Zeny is caring for a client in acute addisonian crisis.
A. Osteoarthritis is gender-specific, rheumatoid Which laboratory data would the nurse expect to find?
arthritis isn’t
A. Hyperkalemia
B. Osteoarthritis is a localized disease rheumatoid
arthritis is systemic B. Reduced blood urea nitrogen (BUN)

C. Osteoarthritis is a systemic disease, rheumatoid C. Hypernatremia

arthritis is localized
D. Hyperglycemia
72. A client is admitted for treatment of the syndrome of A. Nights sweats, weight loss, and diarrhea
inappropriate antidiuretic hormone (SIADH). Which nursing
intervention is appropriate? B. Dyspnea, tachycardia, and pallor

A. Infusing I.V. fluids rapidly as ordered C. Nausea, vomiting, and anorexia

B. Encouraging increased oral intake D. Itching, rash, and jaundice

C. Restricting fluids 79. In teaching a female client who is HIV-positive about

pregnancy, the nurse would know more teaching is necessary
D. Administering glucose-containing I.V. fluids as when the client says:
ordered
A. The baby can get the virus from my placenta.”
73. A female client tells nurse Nikki that she has been working
hard for the last 3 months to control her type 2 diabetes mellitus B. “I’m planning on starting on birth control pills.”
with diet and exercise. To determine the effectiveness of the
client’s efforts, the nurse should check: C. “Not everyone who has the virus gives birth to a
baby who has the virus.”
A. urine glucose level.
D. “I’ll need to have a C-section if I become
B. fasting blood glucose level. pregnant and have a baby.”

C. serum fructosamine level. 80. When preparing Judy with acquired immunodeficiency
syndrome (AIDS) for discharge to the home, the nurse should be
D. glycosylated hemoglobin level. sure to include which instruction?

74. Nurse Trinity administered neutral protamine Hagedorn A. “Put on disposable gloves before bathing.”
(NPH) insulin to a diabetic client at 7 a.m. At what time would
the nurse expect the client to be most at risk for a hypoglycemic B. “Sterilize all plates and utensils in boiling water.”
reaction?
C. “Avoid sharing such articles as toothbrushes and
A. 10:00 am razors.”

B. Noon D. “Avoid eating foods from serving dishes shared

by other family members.”
C. 4:00 pm
81. Nurse Marie is caring for a 32-year-old client admitted with
D. 10:00 pm pernicious anemia. Which set of findings should the nurse
expect when assessing the
75. The adrenal cortex is responsible for producing which
substances? client?

A. Glucocorticoids and androgens A. Pallor, bradycardia, and reduced pulse pressure

B. Catecholamines and epinephrine B. Pallor, tachycardia, and a sore tongue

C. Mineralocorticoids and catecholamines C. Sore tongue, dyspnea, and weight gain

D. Norepinephrine and epinephrine D. Angina, double vision, and anorexia

76. On the third day after a partial thyroidectomy, Proserfina 82. After receiving a dose of penicillin, a client develops
exhibits muscle twitching and hyperirritability of the nervous dyspnea and hypotension. Nurse Celestina suspects the client is
system. When questioned, the client reports numbness and experiencing anaphylactic shock. What should the nurse do
tingling of the mouth and fingertips. Suspecting a lifethreatening first?
electrolyte disturbance, the nurse notifies the surgeon
immediately. Which electrolyte disturbance most commonly A. Page an anesthesiologist immediately and prepare
follows thyroid surgery? to intubate the client.

A. Hypocalcemia B. Administer epinephrine, as prescribed, and

prepare to intubate the client if necessary.
B. Hyponatremia
C. Administer the antidote for penicillin, as
C. Hyperkalemia prescribed, and continue to monitor the client’s
vital signs.
D. Hypermagnesemia
D. Insert an indwelling urinary catheter and begin to
77. Which laboratory test value is elevated in clients who smoke infuse I.V. fluids as ordered.
and can’t be used as a general indicator of cancer?
83. Mr. Marquez with rheumatoid arthritis is about to begin
A. Acid phosphatase level aspirin therapy to reduce inflammation. When teaching the
client about aspirin, the nurse discusses adverse reactions to
B. Serum calcitonin level prolonged aspirin therapy. These include:
C. Alkaline phosphatase level A. weight gain.
D. Carcinoembryonic antigen level B. fine motor tremors.
78. Francis with anemia has been admitted to the C. respiratory acidosis.
medical-surgical unit. Which assessment findings are
characteristic of iron-deficiency anemia? D. bilateral hearing loss.
84. A 23-year-old client is diagnosed with human C. Thrombin time, calcium levels, and potassium
immunodeficiency virus (HIV). After recovering from the initial levels
shock of the diagnosis, the client expresses a desire to learn as
much as possible about HIV and acquired immunodeficiency D. Fibrinogen level, WBC, and platelet count
syndrome (AIDS). When teaching the client about the immune
system, the nurse states that adaptive immunity is provided by 90. When taking a dietary history from a newly admitted female
which type of white blood cell? client, Nurse Len should remember that which of the following
foods is a common allergen?
A. Neutrophil
A. Bread
B. Basophil
B. Carrots
C. Monocyte
C. Orange
D. Lymphocyte
D. Strawberries
85. In an individual with Sjögren’s syndrome, nursing care
should focus on: 91. Nurse John is caring for clients in the outpatient clinic.
Which of the following phone calls should the nurse return first?
A. moisture replacement.
A. A client with hepatitis A who states, “My arms
B. electrolyte balance. and legs are itching.”

C. nutritional supplementation. B. A client with cast on the right leg who states, “I
have a funny feeling in my right leg.”
D. arrhythmia management.
C. A client with osteomyelitis of the spine who
86. During chemotherapy for lymphocytic leukemia, Mathew states, “I am so nauseous that I can’t eat.”
develops abdominal pain, fever, and “horse barn” smelling
diarrhea. It would be most important for the nurse to advise the D. A client with rheumatoid arthritis who states, “I
physician to order: am having trouble sleeping.”

A. enzyme-linked immunosuppressant assay 92. Nurse Sarah is caring for clients on the surgical floor and has
(ELISA) test. just received report from the previous shift. Which of the
following clients should the nurse see first?
B. electrolyte panel and hemogram.
A. A 35-year-old admitted three hours ago with a
C. stool for Clostridium difficile test. gunshot wound; 1.5 cm area of dark drainage
noted on the dressing.
D. flat plate X-ray of the abdomen.
B. A 43-year-old who had a mastectomy two days
87. A male client seeks medical evaluation for fatigue, night ago; 23 ml of serosanguinous fluid noted in the
sweats, and a 20-lb weight loss in 6 weeks. To confirm that the Jackson-Pratt drain.
client has been infected with the human immunodeficiency virus
(HIV), the nurse expects the physician to order: C. A 59-year-old with a collapsed lung due to an
accident; no drainage noted in the previous eight
A. E-rosette immunofluorescence. hours.

B. quantification of T-lymphocytes. D. A 62-year-old who had an abdominal-perineal

resection three days ago; client complaints of
C. enzyme-linked immunosorbent assay (ELISA). chills.
D. Western blot test with ELISA. 93. Nurse Eve is caring for a client who had a thyroidectomy 12
hours ago for treatment of Grave’s disease. The nurse would be
88. A complete blood count is commonly performed before a most concerned if which of the following was observed?
Joe goes into surgery. What does this test seek to identify?
A. Blood pressure 138/82, respirations 16, oral
A. Potential hepatic dysfunction indicated by temperature 99 degrees Fahrenheit.
decreased blood urea nitrogen (BUN) and
creatinine levels B. The client supports his head and neck when
turning his head to the right.
B. Low levels of urine constituents normally
excreted in the urine C. The client spontaneously flexes his wrist when the
blood pressure is obtained.
C. Abnormally low hematocrit (HCT) and
hemoglobin (Hb) levels D. The client is drowsy and complains of sore throat.
D. Electrolyte imbalance that could affect the blood’s 94. Julius is admitted with complaints of severe pain in the
ability to coagulate properly lower right quadrant of the abdomen. To assist with pain relief,
the nurse should take which of the following actions?
89. While monitoring a client for the development of
disseminated intravascular coagulation (DIC), the nurse should A. Encourage the client to change positions
take note of what assessment parameters? frequently in bed.
A. Platelet count, prothrombin time, and partial B. Administer Demerol 50 mg IM q 4 hours and
thromboplastin time PRN.
B. Platelet count, blood glucose levels, and white C. Apply warmth to the abdomen with a heating pad.
blood cell (WBC) count
 D. Use comfort measures and pillows to position the B. Decreased visual, auditory, and gustatory abilities.
client.
C. Isolation from their families and familiar
95. Nurse Tina prepares a client for peritoneal dialysis. Which of surroundings.
the following actions should the nurse take first?
D. Decrease musculoskeletal function and mobility.
A. Assess for a bruit and a thrill.
100. A male client with emphysema becomes restless and
B. Warm the dialysate solution. confused. What step should nurse Jasmine take next?

C. Position the client on the left side. A. Encourage the client to perform pursed lip
breathing.
D. Insert a Foley catheter
B. Check the client’s temperature.
96. Nurse Jannah teaches an elderly client with right-sided
weakness how to use cane. Which of the following behaviors, if C. Assess the client’s potassium level.
demonstrated by the client to the nurse, indicates that the
teaching was effective? D. Increase the client’s oxygen flow rate.

A. The client holds the cane with his right hand,

moves the can forward followed by the right leg,
and then moves the left leg.

B. The client holds the cane with his right hand,

moves the cane forward followed by his left leg,
and then moves the right leg.

C. The client holds the cane with his left hand,

moves the cane forward followed by the right leg,
and then moves the left leg.

D. The client holds the cane with his left hand,

moves the cane forward followed by his left leg,
and then moves the right leg.

97. An elderly client is admitted to the nursing home setting.

The client is occasionally confused and her gait is often
unsteady. Which of the following actions, if taken by the nurse,
is most appropriate?

A. Ask the woman’s family to provide personal items

such as photos or mementos.

B. Select a room with a bed by the door so the

woman can look down the hall.

C. Suggest the woman eat her meals in the room with

her roommate.

D. Encourage the woman to ambulate in the halls

twice a day.

98. Nurse Evangeline teaches an elderly client how to use a

standard aluminum walker. Which of the following behaviors, if
demonstrated by the client, indicates that the nurse’s teaching
was effective?

A. The client slowly pushes the walker forward 12

inches, then takes small steps forward while
leaning on the walker.

B. The client lifts the walker, moves it forward 10

inches, and then takes several small steps forward.

C. The client supports his weight on the walker while

advancing it forward, then takes small steps while
balancing on the walker.

D. The client slides the walker 18 inches forward,

then takes small steps while holding onto the
walker for balance.

99. Nurse Deric is supervising a group of elderly clients in a

residential home setting. The nurse knows that the elderly are at
greater risk of developing sensory deprivation for what reason?

A. Increased sensitivity to the side effects of

medications.
 and photophobia aren’t usual TB symptoms.
Care of Clients with
13. Answer:(A) Acute asthma. Based on the client’s history and
Physiologic and Psychosocial symptoms, acute asthma is the most likely diagnosis. He’s
unlikely to have bronchial pneumonia without a productive
Alterations (Part 1) cough and fever and he’s too young to have developed
(COPD) and emphysema.
1. Answer: (C) Loose, bloody. Normal bowel function and
soft-formed stool usually do not occur until around the 14. Answer: (B) Respiratory arrest. Narcotics can cause
seventh day following surgery. The stool consistency is respiratory arrest if given in large quantities. It’s unlikely
related to how much water is being absorbed. the client will have asthma attack or a seizure or wake up on
his own.
2. Answer: (A) On the client’s right side. The client has left
visual field blindness. The client will see only from the 15. Answer: (D) Decreased vital capacity. Reduction in vital
right side. capacity is a normal physiologic changes include decreased
elastic recoil of the lungs, fewer functional capillaries in the
3. Answer: (C) Check respirations, stabilize spine, and check alveoli, and an increased in residual volume.
circulation. Checking the airway would be priority, and a
neck injury should be suspected. 16. Answer: (C) Presence of premature ventricular contractions
(PVCs) on a cardiac monitor. Lidocaine drips are
4. Answer: (D) Decreasing venous return through commonly used to treat clients whose arrhythmias haven’t
vasodilation. The significant effect of nitroglycerin is been controlled with oral medication and who are having
vasodilation and decreased venous return, so the heart does PVCs that are visible on the cardiac monitor. SaO2, blood
not have to work hard. pressure, and ICP are important factors but aren’t as
significant as PVCs in the situation.
5. Answer: (A) Call for help and note the time. Having
established, by stimulating the client, that the client is 17. Answer: (B) Avoid foods high in vitamin K. The client
unconscious rather than sleep, the nurse should immediately should avoid consuming large amounts of vitamin K
call for help. This may be done by dialing the operator from because vitamin K can interfere with anticoagulation. The
the client’s phone and giving the hospital code for cardiac client may need to report diarrhea, but isn’t effect of taking
arrest and the client’s room number to the operator, of if the an anticoagulant. An electric razor-not a straight
phone is not available, by pulling the emergency call razor-should be used to prevent cuts that cause bleeding.
button. Noting the time is important baseline information Aspirin may increase the risk of bleeding; acetaminophen
for cardiac arrest procedure. should be used to pain relief.

6. Answer: (C) Make sure that the client takes food and 18. Answer: (C) Clipping the hair in the area. Hair can be a
medications at prescribed intervals. Food and drug therapy source of infection and should be removed by clipping.
will prevent the accumulation of hydrochloric acid, or will Shaving the area can cause skin abrasions and depilatories
neutralize and buffer the acid that does accumulate. can irritate the skin.

7. Answer: (B) Continue treatment as ordered. The effects of 19. Answer: (A) Bone fracture. Bone fracture is a major
heparin are monitored by the PTT is normally 30 to 45 complication of osteoporosis that results when loss of
seconds; the therapeutic level is 1.5 to 2 times the normal calcium and phosphate increased the fragility of bones.
level. Estrogen deficiencies result from menopause-not
osteoporosis. Calcium and vitamin D supplements may be
8. Answer: (B) In the operating room. The stoma drainage bag used to support normal bone metabolism, But a negative
is applied in the operating room. Drainage from the calcium balance isn’t a complication of osteoporosis.
ileostomy contains secretions that are rich in digestive Dowager’s hump results from bone fractures. It develops
enzymes and highly irritating to the skin. Protection of the when repeated vertebral fractures increase spinal curvature.
skin from the effects of these enzymes is begun at once.
Skin exposed to these enzymes even for a short time 20. Answer: (C) Changes from previous examinations. Women
becomes reddened, painful, and excoriated. are instructed to examine themselves to discover changes
that have occurred in the breast. Only a physician can
9. Answer: (B) Flat on back. To avoid the complication of a diagnose lumps that are cancerous, areas of thickness or
painful spinal headache that can last for several days, the fullness that signal the presence of a malignancy, or masses
client is kept in flat in a supine position for approximately 4 that are fibrocystic as opposed to malignant.
to 12 hours postoperatively. Headaches are believed to be
causes by the seepage of cerebral spinal fluid from the 21. Answer: (C) Balance the client’s periods of activity and
puncture site. By keeping the client flat, cerebral spinal rest. A client with hyperthyroidism needs to be encouraged
fluid pressures are equalized, which avoids trauma to the to balance periods of activity and rest. Many clients with
neurons. hyperthyroidism are hyperactive and complain of feeling
very warm.
10. Answer: (C) The client is oriented when aroused from
sleep, and goes back to sleep immediately. This finding 22. Answer: (B) Increase his activity level. The client should be
suggest that the level of consciousness is decreasing. encouraged to increase his activity level. Maintaining an
ideal weight; following a low-cholesterol, low sodium diet;
11. Answer: (A) Altered mental status and dehydration. Fever, and avoiding stress are all important factors in decreasing
chills, hemortysis, dyspnea, cough, and pleuritic chest pain the risk of atherosclerosis.
are the common symptoms of pneumonia, but elderly
clients may first appear with only an altered lentil status and 23. Answer: (A) Laminectomy. The client who has had spinal
dehydration due to a blunted immune response. surgery, such as laminectomy, must be log rolled to keep the
spinal column straight when turning. Thoracotomy and
12. Answer: (B) Chills, fever, night sweats, and hemoptysis. cystectomy may turn themselves or may be assisted into a
Typical signs and symptoms are chills, fever, night sweats, comfortable position. Under normal circumstances,
and hemoptysis. Chest pain may be present from coughing, hemorrhoidectomy is an outpatient procedure, and the client
but isn’t usual. Clients with TB typically have low-grade may resume normal activities immediately after surgery.
fevers, not higher than 102°F (38.9°C). Nausea, headache,
24. Answer: (D) Avoiding straining during bowel movement or 34. Answer: (C) Place the client in a side lying position, with
bending at the waist. The client should avoid straining, the head of the bed lowered. The client should be
lifting heavy objects, and coughing harshly because these positioned in a side-lying position with the head of the bed
activities increase intraocular pressure. Typically, the client lowered to prevent aspiration. A small amount of toothpaste
is instructed to avoid lifting objects weighing more than 15 should be used and the mouth swabbed or suctioned to
lb (7kg) – not 5lb. instruct the client when lying in bed to remove pooled secretions. Lemon glycerin can be drying if
lie on either the side or back. The client should avoid bright used for extended periods. Brushing the teeth with the client
light by wearing sunglasses. lying supine may lead to aspiration. Hydrogen peroxide is
caustic to tissues and should not be used.
25. Answer: (D) Before age 20. Testicular cancer commonly
occurs in men between ages 20 and 30. A male client 35. Answer: (C) Pneumonia. Fever productive cough and
should be taught how to perform testicular selfexamination pleuritic chest pain are common signs and symptoms of
before age 20, preferably when he enters his teens. pneumonia. The client with ARDS has dyspnea and
hypoxia with worsening hypoxia over time, if not treated
26. Answer: (B) Place a saline-soaked sterile dressing on the aggressively. Pleuritic chest pain varies with respiration,
wound. The nurse should first place saline-soaked sterile unlike the constant chest pain during an MI; so this client
dressings on the open wound to prevent tissue drying and most likely isn’t having an MI. the client with TB typically
possible infection. Then the nurse should call the physician has a cough producing blood-tinged sputum. A sputum
and take the client’s vital signs. The dehiscence needs to be culture should be obtained to confirm the nurse’s
surgically closed, so the nurse should never try to close it. suspicions.

27. Answer: (A) A progressively deeper breaths followed by 36. Answer: (C) A 43-yesr-old homeless man with a history of
shallower breaths with apneic periods. Cheyne-Strokes alcoholism. Clients who are economically disadvantaged,
respirations are breaths that become progressively deeper malnourished, and have reduced immunity, such as a client
fallowed by shallower respirations with apneas periods. with a history of alcoholism, are at extremely high risk for
Biot’s respirations are rapid, deep breathing with abrupt developing TB. A high school student, daycare worker, and
pauses between each breath, and equal depth between each businessman probably have a much low risk of contracting
breath. Kussmaul’s respirations are rapid, deep breathing TB.
without pauses. Tachypnea is shallow breathing with
increased respiratory rate. 37. Answer: (C ) To determine the extent of lesions. If the
lesions are large enough, the chest X-ray will show their
28. Answer: (B) Fine crackles. Fine crackles are caused by fluid presence in the lungs. Sputum culture confirms the
in the alveoli and commonly occur in clients with heart diagnosis. There can be false-positive and false-negative
failure. Tracheal breath sounds are auscultated over the skin test results. A chest X-ray can’t determine if this is a
trachea. Coarse crackles are caused by secretion primary or secondary infection.
accumulation in the airways. Friction rubs occur with
pleural inflammation. 38. Answer: (B) Bronchodilators. Bronchodilators are the first
line of treatment for asthma because broncho-constriction is
29. Answer: (B) The airways are so swollen that no air cannot the cause of reduced airflow. Beta adrenergic blockers
get through. During an acute attack, wheezing may stop and aren’t used to treat asthma and can cause
breath sounds become inaudible because the airways are so bronchoconstriction. Inhaled oral steroids may be given to
swollen that air can’t get through. If the attack is over and reduce the inflammation but aren’t used for emergency
swelling has decreased, there would be no more wheezing relief.
and less emergent concern. Crackles do not replace wheezes
during an acute asthma attack. 39. Answer: (C) Chronic obstructive bronchitis. Because of this
extensive smoking history and symptoms the client most
30. Answer: (D) Place the client on his side, remove dangerous likely has chronic obstructive bronchitis. Client with ARDS
objects, and protect his head. During the active seizure have acute symptoms of hypoxia and typically need large
phase, initiate precautions by placing the client on his side, amounts of oxygen. Clients with asthma and emphysema
removing dangerous objects, and protecting his head from tend not to have chronic cough or peripheral edema.
injury. A bite block should never be inserted during the
active seizure phase. Insertion can break the teeth and lead 40. Answer: (A) The patient is under local anesthesia during the
to aspiration. procedure. Before the procedure, the patient is administered
with drugs that would help to prevent infection and
31. Answer: (B) Kinked or obstructed chest tube. Kinking and rejection of the transplanted cells such as antibiotics,
blockage of the chest tube is a common cause of a tension cytotoxic, and corticosteroids. During the transplant, the
pneumothorax. Infection and excessive drainage won’t patient is placed under general anesthesia.
cause a tension pneumothorax. Excessive water won’t affect
the chest tube drainage. 41. Answer: (D) Raise the side rails. A patient who is
disoriented is at risk of falling out of bed. The initial action
32. Answer: (D) Stay with him but not intervene at this time. If of the nurse should be raising the side rails to ensure
the client is coughing, he should be able to dislodge the patients safety.
object or cause a complete obstruction. If complete
obstruction occurs, the nurse should perform the abdominal 42. Answer: (A) Crowd red blood cells. The excessive
thrust maneuver with the client standing. If the client is production of white blood cells crowd out red blood cells
unconscious, she should lay him down. A nurse should production which causes anemia to occur.
never leave a choking client alone.
43. Answer: (B) Leukocytosis. Chronic Lymphocytic leukemia
33. Answer: (B) Current health promotion activities. (CLL) is characterized by increased production of
Recognizing an individual’s positive health measures is leukocytes and lymphocytes resulting in leukocytosis, and
very useful. General health in the previous 10 years is proliferation of these cells within the bone marrow, spleen
important, however, the current activities of an 84 year old and liver.
client are most significant in planning care. Family history
of disease for a client in later years is of minor significance. 44. Answer: (A) Explain the risks of not having the surgery.
Marital status information may be important for discharge The best initial response is to explain the risks of not having
planning but is not as significant for addressing the the surgery. If the client understands the risks but still
immediate medical problem. refuses the nurse should notify the physician and the nurse
 supervisor and then record the client’s refusal in the nurses’ and atrophy of the arm and hand muscles on the affected
notes. side suggest Pancoast’s tumor, a lung tumor involving the
first thoracic and eighth cervical nerves within the brachial
45. Answer: (D) The 75-year-old client who was admitted 1 plexus. Hoarseness in a client with lung cancer suggests
hour ago with new-onset atrial fibrillation and is receiving that the tumor has extended to the recurrent laryngeal nerve;
L.V. dilitiazem (Cardizem). The client with atrial fibrillation dysphagia suggests that the lung tumor is compressing the
has the greatest potential to become unstable and is on L.V. esophagus.
medication that requires close monitoring. After assessing
this client, the nurse should assess the client with 53. Answer: (A) prostate-specific antigen, which is used to
thrombophlebitis who is receiving a heparin infusion, and screen for prostate cancer. PSA stands for prostate-specific
then the 58- year-old client admitted 2 days ago with heart antigen, which is used to screen for prostate cancer. The
failure (his signs and symptoms are resolving and don’t other answers are incorrect.
require immediate attention). The lowest priority is the
89-year-old with end stage right-sided heart failure, who 54. Answer: (D) “Remain supine for the time specified by the
requires time-consuming supportive measures. physician.” The nurse should instruct the client to remain
supine for the time specified by the physician. Local
46. Answer: (C) Cocaine. Because of the client’s age and anesthetics used in a subarachnoid block don’t alter the gag
negative medical history, the nurse should question her reflex. No interactions between local anesthetics and food
about cocaine use. Cocaine increases myocardial oxygen occur. Local anesthetics don’t cause hematuria.
consumption and can cause coronary artery spasm, leading
to tachycardia, ventricular fibrillation, myocardial ischemia, 55. Answer: (C) Sigmoidoscopy. Used to visualize the lower GI
and myocardial infarction. Barbiturate overdose may trigger tract, sigmoidoscopy and proctoscopy aid in the detection of
respiratory depression and slow pulse. Opioids can cause two-thirds of all colorectal cancers. Stool Hematest detects
marked respiratory depression, while benzodiazepines can blood, which is a sign of colorectal cancer; however, the
cause drowsiness and confusion. test doesn’t confirm the diagnosis. CEA may be elevated in
colorectal cancer but isn’t considered a confirming test. An
47. Answer: (B) Nonmobile mass with irregular edges. Breast abdominal CT scan is used to stage the presence of
cancer tumors are fixed, hard, and poorly delineated with colorectal cancer.
irregular edges. A mobile mass that is soft and easily
delineated is most often a fluid-filled benign cyst. Axillary 56. Answer: (B) A fixed nodular mass with dimpling of the
lymph nodes may or may not be palpable on initial overlying skin. A fixed nodular mass with dimpling of the
detection of a cancerous mass. Nipple retraction — not overlying skin is common during late stages of breast
eversion — may be a sign of cancer. cancer. Many women have slightly asymmetrical breasts.
Bloody nipple discharge is a sign of intraductal papilloma, a
48. Answer: (C) Radiation. The usual treatment for vaginal benign condition. Multiple firm, round, freely movable
cancer is external or intravaginal radiation therapy. Less masses that change with the menstrual cycle indicate
often, surgery is performed. Chemotherapy typically is fibrocystic breasts, a benign condition.
prescribed only if vaginal cancer is diagnosed in an early
stage, which is rare. Immunotherapy isn’t used to treat 57. Answer: (A) Liver. The liver is one of the five most
vaginal cancer. common cancer metastasis sites. The others are the lymph
nodes, lung, bone, and brain. The colon, reproductive tract,
49. Answer: (B) Carcinoma in situ, no abnormal regional and WBCs are occasional metastasis sites.
lymph nodes, and no evidence of distant metastasis. TIS,
N0, M0 denotes carcinoma in situ, no abnormal regional 58. Answer: (D) The client wears a watch and wedding band.
lymph nodes, and no evidence of distant metastasis. No During an MRI, the client should wear no metal objects,
evidence of primary tumor, no abnormal regional lymph such as jewelry, because the strong magnetic field can pull
nodes, and no evidence of distant metastasis is classified as on them, causing injury to the client and (if they fly off) to
T0, N0, M0. If the tumor and regional lymph nodes can’t be others. The client must lie still during the MRI but can talk
assessed and no evidence of metastasis exists, the lesion is to those performing the test by way of the microphone
classified as TX, NX, M0. A progressive increase in tumor inside the scanner tunnel. The client should hear thumping
size, no demonstrable metastasis of the regional lymph sounds, which are caused by the sound waves thumping on
nodes, and ascending degrees of distant metastasis is the magnetic field.
classified as T1, T2, T3, or T4; N0; and M1, M2, or M3.
59. Answer: (C) The recommended daily allowance of calcium
50. Answer: (D) “Keep the stoma moist.” The nurse should may be found in a wide variety of foods. Premenopausal
instruct the client to keep the stoma moist, such as by women require 1,000 mg of calcium per day.
applying a thin layer of petroleum jelly around the edges, Postmenopausal women require 1,500 mg per day. It’s
because a dry stoma may become irritated. The nurse often, though not always, possible to get the recommended
should recommend placing a stoma bib over the stoma to daily requirement in the foods we eat. Supplements are
filter and warm air before it enters the stoma. The client available but not always necessary. Osteoporosis doesn’t
should begin performing stoma care without assistance as show up on ordinary X-rays until 30% of the bone loss has
soon as possible to gain independence in self-care activities. occurred. Bone densitometry can detect bone loss of 3% or
less. This test is sometimes recommended routinely for
51. Answer: (B) Lung cancer. Lung cancer is the most deadly women over 35 who are at risk. Strenuous exercise won’t
type of cancer in both women and men. Breast cancer ranks cause fractures.
second in women, followed (in descending order) by colon
and rectal cancer, pancreatic cancer, ovarian cancer, uterine 60. Answer: (C) Joint flexion of less than 50%. Arthroscopy is
cancer, lymphoma, leukemia, liver cancer, brain cancer, contraindicated in clients with joint flexion of less than 50%
stomach cancer, and multiple myeloma. because of technical problems in inserting the instrument
into the joint to see it clearly. Other contraindications for
52. Answer: (A) miosis, partial eyelid ptosis, and anhidrosis on this procedure include skin and wound infections. Joint pain
the affected side of the face. Horner’s syndrome, which may be an indication, not a contraindication, for
occurs when a lung tumor invades the ribs and affects the arthroscopy. Joint deformity and joint stiffness aren’t
sympathetic nerve ganglia, is characterized by miosis, contraindications for this procedure.
partial eyelid ptosis, and anhidrosis on the affected side of
the face. Chest pain, dyspnea, cough, weight loss, and fever 61. Answer: (D) Gouty arthritis. Gouty arthritis, a metabolic
are associated with pleural tumors. Arm and shoulder pain disease, is characterized by urate deposits and pain in the
 joints, especially those in the feet and legs. Urate deposits sterile dressings protect the wound from mechanical trauma
don’t occur in septic or traumatic arthritis. Septic arthritis and promote healing.
results from bacterial invasion of a joint and leads to
inflammation of the synovial lining. Traumatic arthritis 71. Answer: (A) Hyperkalemia. In adrenal insufficiency, the
results from blunt trauma to a joint or ligament. Intermittent client has hyperkalemia due to reduced aldosterone
arthritis is a rare, benign condition marked by regular, secretion. BUN increases as the glomerular filtration rate is
recurrent joint effusions, especially in the knees. reduced. Hyponatremia is caused by reduced aldosterone
secretion. Reduced cortisol secretion leads to impaired
62. Answer: (B) 30 ml/hour. An infusion prepared with 25,000 glyconeogenesis and a reduction of glycogen in the liver
units of heparin in 500 ml of saline solution yields 50 units and muscle, causing hypoglycemia.
of heparin per milliliter of solution. The equation is set up
as 50 units times X (the unknown quantity) equals 1,500 72. Answer: (C) Restricting fluids. To reduce water retention in
units/hour, X equals 30 ml/hour. a client with the SIADH, the nurse should restrict fluids.
Administering fluids by any route would further increase
63. Answer: (B) Loss of muscle contraction decreasing venous the client’s already heightened fluid load.
return. In clients with hemiplegia or hemiparesis loss of
muscle contraction decreases venous return and may cause 73. Answer: (D) glycosylated hemoglobin level. Because some
swelling of the affected extremity. Contractures, or bony of the glucose in the bloodstream attaches to some of the
calcifications may occur with a stroke, but don’t appear hemoglobin and stays attached during the 120-day life span
with swelling. DVT may develop in clients with a stroke of red blood cells, glycosylated hemoglobin levels provide
but is more likely to occur in the lower extremities. A information about blood glucose levels during the previous
stroke isn’t linked to protein loss. 3 months. Fasting blood glucose and urine glucose levels
only give information about glucose levels at the point in
64. Answer: (B) It appears on the distal interphalangeal joint. time when they were obtained. Serum fructosamine levels
Heberden’s nodes appear on the distal interphalageal joint provide information about blood glucose control over the
on both men and women. Bouchard’s node appears on the past 2 to 3 weeks.
dorsolateral aspect of the proximal interphalangeal joint.
74. Answer: (C) 4:00 pm. NPH is an intermediate-acting insulin
65. Answer: (B) Osteoarthritis is a localized disease rheumatoid that peaks 8 to 12 hours after administration. Because the
arthritis is systemic. Osteoarthritis is a localized disease, nurse administered NPH insulin at 7 a.m., the client is at
rheumatoid arthritis is systemic. Osteoarthritis isn’t greatest risk for hypoglycemia from 3 p.m. to 7 p.m.
gender-specific, but rheumatoid arthritis is. Clients have
dislocations and subluxations in both disorders. 75. Answer: (A) Glucocorticoids and androgens. The adrenal
glands have two divisions, the cortex and medulla. The
66. Answer: (C) The cane should be used on the unaffected cortex produces three types of hormones: glucocorticoids,
side. A cane should be used on the unaffected side. A client mineralocorticoids, and androgens. The medulla produces
with osteoarthritis should be encouraged to ambulate with a catecholamines — epinephrine and norepinephrine.
cane, walker, or other assistive device as needed; their use
takes weight and stress off joints. 76. Answer: (A) Hypocalcemia. Hypocalcemia may follow
thyroid surgery if the parathyroid glands were removed
67. Answer: (A) 9 U regular insulin and 21 U neutral protamine accidentally. Signs and symptoms of hypocalcemia may be
Hagedorn (NPH). A 70/30 insulin preparation is 70% NPH delayed for up to 7 days after surgery. Thyroid surgery
and 30% regular insulin. Therefore, a correct substitution doesn’t directly cause serum sodium, potassium, or
requires mixing 21 U of NPH and 9 U of regular insulin. magnesium abnormalities. Hyponatremia may occur if the
The other choices are incorrect dosages for the prescribed client inadvertently received too much fluid; however, this
insulin. can happen to any surgical client receiving I.V. fluid
therapy, not just one recovering from thyroid surgery.
68. Answer: (C) colchicines. A disease characterized by joint Hyperkalemia and hypermagnesemia usually are associated
inflammation (especially in the great toe), gout is caused by with reduced renal excretion of potassium and magnesium,
urate crystal deposits in the joints. The physician prescribes not thyroid surgery.
colchicine to reduce these deposits and thus ease joint
inflammation. Although aspirin is used to reduce joint 77. Answer: (D) Carcinoembryonic antigen level. In clients
inflammation and pain in clients with osteoarthritis and who smoke, the level of carcinoembryonic antigen is
rheumatoid arthritis, it isn’t indicated for gout because it has elevated. Therefore, it can’t be used as a general indicator
no effect on urate crystal formation. Furosemide, a diuretic, of cancer. However, it is helpful in monitoring cancer
doesn’t relieve gout. Calcium gluconate is used to reverse a treatment because the level usually falls to normal within 1
negative calcium balance and relieve muscle cramps, not to month if treatment is successful. An elevated acid
treat gout. phosphatase level may indicate prostate cancer. An elevated
alkaline phosphatase level may reflect bone metastasis. An
69. Answer: (A) Adrenal cortex. Excessive secretion of elevated serum calcitonin level usually signals thyroid
aldosterone in the adrenal cortex is responsible for the cancer.
client’s hypertension. This hormone acts on the renal
tubule, where it promotes reabsorption of sodium and 78. Answer: (B) Dyspnea, tachycardia, and pallor. Signs of
excretion of potassium and hydrogen ions. The pancreas iron-deficiency anemia include dyspnea, tachycardia, and
mainly secretes hormones involved in fuel metabolism. The pallor as well as fatigue, listlessness, irritability, and
adrenal medulla secretes the catecholamines — epinephrine headache. Night sweats, weight loss, and diarrhea may
and norepinephrine. The parathyroids secrete parathyroid signal acquired immunodeficiency syndrome (AIDS).
hormone. Nausea, vomiting, and anorexia may be signs of hepatitis B.
Itching, rash, and jaundice may result from an allergic or
70. Answer: (C) They debride the wound and promote healing hemolytic reaction.
by secondary intention. For this client, wet-to-dry dressings
are most appropriate because they clean the foot ulcer by 79. Answer: (D) “I’ll need to have a C-section if I become
debriding exudate and necrotic tissue, thus promoting pregnant and have a baby.” The human immunodeficiency
healing by secondary intention. Moist, transparent dressings virus (HIV) is transmitted from mother to child via the
contain exudate and provide a moist wound environment. transplacental route, but a Cesarean section delivery isn’t
Hydrocolloid dressings prevent the entrance of necessary when the mother is HIV-positive. The use of birth
microorganisms and minimize wound discomfort. Dry control will prevent the conception of a child who might
 have HIV. It’s true that a mother who’s HIV positive can and denote infection. The Western blot test —
give birth to a baby who’s HIV negative. electrophoresis of antibody proteins — is more than 98%
accurate in detecting HIV antibodies when used in
80. Answer: (C) “Avoid sharing such articles as toothbrushes conjunction with the ELISA. It isn’t specific when used
and razors.” The human immunodeficiency virus (HIV), alone. Erosette immunofluorescence is used to detect
which causes AIDS, is most concentrated in the blood. For viruses in general; it doesn’t confirm HIV infection.
this reason, the client shouldn’t share personal articles that Quantification of T-lymphocytes is a useful monitoring test
may be blood-contaminated, such as toothbrushes and but isn’t diagnostic for HIV. The ELISA test detects HIV
razors, with other family members. HIV isn’t transmitted by antibody particles but may yield inaccurate results; a
bathing or by eating from plates, utensils, or serving dishes positive ELISA result must be confirmed by the Western
used by a person with AIDS. blot test.

81. Answer: (B) Pallor, tachycardia, and a sore tongue. Pallor, 88. Answer: (C) Abnormally low hematocrit (HCT) and
tachycardia, and a sore tongue are all characteristic findings hemoglobin (Hb) levels. Low preoperative HCT and Hb
in pernicious anemia. Other clinical manifestations include levels indicate the client may require a blood transfusion
anorexia; weight loss; a smooth, beefy red tongue; a wide before surgery. If the HCT and Hb levels decrease during
pulse pressure; palpitations; angina; weakness; fatigue; and surgery because of blood loss, the potential need for a
paresthesia of the hands and feet. Bradycardia, reduced transfusion increases. Possible renal failure is indicated by
pulse pressure, weight gain, and double vision aren’t elevated BUN or creatinine levels. Urine constituents aren’t
characteristic findings in pernicious anemia. found in the blood. Coagulation is determined by the
presence of appropriate clotting factors, not electrolytes.
82. Answer: (B) Administer epinephrine, as prescribed, and
prepare to intubate the client if necessary. To reverse 89. Answer: (A) Platelet count, prothrombin time, and partial
anaphylactic shock, the nurse first should administer thromboplastin time. The diagnosis of DIC is based on the
epinephrine, a potent bronchodilator as prescribed. The results of laboratory studies of prothrombin time, platelet
physician is likely to order additional medications, such as count, thrombin time, partial thromboplastin time, and
antihistamines and corticosteroids; if these medications fibrinogen level as well as client history and other
don’t relieve the respiratory compromise associated with assessment factors. Blood glucose levels, WBC count,
anaphylaxis, the nurse should prepare to intubate the client. calcium levels, and potassium levels aren’t used to confirm
No antidote for penicillin exists; however, the nurse should a diagnosis of DIC.
continue to monitor the client’s vital signs. A client who
remains hypotensive may need fluid resuscitation and fluid 90. Answer: (D) Strawberries. Common food allergens include
intake and output monitoring; however, administering berries, peanuts, Brazil nuts, cashews, shellfish, and eggs.
epinephrine is the first priority. Bread, carrots, and oranges rarely cause allergic reactions.

83. Answer: (D) bilateral hearing loss. Prolonged use of aspirin 91. Answer: (B) A client with cast on the right leg who states,
and other salicylates sometimes causes bilateral hearing loss “I have a funny feeling in my right leg.” It may indicate
of 30 to 40 decibels. Usually, this adverse effect resolves neurovascular compromise, requires immediate assessment.
within 2 weeks after the therapy is discontinued. Aspirin
doesn’t lead to weight gain or fine motor tremors. Large or 92. Answer: (D) A 62-year-old who had an abdominal-perineal
toxic salicylate doses may cause respiratory alkalosis, not resection three days ago; client complaints of chills. The
respiratory acidosis. client is at risk for peritonitis; should be assessed for further
symptoms and infection.
84. Answer: (D) Lymphocyte. The lymphocyte provides
adaptive immunity — recognition of a foreign antigen and 93. Answer: (C) The client spontaneously flexes his wrist when
formation of memory cells against the antigen. Adaptive the blood pressure is obtained. Carpal spasms indicate
immunity is mediated by B and T lymphocytes and can be hypocalcemia.
acquired actively or passively. The neutrophil is crucial to
phagocytosis. The basophil plays an important role in the 94. Answer: (D) Use comfort measures and pillows to position
release of inflammatory mediators. The monocyte functions the client.Using comfort measures and pillows to position
in phagocytosis and monokine production. the client is a non-pharmacological methods of pain relief.

85. Answer: (A) moisture replacement. Sjogren’s syndrome is 95. Answer: (B) Warm the dialysate solution. Cold dialysate
an autoimmune disorder leading to progressive loss of increases discomfort. The solution should be warmed to
lubrication of the skin, GI tract, ears, nose, and vagina. body temperature in warmer or heating pad; don’t use
Moisture replacement is the mainstay of therapy. Though microwave oven.
malnutrition and electrolyte imbalance may occur as a result
of Sjogren’s syndrome’s effect on the GI tract, it isn’t the 96. Answer: (C) The client holds the cane with his left hand,
predominant problem. Arrhythmias aren’t a problem moves the cane forward followed by the right leg, and then
associated with Sjogren’s syndrome. moves the left leg. The cane acts as a support and aids in
weight bearing for the weaker right leg.
86. Answer: (C) stool for Clostridium difficile test.
Immunosuppressed clients — for example, clients receiving 97. Answer: (A) Ask the woman’s family to provide personal
chemotherapy, — are at risk for infection with C. difficile, items such as photos or mementos.Photos and mementos
which causes “horse barn” smelling diarrhea. Successful provide visual stimulation to reduce sensory deprivation.
treatment begins with an accurate diagnosis, which includes
98. Answer: (B) The client lifts the walker, moves it forward 10
a stool test. The ELISA test is diagnostic for human
inches, and then takes several small steps forward. A walker
immunodeficiency virus (HIV) and isn’t indicated in this
needs to be picked up, placed down on all legs.
case. An electrolyte panel and hemogram may be useful in
the overall evaluation of a client but aren’t diagnostic for 99. Answer: (C) Isolation from their families and familiar
specific causes of diarrhea. A flat plate of the abdomen may surroundings. Gradual loss of sight, hearing, and taste
provide useful information about bowel function but isn’t interferes with normal functioning.
indicated in the case of “horse barn” smelling diarrhea.
100.Answer: (A) Encourage the client to perform pursed lip
87. Answer: (D) Western blot test with ELISA. HIV infection is breathing. Purse lip breathing prevents the collapse of lung
detected by analyzing blood for antibodies to HIV, which unit and helps client control rate and depth of breathing.
form approximately 2 to 12 weeks after exposure to HIV
 7. Nurse Ron begins to teach a male client how to perform
Care of Clients with colostomy irrigations. The nurse would evaluate that the
instructions were understood when the client states, “I should:
Physiologic and Psychosocial
A. Lie on my left side while instilling the irrigating
Alterations (Part 2) solution.”

1. Randy has undergone kidney transplant, what assessment B. Keep the irrigating container less than 18 inches
would prompt Nurse Katrina to suspect organ rejection? above the stoma.”

A. Sudden weight loss C. Instill a minimum of 1200 ml of irrigating

solution to stimulate evacuation of the bowel.”
B. Polyuria
D. Insert the irrigating catheter deeper into the stoma
C. Hypertension if cramping occurs during the procedure.”

D. Shock 8. Patrick is in the oliguric phase of acute tubular necrosis and is

experiencing fluid and electrolyte imbalances. The client is
2. The immediate objective of nursing care for an overweight, somewhat confused and complains of nausea and muscle
mildly hypertensive male client with ureteral colic and weakness. As part of the prescribed therapy to correct this
hematuria is to decrease: electrolyte imbalance, the nurse would expect to:

A. Pain A. Administer Kayexalate

B. Weight B. Restrict foods high in protein

C. Hematuria C. Increase oral intake of cheese and milk.

D. Hypertension D. Administer large amounts of normal saline via

I.V.
3. Matilda, with hyperthyroidism is to receive Lugol’s iodine
solution before a subtotal thyroidectomy is performed. The 9. Mario has burn injury. After Forty48 hours, the physician
nurse is aware that this medication is given to: orders for Mario 2 liters of IV fluid to be administered q12 h.
The drop factor of the tubing is 10 gtt/ml. The nurse should set
A. Decrease the total basal metabolic rate. the flow to provide:
B. Maintain the function of the parathyroid glands. A. 18 gtt/min
C. Block the formation of thyroxine by the thyroid B. 28 gtt/min
gland.
C. 32 gtt/min
D. Decrease the size and vascularity of the thyroid
gland. D. 36 gtt/min

4. Ricardo, was diagnosed with type I diabetes. The nurse is 10.Terence suffered form burn injury. Using the rule of nines,
aware that acute hypoglycemia also can develop in the client which has the largest percent of burns?
who is diagnosed with:
A. Face and neck
A. Liver disease
B. Right upper arm and penis
B. Hypertension
C. Right thigh and penis
C. Type 2 diabetes
D. Upper trunk
D. Hyperthyroidism
11. Herbert, a 45 year old construction engineer is brought to the
5. Tracy is receiving combination chemotherapy for treatment of hospital unconscious after falling from a 2-story building. When
metastatic carcinoma. Nurse Ruby should monitor the client for assessing the client, the nurse would be most concerned if the
the systemic side effect of: assessment revealed:

A. Ascites A. Reactive pupils

B. Nystagmus B. A depressed fontanel

C. Leukopenia C. Bleeding from ears

D. Polycythemia D. An elevated temperature

6. Norma, with recent colostomy expresses concern about the 12. Nurse Sherry is teaching male client regarding his
inability to control the passage of gas. Nurse Oliver should permanent artificial pacemaker. Which information given by the
suggest that the client plan to: nurse shows her knowledge deficit about the artificial cardiac
pacemaker?
A. Eliminate foods high in cellulose.
A. take the pulse rate once a day, in the morning
B. Decrease fluid intake at meal times. upon awakening
C. Avoid foods that in the past caused flatus. B. May be allowed to use electrical appliances
D. Adhere to a bland diet prior to social events. C. Have regular follow up care
 D. May engage in contact sports problem and is being examined in the emergency department.
When palpating the her kidneys, the nurse should keep which
13.The nurse is ware that the most relevant knowledge about anatomical fact in mind?
oxygen administration to a male client with COPD is
A. The left kidney usually is slightly higher than the
A. Oxygen at 1-2L/min is given to maintain the right one.
hypoxic stimulus for breathing.
B. The kidneys are situated just above the adrenal
B. Hypoxia stimulates the central chemoreceptors in glands.
the medulla that makes the client breath.
C. The average kidney is approximately 5 cm (2″)
C. Oxygen is administered best using a long and 2 to 3 cm (¾” to 1-1/8″) wide.
non-rebreathing mask
D. The kidneys lie between the 10th and 12th
D. Blood gases are monitored using a pulse oximeter. thoracic vertebrae.

14.Tonny has undergoes a left thoracotomy and a partial 19.Jestoni with chronic renal failure (CRF) is admitted to the
pneumonectomy. Chest tubes are inserted, and one-bottle urology unit. The nurse is aware that the diagnostic test are
water-seal drainage is instituted in the operating room. In the consistent with CRF if the result is:
postanesthesia care unit Tonny is placed in Fowler’s position on
either his right side or on his back. The nurse is aware that this A. Increased pH with decreased hydrogen ions.
position:
B. Increased serum levels of potassium, magnesium,
A. Reduce incisional pain. and calcium.

B. Facilitate ventilation of the left lung. C. Blood urea nitrogen (BUN) 100 mg/dl and serum
creatinine 6.5 mg/ dl.
C. Equalize pressure in the pleural space.
D. Uric acid analysis 3.5 mg/dl and
D. Increase venous return phenolsulfonphthalein (PSP) excretion 75%.

15.Kristine is scheduled for a bronchoscopy. When teaching 20. Katrina has an abnormal result on a Papanicolaou test. After
Kristine what to expect afterward, the nurse’s highest priority of admitting that she read her chart while the nurse was out of the
information would be: room, Katrina asks what dysplasia means. Which definition
should the nurse provide?
A. Food and fluids will be withheld for at least 2
hours. A. Presence of completely undifferentiated tumor
cells that don’t resemble cells of the tissues of
B. Warm saline gargles will be done q 2h. their origin.
C. Coughing and deep-breathing exercises will be B. Increase in the number of normal cells in a normal
done q2h. arrangement in a tissue or an organ.
D. Only ice chips and cold liquids will be allowed C. Replacement of one type of fully differentiated
initially. cell by another in tissues where the second type
normally isn’t found.
16.Nurse Tristan is caring for a male client in acute renal failure.
The nurse should expect hypertonic glucose, insulin infusions, D. Alteration in the size, shape, and organization of
and sodium bicarbonate to be used to treat: differentiated cells.
A. hypernatremia. 21. During a routine checkup, Nurse Mariane assesses a male
client with acquired immunodeficiency syndrome (AIDS) for
B. hypokalemia. signs and symptoms of cancer. What is the most common
AIDS-related cancer?
C. hyperkalemia.
A. Squamous cell carcinoma
D. hypercalcemia.
B. Multiple myeloma
17.Ms. X has just been diagnosed with condylomata acuminata
(genital warts). What information is appropriate to tell this C. Leukemia
client?
D. Kaposi’s sarcoma
A. This condition puts her at a higher risk for
cervical cancer; therefore, she should have a 22.Ricardo is scheduled for a prostatectomy, and the
Papanicolaou (Pap) smear annually. anesthesiologist plans to use a spinal (subarachnoid) block
during surgery. In the operating room, the nurse positions the
B. The most common treatment is metronidazole client according to the anesthesiologist’s instructions. Why does
(Flagyl), which should eradicate the problem the client require special positioning for this type of anesthesia?
within 7 to 10 days.
A. To prevent confusion
C. The potential for transmission to her sexual
partner will be eliminated if condoms are used B. To prevent seizures
every time they have sexual intercourse.
C. To prevent cerebrospinal fluid (CSF) leakage
D. The human papillomavirus (HPV), which causes
condylomata acuminata, can’t be transmitted D. To prevent cardiac arrhythmias
during oral sex.
23.A male client had a nephrectomy 2 days ago and is now
18.Maritess was recently diagnosed with a genitourinary complaining of abdominal pressure and nausea. The first
nursing action should be to: C. In long, even, outward, and downward strokes in
the direction of hair growth
A. Auscultate bowel sounds.
D. In long, even, outward, and upward strokes in the
B. Palpate the abdomen. direction opposite hair growth

C. Change the client’s position. 30.Nurse Kate is aware that one of the following classes of
medication protect the ischemic myocardium by blocking
D. Insert a rectal tube. catecholamines and sympathetic nerve stimulation is:
24.Wilfredo with a recent history of rectal bleeding is being A. Beta -adrenergic blockers
prepared for a colonoscopy. How should the nurse Patricia
position the client for this test initially? B. Calcium channel blocker

A. Lying on the right side with legs straight C. Narcotics

B. Lying on the left side with knees bent D. Nitrates

C. Prone with the torso elevated 31.A male client has jugular distention. On what position should
the nurse place the head of the bed to obtain the most accurate
D. Bent over with hands touching the floor reading of jugular vein distention?
25.A male client with inflammatory bowel disease undergoes an A. High Fowler’s
ileostomy. On the first day after surgery, Nurse Oliver notes that
the client’s stoma appears dusky. How should the nurse interpret B. Raised 10 degrees
this finding?
C. Raised 30 degrees
A. Blood supply to the stoma has been interrupted.
D. Supine position
B. This is a normal finding 1 day after surgery.
32.The nurse is aware that one of the following classes of
C. The ostomy bag should be adjusted. medications maximizes cardiac performance in clients with
heart failure by increasing ventricular contractility?
D. An intestinal obstruction has occurred.
A. Beta-adrenergic blockers
26.Anthony suffers burns on the legs, which nursing
intervention helps prevent contractures? B. Calcium channel blocker
A. Applying knee splints C. Diuretics

B. Elevating the foot of the bed D. Inotropic agents

C. Hyperextending the client’s palms 33.A male client has a reduced serum high-density lipoprotein
(HDL) level and an elevated low-density lipoprotein (LDL)
D. Performing shoulder range-of-motion exercises level. Which of the following dietary modifications is not
appropriate for this client?
27.Nurse Ron is assessing a client admitted with second- and
third-degree burns on the face, arms, and chest. Which finding A. Fiber intake of 25 to 30 g daily
indicates a potential problem?
B. Less than 30% of calories form fat
A. Partial pressure of arterial oxygen (PaO2) value of
80 mm Hg. C. Cholesterol intake of less than 300 mg daily

B. Urine output of 20 ml/hour. D. Less than 10% of calories from saturated fat

C. White pulmonary secretions. 34. A 37-year-old male client was admitted to the coronary care
unit (CCU) 2 days ago with an acute myocardial infarction.
D. Rectal temperature of 100.6° F (38° C). Which of the following actions would breach the client
confidentiality?
28. Mr. Mendoza who has suffered a cerebrovascular accident
(CVA) is too weak to move on his own. To help the client avoid A. The CCU nurse gives a verbal report to the nurse
pressure ulcers, Nurse Celia should: on the telemetry unit before transferring the client
to that unit
A. Turn him frequently.
B. The CCU nurse notifies the on-call physician
B. Perform passive range-of-motion (ROM) about a change in the client’s condition
exercises.
C. The emergency department nurse calls up the
C. Reduce the client’s fluid intake. latest electrocardiogram results to check the
client’s progress.
D. Encourage the client to use a footboard.
D. At the client’s request, the CCU nurse updates the
29.Nurse Maria plans to administer dexamethasone cream to a
client’s wife on his condition
female client who has dermatitis over the anterior chest. How
should the nurse apply this topical agent? 35. A male client arriving in the emergency department is
receiving cardiopulmonary resuscitation from paramedics who
A. With a circular motion, to enhance absorption.
are giving ventilations through an endotracheal (ET) tube that
B. With an upward motion, to increase blood supply they placed in the client’s home. During a pause in
to the affected area compressions, the cardiac monitor shows narrow QRS
complexes and a heart rate of beats/minute with a palpable D. Xenogeneic
pulse. Which of the following actions
41. Marco falls off his bicycle and injuries his ankle. Which of
should the nurse take first? the following actions shows the initial response to the injury in
the extrinsic pathway?
A. Start an L.V. line and administer amiodarone
(Cardarone), 300 mg L.V. over 10 minutes. A. Release of Calcium

B. Check endotracheal tube placement. B. Release of tissue thromboplastin

C. Obtain an arterial blood gas (ABG) sample. C. Conversion of factors XII to factor XIIa

D. Administer atropine, 1 mg L.V. D. Conversion of factor VIII to factor VIIIa

36. After cardiac surgery, a client’s blood pressure measures 42. Instructions for a client with systemic lupus erythematosus
126/80 mm Hg. Nurse Katrina determines that mean arterial (SLE) would include information about which of the following
pressure (MAP) is which of the following? blood dyscrasias?

A. 46 mm Hg A. Dressler’s syndrome

B. 80 mm Hg B. Polycythemia

C. 95 mm Hg C. Essential thrombocytopenia

D. 90 mm Hg D. Von Willebrand’s disease

37. A female client arrives at the emergency department with 43. The nurse is aware that the following symptoms is most
chest and stomach pain and a report of black tarry stool for commonly an early indication of stage 1 Hodgkin’s disease?
several months. Which of the following order should the nurse
Oliver anticipate? A. Pericarditis

A. Cardiac monitor, oxygen, creatine kinase and B. Night sweat

lactate dehydrogenase levels
C. Splenomegaly
B. Prothrombin time, partial thromboplastin time,
fibrinogen and fibrin split product values. D. Persistent hypothermia

C. Electrocardiogram, complete blood count, 44. Francis with leukemia has neutropenia. Which of the
testing for occult blood, comprehensive serum following functions must frequently assessed?
metabolic panel.
A. Blood pressure
D. Electroencephalogram, alkaline phosphatase and
aspartate aminotransferase levels, basic serum B. Bowel sounds
metabolic panel
C. Heart sounds
38. Macario had coronary artery bypass graft (CABG) surgery 3
D. Breath sounds
days ago. Which of the following conditions is suspected by the
nurse when a decrease in platelet count from 230,000 ul to 5,000 45. The nurse knows that neurologic complications of multiple
ul is noted? myeloma (MM) usually involve which of the following body
system?
A. Pancytopenia
A. Brain
B. Idiopathic thrombocytopemic purpura (ITP)
B. Muscle spasm
C. Disseminated intravascular coagulation (DIC)
C. Renal dysfunction
D. Heparin-associated thrombosis and
thrombocytopenia (HATT) D. Myocardial irritability
39. Which of the following drugs would be ordered by the 46. Nurse Patricia is aware that the average length of time from
physician to improve the platelet count in a male client with human immunodeficiency virus (HIV) infection to the
idiopathic thrombocytopenic purpura (ITP)? development of acquired immunodeficiency syndrome (AIDS)?
A. Acetylsalicylic acid (ASA) A. Less than 5 years
B. Corticosteroids B. 5 to 7 years
C. Methotrezate C. 10 years
D. Vitamin K D. More than 10 years
40. A female client is scheduled to receive a heart valve 47. An 18-year-old male client admitted with heat stroke begins
replacement with a porcine valve. Which of the following types to show signs of disseminated intravascular coagulation (DIC).
of transplant is this? Which of the following laboratory findings is most consistent
with DIC?
A. Allogeneic
A. Low platelet count
B. Autologous
B. Elevated fibrinogen levels
C. Syngeneic
 C. Low levels of fibrin degradation products is touched Stacy shouts in pain. The first nursing action to take
is:
D. Reduced prothrombin time
A. Notify the physician
48. Mario comes to the clinic complaining of fever, drenching
night sweats, and unexplained weight loss over the past 3 B. Flush the IV line with saline solution
months. Physical examination reveals a single enlarged
supraclavicular lymph node. Which of the following is the most C. Immediately discontinue the infusion
probable diagnosis?
D. Apply an ice pack to the site, followed by warm
A. Influenza compress.

B. Sickle cell anemia 54. The term “blue bloater” refers to a male client which of the
following conditions?
C. Leukemia
A. Adult respiratory distress syndrome (ARDS)
D. Hodgkin’s disease
B. Asthma
49. A male client with a gunshot wound requires an emergency
blood transfusion. His blood type is AB negative. Which blood C. Chronic obstructive bronchitis
type would be the safest for him to receive?
D. Emphysema
A. AB Rh-positive
55. The term “pink puffer” refers to the female client with which
B. A Rh-positive of the following conditions?

C. A Rh-negative A. Adult respiratory distress syndrome (ARDS)

D. O Rh-positive B. Asthma

Situation: Stacy is diagnosed with acute lymphoid leukemia C. Chronic obstructive bronchitis
(ALL) and beginning chemotherapy.
D. Emphysema
50. Stacy is discharged from the hospital following her
chemotherapy treatments. Which statement of Stacy’s mother 56. Jose is in danger of respiratory arrest following the
indicated that she understands when she will contact the administration of a narcotic analgesic. An arterial blood gas
physician? value is obtained. Nurse Oliver would expect the paco2 to be
which of the following values?
A. “I should contact the physician if Stacy has
difficulty in sleeping”. A. 15 mm Hg

B. “I will call my doctor if Stacy has persistent B. 30 mm Hg

vomiting and diarrhea”.
C. 40 mm Hg
C. “My physician should be called if Stacy is
irritable and unhappy”. D. 80 mm Hg

D. “Should Stacy have continued hair loss, I need to 57. Timothy’s arterial blood gas (ABG) results are as follows;
call the doctor”. pH 7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L;
Sao2 81%. This ABG result represents which of the following
51. Stacy’s mother states to the nurse that it is hard to see Stacy conditions?
with no hair. The best response for the nurse is:
A. Metabolic acidosis
A. “Stacy looks very nice wearing a hat”.
B. Metabolic alkalosis
B. “You should not worry about her hair, just be
glad that she is alive”. C. Respiratory acidosis

C. “Yes it is upsetting. But try to cover up your D. Respirator y alkalosis

feelings when you are with her or else she may
58. Norma has started a new drug for hypertension. Thirty
be upset”.
minutes after she takes the drug, she develops chest tightness
D. “This is only temporary; Stacy will re-grow new and becomes short of breath and tachypneic. She has a
hair in 3-6 months, but may be different in decreased level of consciousness. These signs indicate which of
texture”. the following conditions?

52. Stacy has beginning stomatitis. To promote oral hygiene and A. Asthma attack
comfort, the nurse in-charge should:
B. Pulmonary embolism
A. Provide frequent mouthwash with normal saline.
C. Respiratory failure
B. Apply viscous Lidocaine to oral ulcers as
D. Rheumatoid arthritis
needed.
Situation: Mr. Gonzales was admitted to the hospital with ascites
C. Use lemon glycerine swabs every 2 hours.
and jaundice. To rule out cirrhosis of the liver:
D. Rinse mouth with Hydrogen Peroxide.
59. Which laboratory test indicates liver cirrhosis?
53. During the administration of chemotherapy agents, Nurse
A. Decreased red blood cell count
Oliver observed that the IV site is red and swollen, when the IV
 B. Decreased serum acid phosphate level B. Echocardiogram

C. Elevated white blood cell count C. Nitroglycerin

D. Elevated serum aminotransferase D. Percutaneous transluminal coronary angioplasty

(PTCA)
60.The biopsy of Mr. Gonzales confirms the diagnosis of
cirrhosis. Mr. Gonzales is at increased risk for excessive 66. The nurse is aware that the following terms used to describe
bleeding primarily because of: reduced cardiac output and perfusion impairment due to
ineffective pumping of the heart is:
A. Impaired clotting mechanism
A. Anaphylactic shock
B. Varix formation
B. Cardiogenic shock
C. Inadequate nutrition
C. Distributive shock
D. Trauma of invasive procedure
D. Myocardial infarction (MI)
61. Mr. Gonzales develops hepatic encephalopathy. Which
clinical manifestation is most common with this condition? 67. A client with hypertension ask the nurse which factors can
cause blood pressure to drop to normal levels?
A. Increased urine output
A. Kidneys’ excretion to sodium only.
B. Altered level of consciousness
B. Kidneys’ retention of sodium and water
C. Decreased tendon reflex
C. Kidneys’ excretion of sodium and water
D. Hypotension
D. Kidneys’ retention of sodium and excretion of
62. When Mr. Gonzales regained consciousness, the physician water
orders 50 ml of Lactose p.o. every 2 hours. Mr. Gozales
develops diarrhea. The nurse best action would be: 68. Nurse Rose is aware that the statement that best explains
why furosemide (Lasix) is administered to treat hypertension is:
A. “I’ll see if your physician is in the hospital”.
A. It dilates peripheral blood vessels.
B. “Maybe your reacting to the drug; I will
withhold the next dose”. B. It decreases sympathetic cardioacceleration.

C. “I’ll lower the dosage as ordered so the drug C. It inhibits the angiotensin-coverting enzymes
causes only 2 to 4 stools a day”.
D. It inhibits reabsorption of sodium and water in
D. “Frequently, bowel movements are needed to the loop of Henle.
reduce sodium level”.
69. Nurse Nikki knows that laboratory results supports the
63. Which of the following groups of symptoms indicates a diagnosis of systemic lupus erythematosus (SLE) is:
ruptured abdominal aortic aneurysm?
A. Elavated serum complement level
A. Lower back pain, increased blood pressure,
decreased re blood cell (RBC) count, increased B. Thrombocytosis, elevated sedimentation rate
white blood (WBC) count.
C. Pancytopenia, elevated antinuclear antibody
B. Severe lower back pain, decreased blood (ANA) titer
pressure, decreased RBC count, increased WBC
count. D. Leukocysis, elevated blood urea nitrogen (BUN)
and creatinine levels
C. Severe lower back pain, decreased blood
pressure, decreased RBC count, decreased RBC 70. Arnold, a 19-year-old client with a mild concussion is
count, decreased WBC count. discharged from the emergency department. Before discharge,
he complains of a headache. When offered acetaminophen, his
D. Intermitted lower back pain, decreased blood mother tells the nurse the headache is severe and she would like
pressure, decreased RBC count, increased WBC her son to have something stronger. Which of the following
count. responses by the nurse is appropriate?

64. After undergoing a cardiac catheterization, Tracy has a large A. “Your son had a mild concussion,
puddle of blood under his buttocks. Which of the following acetaminophen is strong enough.”
steps should the nurse take first?
B. “Aspirin is avoided because of the danger of
A. Call for help. Reye’s syndrome in children or young adults.”

B. Obtain vital signs C. “Narcotics are avoided after a head injury

because they may hide a worsening condition.”
C. Ask the client to “lift up”
D. Stronger medications may lead to vomiting,
D. Apply gloves and assess the groin site which increases the intracarnial pressure (ICP).”

65. Which of the following treatment is a suitable surgical 71. When evaluating an arterial blood gas from a male client
intervention for a client with unstable angina? with a subdural hematoma, the nurse notes the Paco2 is 30 mm
Hg. Which of the following responses best describes the result?
A. Cardiac catheterization
A. Appropriate; lowering carbon dioxide (CO2)
 reduces intracranial pressure (ICP) B. Below-normal urine and serum osmolality levels

B. Emergent; the client is poorly oxygenated C. Above-normal urine osmolality level,

below-normal serum osmolality level
C. Normal
D. Below-normal urine osmolality level,
D. Significant; the client has alveolar above-normal serum osmolality level
hypoventilation
78. Jomari is diagnosed with hyperosmolar hyperglycemic
72. When prioritizing care, which of the following clients nonketotic syndrome (HHNS) is stabilized and prepared for
should the nurse Olivia assess first? discharge. When preparing the client for discharge and home
management, which of the following statements indicates that
A. A 17-year-old clients 24-hours postappendectomy the client understands her condition and how to control it?
B. A 33-year-old client with a recent diagnosis of A. “I can avoid getting sick by not becoming
Guillain-Barre syndrome dehydrated and by paying attention to my need
to urinate, drink, or eat more than usual.”
C. A 50-year-old client 3 days postmyocardial
infarction B. “If I experience trembling, weakness, and
headache, I should drink a glass of soda that
D. A 50-year-old client with diverticulitis contains sugar.”
73. JP has been diagnosed with gout and wants to know why C. “I will have to monitor my blood glucose level
colchicine is used in the treatment of gout. Which of the closely and notify the physician if it’s constantly
following actions of colchicines explains why it’s effective for elevated.”
gout?
D. “If I begin to feel especially hungry and thirsty,
A. Replaces estrogen I’ll eat a snack high in carbohydrates.”
B. Decreases infection 79. A 66-year-old client has been complaining of sleeping more,
increased urination, anorexia, weakness, irritability, depression,
C. Decreases inflammation
and bone pain that interferes with her going outdoors. Based on
D. Decreases bone demineralization these assessment findings, the nurse would suspect which of the
following disorders?
74. Norma asks for information about osteoarthritis. Which of
the following statements about osteoarthritis is correct? A. Diabetes mellitus

A. Osteoarthritis is rarely debilitating B. Diabetes insipidus

B. Osteoarthritis is a rare form of arthritis C. Hypoparathyroidism

C. Osteoarthritis is the most common form of D. Hyperparathyroidism

arthritis
80. Nurse Lourdes is teaching a client recovering from
D. Osteoarthritis afflicts people over 60 addisonian crisis about the need to take fludrocortisone acetate
and hydrocortisone at home. Which statement by the client
75. Ruby is receiving thyroid replacement therapy develops the indicates an understanding of the instructions?
flu and forgets to take her thyroid replacement medicine. The
nurse understands that skipping this medication will put the A. “I’ll take my hydrocortisone in the late
client at risk for developing which of the following afternoon, before dinner.”
lifethreatening complications?
B. “I’ll take all of my hydrocortisone in the
A. Exophthalmos morning, right after I wake up.”

B. Thyroid storm C. “I’ll take two-thirds of the dose when I wake up

and one-third in the late afternoon.”
C. Myxedema coma
D. “I’ll take the entire dose at bedtime.”
D. Tibial myxedema
81. Which of the following laboratory test results would suggest
76. Nurse Sugar is assessing a client with Cushing’s syndrome. to the nurse Len that a client has a corticotropin-secreting
Which observation should the nurse report to the physician pituitary adenoma?
immediately?
A. High corticotropin and low cortisol levels
A. Pitting edema of the legs
B. Low corticotropin and high cortisol levels
B. An irregular apical pulse
C. High corticotropin and high cortisol levels
C. Dry mucous membranes
D. Low corticotropin and low cortisol levels
D. Frequent urination
82. A male client is scheduled for a transsphenoidal
77. Cyrill with severe head trauma sustained in a car accident is hypophysectomy to remove a pituitary tumor. Preoperatively,
admitted to the intensive care unit. Thirty-six hours later, the the nurse should assess for potential complications by doing
client’s urine output suddenly rises above 200 ml/hour, leading which of the following?
the nurse to suspect diabetes insipidus. Which laboratory
findings support the nurse’s suspicion of diabetes insipidus? A. Testing for ketones in the urine

A. Above-normal urine and serum osmolality levels B. Testing urine specific gravity
 C. Checking temperature every 4 hours C. Limiting intake of high-carbohydrate foods

D. Performing capillary glucose testing every 4 D. Maintaining room temperature in the low-normal
hours range

83. Capillary glucose monitoring is being performed every 4 88. Patrick is treated in the emergency department for a Colles’
hours for a client diagnosed with diabetic ketoacidosis. Insulin is fracture sustained during a fall. What is a Colles’ fracture?
administered using a scale of regular insulin according to
glucose results. At 2 p.m., the client has a capillary glucose level A. Fracture of the distal radius
of 250 mg/dl for which he receives 8 U of regular insulin. Nurse
Mariner should expect the dose’s: B. Fracture of the olecranon

A. onset to be at 2 p.m. and its peak to be at 3 p.m. C. Fracture of the humerus

B. onset to be at 2:15 p.m. and its peak to be at 3 D. Fracture of the carpal scaphoid
p.m.
89. Cleo is diagnosed with osteoporosis. Which electrolytes are
C. onset to be at 2:30 p.m. and its peak to be at 4 involved in the development of this disorder?
p.m.
A. Calcium and sodium
D. onset to be at 4 p.m. and its peak to be at 6 p.m.
B. Calcium and phosphorous
84. The physician orders laboratory tests to confirm
hyperthyroidism in a female client with classic signs and C. Phosphorous and potassium
symptoms of this disorder. Which test result would confirm the
D. Potassium and sodium
diagnosis?
90. Johnny a firefighter was involved in extinguishing a house
A. No increase in the thyroid-stimulating hormone
fire and is being treated to smoke inhalation. He develops severe
(TSH) level after 30 minutes during the TSH
hypoxia 48 hours after the incident, requiring intubation and
stimulation test
mechanical ventilation. He most likely has developed which of
B. A decreased TSH level the following conditions?

C. An increase in the TSH level after 30 minutes A. Adult respiratory distress syndrome (ARDS)
during the TSH stimulation test
B. Atelectasis
D. Below-normal levels of serum triiodothyronine
C. Bronchitis
(T3) and serum thyroxine (T4) as detected by
radioimmunoassay D. Pneumonia
85. Rico with diabetes mellitus must learn how to 91. A 67-year-old client develops acute shortness of breath and
self-administer insulin. The physician has prescribed 10 U of progressive hypoxia requiring right femur. The hypoxia was
U-100 regular insulin and 35 U of U-100 isophane insulin probably caused by which of the following conditions?
suspension (NPH) to be taken before breakfast. When teaching
the client how to select and rotate insulin injection sites, the A. Asthma attack
nurse should provide which instruction?
B. Atelectasis
A. “Inject insulin into healthy tissue with large
blood vessels and nerves.” C. Bronchitis

B. “Rotate injection sites within the same anatomic D. Fat embolism

region, not among different regions.”
92. A client with shortness of breath has decreased to absent
C. “Administer insulin into areas of scar tissue or breath sounds on the right side, from the apex to the base.
hypotrophy whenever possible.” Which of the following conditions would best explain this?

D. “Administer insulin into sites above muscles that A. Acute asthma

you plan to exercise heavily later that day.”
B. Chronic bronchitis
86. Nurse Sarah expects to note an elevated serum glucose level
in a client with hyperosmolar hyperglycemic nonketotic C. Pneumonia
syndrome (HHNS). Which other laboratory finding should the
nurse anticipate? D. Spontaneous pneumothorax

A. Elevated serum acetone level 93. A 62-year-old male client was in a motor vehicle accident as
an unrestrained driver. He’s now in the emergency department
B. Serum ketone bodies complaining of difficulty of breathing and chest pain. On
auscultation of his lung field, no breath sounds are present in the
C. Serum alkalosis upper lobe. This client may have which of the following
conditions?
D. Below-normal serum potassium level
A. Bronchitis
87. For a client with Graves’ disease, which nursing intervention
promotes comfort? B. Pneumonia

A. Restricting intake of oral fluids C. Pneumothorax

B. Placing extra blankets on the client’s bed D. Tuberculosis (TB)

94. If a client requires a pneumonectomy, what fills the area of Which of the following statements, if made by the client,
the thoracic cavity? indicates to the nurse that the teaching was successful?

A. The space remains filled with air only A. “I will wear the stockings until the physician tells
me to remove them.”
B. The surgeon fills the space with a gel
B. “I should wear the stockings even when I am
C. Serous fluids fills the space and consolidates the sleep.”
region
C. “Every four hours I should remove the stockings
D. The tissue from the other lung grows over to the for a half hour.”
other side
D. “I should put on the stockings before getting out
95. Hemoptysis may be present in the client with a pulmonary of bed in the morning.”
embolism because of which of the following reasons?

A. Alveolar damage in the infracted area

B. Involvement of major blood vessels in the

occluded area

C. Loss of lung parenchyma

D. Loss of lung tissue

96. Aldo with a massive pulmonary embolism will have an

arterial blood gas analysis performed to determine the extent of
hypoxia. The acid-base disorder that may be present is?

A. Metabolic acidosis

B. Metabolic alkalosis

C. Respiratory acidosis

D. Respiratory alkalosis

97. After a motor vehicle accident, Armand an 22-year-old

client is admitted with a pneumothorax. The surgeon inserts a
chest tube and attaches it to a chest drainage system. Bubbling
soon appears in the water seal chamber. Which of the following
is the most likely cause of the bubbling?

A. Air leak

B. Adequate suction

C. Inadequate suction

D. Kinked chest tube

98. Nurse Michelle calculates the IV flow rate for a

postoperative client. The client receives 3,000 ml of Ringer’s
lactate solution IV to run over 24 hours. The IV infusion set has
a drop factor of 10 drops per milliliter. The nurse should
regulate the client’s IV to deliver how many drops per minute?

A. 18

B. 21

C. 35

D. 40

99. Mickey, a 6-year-old child with a congenital heart disorder is

admitted with congestive heart failure. Digoxin (lanoxin) 0.12
mg is ordered for the child. The bottle of Lanoxin contains .05
mg of Lanoxin in 1 ml of solution. What amount should the
nurse administer to the child?

A. 1.2 ml

B. 2.4 ml

C. 3.5 ml

D. 4.2 ml

100. Nurse Alexandra teaches a client about elastic stockings.

 client on the opposite unoperated side.
Care of Clients with
15. Answer: (A) Food and fluids will be withheld for at least 2
Physiologic and Psychosocial hours. Prior to bronchoscopy, the doctors sprays the back of
the throat with anesthetic to minimize the gag reflex and thus
Alterations (Part 2) facilitate the insertion of the bronchoscope. Giving the client
food and drink after the procedure without checking on the
1. Answer: (C) Hypertension. Hypertension, along with fever, return of the gag reflex can cause the client to aspirate. The
and tenderness over the grafted kidney, reflects acute gag reflex usually returns after two hours.
rejection.
16. Answer: (C) hyperkalemia. Hyperkalemia is a common
2. Answer: (A) Pain. Sharp, severe pain (renal colic) radiating complication of acute renal failure. It’s life-threatening if
toward the genitalia and thigh is caused by uretheral immediate action isn’t taken to reverse it. The administration
distention and smooth muscle spasm; relief form pain is the of glucose and regular insulin, with sodium bicarbonate if
priority. necessary, can temporarily prevent cardiac arrest by moving
potassium into the cells and temporarily reducing serum
3. Answer: (D) Decrease the size and vascularity of the thyroid potassium levels. Hypernatremia, hypokalemia, and
gland. Lugol’s solution provides iodine, which aids in hypercalcemia don’t usually occur with acute renal failure
decreasing the vascularity of the thyroid gland, which limits and aren’t treated with glucose, insulin, or sodium
the risk of hemorrhage when surgery is performed. bicarbonate.

4. Answer: (A) Liver Disease. The client with liver disease has 17. Answer: (A) This condition puts her at a higher risk for
a decreased ability to metabolize carbohydrates because of a cervical cancer; therefore, she should have a Papanicolaou
decreased ability to form glycogen (glycogenesis) and to (Pap) smear annually. Women with condylomata acuminata
form glucose from glycogen. are at risk for cancer of the cervix and vulva. Yearly Pap
smears are very important for early detection. Because
5. Answer: (C) Leukopenia. Leukopenia, a reduction in WBCs, condylomata acuminata is a virus, there is no permanent
is a systemic effect of chemotherapy as a result of cure. Because condylomata acuminata can occur on the
myelosuppression. vulva, a condom won’t protect sexual partners. HPV can be
transmitted to other parts of the body, such as the mouth,
6. Answer: (C) Avoid foods that in the past caused flatus. oropharynx, and larynx.
Foods that bothered a person preoperatively will continue to
do so after a colostomy. 18. Answer: (A) The left kidney usually is slightly higher than
the right one. The left kidney usually is slightly higher than
7. Answer: (B) Keep the irrigating container less than 18 inches the right one. An adrenal gland lies atop each kidney. The
above the stoma.” This height permits the solution to flow average kidney measures approximately 11 cm (4-3/8″) long,
slowly with little force so that excessive peristalsis is not 5 to 5.8 cm (2″ to 2¼”) wide, and 2.5 cm (1″) thick. The
immediately precipitated. kidneys are located retroperitoneally, in the posterior aspect
of the abdomen, on either side of the vertebral column. They
8. Answer: (A) Administer Kayexalate. Kayexalate,a potassium
lie between the 12th thoracic and 3rd lumbar vertebrae.
exchange resin, permits sodium to be exchanged for
potassium in the intestine, reducing the serum potassium 19. Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and
level. serum creatinine 6.5 mg/dl. The normal BUN level ranges 8
to 23 mg/dl; the normal serum creatinine level ranges from
9. Answer:(B) 28 gtt/min. This is the correct flow rate;
0.7 to 1.5 mg/dl. The test results in option C are abnormally
multiply the amount to be infused (2000 ml) by the drop
elevated, reflecting CRF and the kidneys’ decreased ability
factor (10) and divide the result by the amount of time in
to remove nonprotein nitrogen waste from the blood. CRF
minutes (12 hours x 60 minutes)
causes decreased pH and increased hydrogen ions — not
10. Answer: (D) Upper trunk. The percentage designated for vice versa. CRF also increases serum levels of potassium,
each burned part of the body using the rule of nines: Head magnesium, and phosphorous, and decreases serum levels of
and neck 9%; Right upper extremity 9%; Left upper calcium. A uric acid analysis of 3.5 mg/dl falls within the
extremity 9%; Anterior trunk 18%; Posterior trunk 18%; normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also
Right lower extremity 18%; Left lower extremity 18%; falls with the normal range of 60% to 75%.
Perineum 1%.
20. Answer: (D) Alteration in the size, shape, and organization
11. Answer: (C) Bleeding from ears. The nurse needs to of differentiated cells. Dysplasia refers to an alteration in the
perform a thorough assessment that could indicate alterations size, shape, and organization of differentiated cells. The
in cerebral function, increased intracranial pressures, presence of completely undifferentiated tumor cells that
fractures and bleeding. Bleeding from the ears occurs only don’t resemble cells of the tissues of their origin is called
with basal skull fractures that can easily contribute to anaplasia. An increase in the number of normal cells in a
increased intracranial pressure and brain herniation. normal arrangement in a tissue or an organ is called
hyperplasia. Replacement of one type of fully differentiated
12. Answer: (D) may engage in contact sports. The client should cell by another in tissues where the second type normally
be advised by the nurse to avoid contact sports. This will isn’t found is called metaplasia.
prevent trauma to the area of the pacemaker generator.
21. Answer: (D) Kaposi’s sarcoma. Kaposi’s sarcoma is the most
13. Answer: (A) Oxygen at 1-2L/min is given to maintain the common cancer associated with AIDS. Squamous cell
hypoxic stimulus for breathing. COPD causes a chronic CO2 carcinoma, multiple myeloma, and leukemia may occur in
retention that renders the medulla insensitive to the CO2 anyone and aren’t associated specifically with AIDS.
stimulation for breathing. The hypoxic state of the client then
becomes the stimulus for breathing. Giving the client oxygen 22. Answer: (C) To prevent cerebrospinal fluid (CSF) leakage.
in low concentrations will maintain the client’s hypoxic The client receiving a subarachnoid block requires special
drive. positioning to prevent CSF leakage and headache and to
ensure proper anesthetic distribution. Proper positioning
14. Answer: (B) Facilitate ventilation of the left lung. Since only doesn’t help prevent confusion, seizures, or cardiac
a partial pneumonectomy is done, there is a need to promote arrhythmias.
expansion of this remaining Left lung by positioning the
23. Answer: (A) Auscultate bowel sounds. If abdominal vascular resistance (afterload).
distention is accompanied by nausea, the nurse must first
auscultate bowel sounds. If bowel sounds are absent, the 31. Answer: (C) Raised 30 degrees. Jugular venous pressure is
nurse should suspect gastric or small intestine dilation and measured with a centimeter ruler to obtain the vertical
these findings must be reported to the physician. Palpation distance between the sternal angle and the point of highest
should be avoided postoperatively with abdominal pulsation with the head of the bed inclined between 15 to 30
distention. If peristalsis is absent, changing positions and degrees. Increased pressure can’t be seen when the client is
inserting a rectal tube won’t relieve the client’s discomfort. supine or when the head of the bed is raised 10 degrees
because the point that marks the pressure level is above the
24. Answer: (B) Lying on the left side with knees bent. For a jaw (therefore, not visible). In high Fowler’s position, the
colonoscopy, the nurse initially should position the client on veins would be barely discernible above the clavicle.
the left side with knees bent. Placing the client on the right
side with legs straight, prone with the torso elevated, or bent 32. Answer: (D) Inotropic agents. Inotropic agents are
over with hands touching the floor wouldn’t allow proper administered to increase the force of the heart’s contractions,
visualization of the large intestine. thereby increasing ventricular contractility and ultimately
increasing cardiac output. Beta-adrenergic blockers and
25. Answer: (A) Blood supply to the stoma has been interrupted. calcium channel blockers decrease the heart rate and
An ileostomy stoma forms as the ileum is brought through ultimately decreased the workload of the heart. Diuretics are
the abdominal wall to the surface skin, creating an artificial administered to decrease the overall vascular volume, also
opening for waste elimination. The stoma should appear decreasing the workload of the heart.
cherry red, indicating adequate arterial perfusion. A dusky
stoma suggests decreased perfusion, which may result from 33. Answer: (B) Less than 30% of calories form fat. A client
interruption of the stoma’s blood supply and may lead to with low serum HDL and high serum LDL levels should get
tissue damage or necrosis. A dusky stoma isn’t a normal less than 30% of daily calories from fat. The other
finding. Adjusting the ostomy bag wouldn’t affect stoma modifications are appropriate for this client.
color, which depends on blood supply to the area. An
intestinal obstruction also wouldn’t change stoma color. 34. Answer: (C) The emergency department nurse calls up the
latest electrocardiogram results to check the client’s progress.
26. Answer: (A) Applying knee splints. Applying knee splints The emergency department nurse is no longer directly
prevents leg contractures by holding the joints in a position involved with the client’s care and thus has no legal right to
of function. Elevating the foot of the bed can’t prevent information about his present condition. Anyone directly
contractures because this action doesn’t hold the joints in a involved in his care (such as the telemetry nurse and the
position of function. Hyperextending a body part for an on-call physician) has the right to information about his
extended time is inappropriate because it can cause condition. Because the client requested that the nurse update
contractures. Performing shoulder range-of-motion exercises his wife on his condition, doing so doesn’t breach
can prevent contractures in the shoulders, but not in the legs. confidentiality.

27. Answer: (B) Urine output of 20 ml/hour. A urine output of 35. Answer: (B) Check endotracheal tube placement. ET tube
less than 40 ml/hour in a client with burns indicates a fluid placement should be confirmed as soon as the client arrives
volume deficit. This client’s PaO2 value falls within the in the emergency department. Once the airways is secured,
normal range (80 to 100 mm Hg). White pulmonary oxygenation and ventilation should be confirmed using an
secretions also are normal. The client’s rectal temperature end-tidal carbon dioxide monitor and pulse oximetry. Next,
isn’t significantly elevated and probably results from the the nurse should make sure L.V. access is established. If the
fluid volume deficit. client experiences symptomatic bradycardia, atropine is
administered as ordered 0.5 to 1 mg every 3 to 5 minutes to a
28. Answer: (A) Turn him frequently. The most important total of 3 mg. Then the nurse should try to find the cause of
intervention to prevent pressure ulcers is frequent position the client’s arrest by obtaining an ABG sample. Amiodarone
changes, which relieve pressure on the skin and underlying is indicated for ventricular tachycardia, ventricular
tissues. If pressure isn’t relieved, capillaries become fibrillation and atrial flutter – not symptomatic bradycardia.
occluded, reducing circulation and oxygenation of the tissues
and resulting in cell death and ulcer formation. During 36. Answer: (C) 95 mm Hg. Use the following formula to
passive ROM exercises, the nurse moves each joint through calculate MAP
its range of movement, which improves joint mobility and
circulation to the affected area but doesn’t prevent pressure ■ MAP = systolic + 2 (diastolic) /3
ulcers. Adequate hydration is necessary to maintain healthy
skin and ensure tissue repair. A footboard prevents plantar ■ MAP=[126 mm Hg + 2 (80 mm Hg) ]/3
flexion and footdrop by maintaining the foot in a dorsiflexed
■ MAP=286 mm HG/ 3
position.
■ MAP=95 mm Hg
29. Answer: (C) In long, even, outward, and downward strokes
in the direction of hair growth. When applying a topical 37. Answer: (C) Electrocardiogram, complete blood count,
agent, the nurse should begin at the midline and use long, testing for occult blood, comprehensive serum metabolic
even, outward, and downward strokes in the direction of hair panel. An electrocardiogram evaluates the complaints of
growth. This application pattern reduces the risk of follicle chest pain, laboratory tests determines anemia, and the stool
irritation and skin inflammation. test for occult blood determines blood in the stool. Cardiac
monitoring, oxygen, and creatine kinase and lactate
30. Answer: (A) Beta -adrenergic blockers. Beta-adrenergic
dehydrogenase levels are appropriate for a cardiac primary
blockers work by blocking beta receptors in the myocardium,
problem. A basic metabolic panel and alkaline phosphatase
reducing the response to catecholamines and sympathetic
and aspartate aminotransferase levels assess liver function.
nerve stimulation. They protect the myocardium, helping to
Prothrombin time, partial thromboplastin time, fibrinogen
reduce the risk of another infraction by decreasing
and fibrin split products are measured to verify bleeding
myocardial oxygen demand. Calcium channel blockers
dyscrasias, An electroencephalogram evaluates brain
reduce the workload of the heart by decreasing the heart rate.
electrical activity.
Narcotics reduce myocardial oxygen demand, promote
vasodilation, and decrease anxiety. Nitrates reduce 38. Answer: (D) Heparin-associated thrombosis and
myocardial oxygen consumption bt decreasing left thrombocytopenia (HATT). HATT may occur after CABG
ventricular end diastolic pressure (preload) and systemic
 surgery due to heparin use during surgery. Although DIC and contain an inherited D antigen. Persons with the D antigen
ITP cause platelet aggregation and bleeding, neither is have Rh-positive blood type; those lacking the antigen have
common in a client after revascularization surgery. Rh-negative blood. It’s important that a person with
Pancytopenia is a reduction in all blood cells. Rhnegative blood receives Rh-negative blood. If Rh-positive
blood is administered to an Rh-negative person, the recipient
39. Answer: (B) Corticosteroids. Corticosteroid therapy can develops anti-Rh agglutinins, and sub sequent transfusions
decrease antibody production and phagocytosis of the with Rh-positive blood may cause serious reactions with
antibody-coated platelets, retaining more functioning clumping and hemolysis of red blood cells.
platelets. Methotrexate can cause thrombocytopenia. Vitamin
K is used to treat an excessive anticoagulate state from 50. Answer: (B) “I will call my doctor if Stacy has persistent
warfarin overload, and ASA decreases platelet aggregation. vomiting and diarrhea”. Persistent (more than 24 hours)
vomiting, anorexia, and diarrhea are signs of toxicity and the
40. Answer: (D) Xenogeneic. An xenogeneic transplant is patient should stop the medication and notify the health care
between is between human and another species. A syngeneic provider. The other manifestations are expected side effects
transplant is between identical twins, allogeneic transplant is of chemotherapy.
between two humans, and autologous is a transplant from the
same individual. 51. Answer: (D) “This is only temporary; Stacy will re-grow
new hair in 3-6 months, but may be different in texture”.
41. Answer: (B). Tissue thromboplastin is released when This is the appropriate response. The nurse should help the
damaged tissue comes in contact with clotting factors. mother how to cope with her own feelings regarding the
Calcium is released to assist the conversion of factors X to child’s disease so as not to affect the child negatively. When
Xa. Conversion of factors XII to XIIa and VIII to VIII a are the hair grows back, it is still of the same color and texture.
part of the intrinsic pathway.
52. Answer: (B) Apply viscous Lidocaine to oral ulcers as
42. Answer: (C) Essential thrombocytopenia. Essential needed. Stomatitis can cause pain and this can be relieved by
thrombocytopenia is linked to immunologic disorders, such applying topical anesthetics such as lidocaine before mouth
as SLE and human immunodeficiency vitus. The disorder care. When the patient is already comfortable, the nurse can
known as von Willebrand’s disease is a type of hemophilia proceed with providing the patient with oral rinses of saline
and isn’t linked to SLE. Moderate to severe anemia is solution mixed with equal part of water or hydrogen
associated with SLE, not polycythermia. Dressler’s peroxide mixed water in 1:3 concentrations to promote oral
syndrome is pericarditis that occurs after a myocardial hygiene. Every 2-4 hours.
infarction and isn’t linked to SLE.
53. Answer: (C) Immediately discontinue the infusion. Edema or
43. Answer: (B) Night sweat. In stage 1, symptoms include a swelling at the IV site is a sign that the needle has been
single enlarged lymph node (usually), unexplained fever, dislodged and the IV solution is leaking into the tissues
night sweats, malaise, and generalized pruritis. Although causing the edema. The patient feels pain as the nerves are
splenomegaly may be present in some clients, night sweats irritated by pressure and the IV solution. The first action of
are generally more prevalent. Pericarditis isn’t associated the nurse would be to discontinue the infusion right away to
with Hodgkin’s disease, nor is hypothermia. Moreover, prevent further edema and other complication.
splenomegaly and pericarditis aren’t symptoms. Persistent
hypothermia is associated with Hodgkin’s but isn’t an early 54. Answer: (C) Chronic obstructive bronchitis. Clients with
sign of the disease. chronic obstructive bronchitis appear bloated; they have
large barrel chest and peripheral edema, cyanotic nail beds,
44. Answer: (D) Breath sounds. Pneumonia, both viral and and at times, circumoral cyanosis. Clients with ARDS are
fungal, is a common cause of death in clients with acutely short of breath and frequently need intubation for
neutropenia, so frequent assessment of respiratory rate and mechanical ventilation and large amount of oxygen. Clients
breath sounds is required. Although assessing blood with asthma don’t exhibit characteristics of chronic disease,
pressure, bowel sounds, and heart sounds is important, it and clients with emphysema appear pink and cachectic.
won’t help detect pneumonia.
55. Answer: (D) Emphysema. Because of the large amount of
45. Answer: (B) Muscle spasm. Back pain or paresthesia in the energy it takes to breathe, clients with emphysema are
lower extremities may indicate impending spinal cord usually cachectic. They’re pink and usually breathe through
compression from a spinal tumor. This should be recognized pursed lips, hence the term “puffer.” Clients with ARDS are
and treated promptly as progression of the tumor may result usually acutely short of breath. Clients with asthma don’t
in paraplegia. The other options, which reflect parts of the have any particular characteristics, and clients with chronic
nervous system, aren’t usually affected by MM. obstructive bronchitis are bloated and cyanotic in
appearance.
46. Answer: (C)10 years. Epidermiologic studies show the
average time from initial contact with HIV to the 56. Answer: D 80 mm Hg. A client about to go into respiratory
development of AIDS is 10 years. arrest will have inefficient ventilation and will be retaining
carbon dioxide. The value expected would be around 80 mm
47. Answer: (A) Low platelet count. In DIC, platelets and Hg. All other values are lower than expected.
clotting factors are consumed, resulting in microthrombi and
excessive bleeding. As clots form, fibrinogen levels decrease 57. Answer: (C) Respiratory acidosis. Because Paco2 is high at
and the prothrombin time increases. Fibrin degeneration 80 mm Hg and the metabolic measure, HCO3- is normal, the
products increase as fibrinolysis takes places. client has respiratory acidosis. The pH is less than 7.35,
academic, which eliminates metabolic and respiratory
48. Answer: (D) Hodgkin’s disease. Hodgkin’s disease typically alkalosis as possibilities. If the HCO3- was below 22 mEq/L
causes fever night sweats, weight loss, and lymph mode the client would have metabolic acidosis.
enlargement. Influenza doesn’t last for months. Clients with
sickle cell anemia manifest signs and symptoms of chronic 58. Answer: (C) Respiratory failure. The client was reacting to
anemia with pallor of the mucous membrane, fatigue, and the drug with respiratory signs of impending anaphylaxis,
decreased tolerance for exercise; they don’t show fever, night which could lead to eventually respiratory failure. Although
sweats, weight loss or lymph node enlargement. Leukemia the signs are also related to an asthma attack or a pulmonary
doesn’t cause lymph node enlargement. embolism, consider the new drug first. Rheumatoid arthritis
doesn’t manifest these signs.
49. Answer: (C) A Rh-negative. Human blood can sometimes
59. Answer: (D) Elevated serum aminotransferase. Hepatic cell the loop of Henle. Furosemide is a loop diuretic that inhibits
death causes release of liver enzymes alanine sodium and water reabsorption in the loop Henle, thereby
aminotransferase (ALT), aspartate aminotransferase (AST) causing a decrease in blood pressure. Vasodilators cause
and lactate dehydrogenase (LDH) into the circulation. Liver dilation of peripheral blood vessels, directly relaxing
cirrhosis is a chronic and irreversible disease of the liver vascular smooth muscle and decreasing blood pressure.
characterized by generalized inflammation and fibrosis of the Adrenergic blockers decrease sympathetic cardioacceleration
liver tissues. and decrease blood pressure. Angiotensin-converting enzyme
inhibitors decrease blood pressure due to their action on
60. Answer: (A) Impaired clotting mechanism. Cirrhosis of the angiotensin.
liver results in decreased Vitamin K absorption and
formation of clotting factors resulting in impaired clotting 69. Answer: (C) Pancytopenia, elevated antinuclear antibody
mechanism. (ANA) titer. Laboratory findings for clients with SLE usually
show pancytopenia, elevated ANA titer, and decreased serum
61. Answer: (B) Altered level of consciousness. Changes in complement levels. Clients may have elevated BUN and
behavior and level of consciousness are the first sins of creatinine levels from nephritis, but the increase does not
hepatic encephalopathy. Hepatic encephalopathy is caused indicate SLE.
by liver failure and develops when the liver is unable to
convert protein metabolic product ammonia to urea. This 70. Answer: (C) Narcotics are avoided after a head injury
results in accumulation of ammonia and other toxic in the because they may hide a worsening condition. Narcotics may
blood that damages the cells. mask changes in the level of consciousness that indicate
increased ICP and shouldn’t acetaminophen is strong enough
62. Answer: (C) “I’ll lower the dosage as ordered so the drug ignores the mother’s question and therefore isn’t appropriate.
causes only 2 to 4 stools a day”. Lactulose is given to a Aspirin is contraindicated in conditions that may have
patients with hepatic encephalopathy to reduce absorption of bleeding, such as trauma, and for children or young adults
ammonia in the intestines by binding with ammonia and with viral illnesses due to the danger of Reye’s syndrome.
promoting more frequent bowel movements. If the patient Stronger medications may not necessarily lead to vomiting
experience diarrhea, it indicates over dosage and the nurse but will sedate the client, thereby masking changes in his
must reduce the amount of medication given to the patient. level of consciousness.
The stool will be mashy or soft. Lactulose is also very sweet
and may cause cramping and bloating. 71. Answer: (A) Appropriate; lowering carbon dioxide (CO2)
reduces intracranial pressure (ICP). A normal Paco2 value is
63. Answer: (B) Severe lower back pain, decreased blood 35 to 45 mm Hg CO2 has vasodilating properties; therefore,
pressure, decreased RBC count, increased WBC lowering Paco2 through hyperventilation will lower ICP
count.Severe lower back pain indicates an aneurysm rupture, caused by dilated cerebral vessels. Oxygenation is evaluated
secondary to pressure being applied within the abdominal through Pao2 and oxygen saturation. Alveolar
cavity. When ruptured occurs, the pain is constant because it hypoventilation would be reflected in an increased Paco2.
can’t be alleviated until the aneurysm is repaired. Blood
pressure decreases due to the loss of blood. After the 72. Answer: (B) A 33-year-old client with a recent diagnosis of
aneurysm ruptures, the vasculature is interrupted and blood Guillain-Barre syndrome . Guillain-Barre syndrome is
volume is lost, so blood pressure wouldn’t increase. For the characterized by ascending paralysis and potential
same reason, the RBC count is decreased – not increased. respiratory failure. The order of client assessment should
The WBC count increases as cell migrate to the site of injury. follow client priorities, with disorder of airways, breathing,
and then circulation. There’s no information to suggest the
64. Answer: (D) Apply gloves and assess the groin site. postmyocardial infarction client has an arrhythmia or other
Observing standard precautions is the first priority when complication. There’s no evidence to suggest hemorrhage or
dealing with any blood fluid. Assessment of the groin site is perforation for the remaining clients as a priority of care.
the second priority. This establishes where the blood is
coming from and determineshow much blood has been lost. 73. Answer: (C) Decreases inflammation. Then action of
The goal in this situation is to stop the bleeding. The nurse colchicines is to decrease inflammation by reducing the
would call for help if it were warranted after the assessment migration of leukocytes to synovial fluid. Colchicine doesn’t
of the situation. After determining the extent of the bleeding, replace estrogen, decrease infection, or decrease bone
vital signs assessment is important. The nurse should never demineralization.
move the client, in case a clot has formed. Moving can
disturb the clot and cause rebleeding. 74. Answer: (C) Osteoarthritis is the most common form of
arthritis. Osteoarthritis is the most common form of arthritis
65. Answer: (D) Percutaneous transluminal coronary angioplasty and can be extremely debilitating. It can afflict people of any
(PTCA). PTCA can alleviate the blockage and restore blood age, although most are elderly.
flow and oxygenation. An echocardiogram is a noninvasive
diagnosis test. Nitroglycerin is an oral sublingual medication. 75. Answer: (C) Myxedema coma. Myxedema coma, severe
Cardiac catheterization is a diagnostic tool – not a treatment. hypothyroidism, is a life-threatening condition that may
develop if thyroid replacement medication isn’t taken.
66. Answer: (B) Cardiogenic shock. Cardiogenic shock is shock Exophthalmos, protrusion of the eyeballs, is seen with
related to ineffective pumping of the heart. Anaphylactic hyperthyroidism. Thyroid storm is life-threatening but is
shock results from an allergic reaction. Distributive shock caused by severe hyperthyroidism. Tibial myxedema,
results from changes in the intravascular volume distribution peripheral mucinous edema involving the lower leg, is
and is usually associated with increased cardiac output. MI associated with hypothyroidism but isn’t life-threatening.
isn’t a shock state, though a severe MI can lead to shock.
76. Answer: (B) An irregular apical pulse. Because Cushing’s
67. Answer: (C) Kidneys’ excretion of sodium and water. The syndrome causes aldosterone overproduction, which
kidneys respond to rise in blood pressure by excreting increases urinary potassium loss, the disorder may lead to
sodium and excess water. This response ultimately affects hypokalemia. Therefore, the nurse should immediately report
sysmolic blood pressure by regulating blood volume. Sodium signs and symptoms of hypokalemia, such as an irregular
or water retention would only further increase blood apical pulse, to the physician. Edema is an expected finding
pressure. Sodium and water travel together across the because aldosterone overproduction causes sodium and fluid
membrane in the kidneys; one can’t travel without the other. retention. Dry mucous membranes and frequent urination
signal dehydration, which isn’t associated with Cushing’s
68. Answer: (D) It inhibits reabsorption of sodium and water in syndrome.
77. Answer: (D) Below-normal urine osmolality level, 85. Answer: (B) “Rotate injection sites within the same anatomic
above-normal serum osmolality level. In diabetes insipidus, region, not among different regions.” The nurse should
excessive polyuria causes dilute urine, resulting in a instruct the client to rotate injection sites within the same
below-normal urine osmolality level. At the same time, anatomic region. Rotating sites among different regions may
polyuria depletes the body of water, causing dehydration that cause excessive day-to-day variations in the blood glucose
leads to an above-normal serum osmolality level. For the level; also, insulin absorption differs from one region to the
same reasons, diabetes insipidus doesn’t cause above-normal next. Insulin should be injected only into healthy tissue
urine osmolality or below-normal serum osmolality levels. lacking large blood vessels, nerves, or scar tissue or other
deviations. Injecting insulin into areas of hypertrophy may
78. Answer: (A) “I can avoid getting sick by not becoming delay absorption. The client shouldn’t inject insulin into
dehydrated and by paying attention to my need to urinate, areas of lipodystrophy (such as hypertrophy or atrophy); to
drink, or eat more than usual.” Inadequate fluid intake during prevent lipodystrophy, the client should rotate injection sites
hyperglycemic episodes often leads to HHNS. By systematically. Exercise speeds drug absorption, so the client
recognizing the signs of hyperglycemia (polyuria, polydipsia, shouldn’t inject insulin into sites above muscles that will be
and polyphagia) and increasing fluid intake, the client may exercised heavily.
prevent HHNS. Drinking a glass of nondiet soda would be
appropriate for hypoglycemia. A client whose diabetes is 86. Answer: (D) Below-normal serum potassium level. A client
controlled with oral antidiabetic agents usually doesn’t need with HHNS has an overall body deficit of potassium
to monitor blood glucose levels. A highcarbohydrate diet resulting from diuresis, which occurs secondary to the
would exacerbate the client’s condition, particularly if fluid hyperosmolar, hyperglycemic state caused by the relative
intake is low. insulin deficiency. An elevated serum acetone level and
serum ketone bodies are characteristic of diabetic
79. Answer: (D) Hyperparathyroidism. Hyperparathyroidism is ketoacidosis. Metabolic acidosis, not serum alkalosis, may
most common in older women and is characterized by bone occur in HHNS.
pain and weakness from excess parathyroid hormone (PTH).
Clients also exhibit hypercaliuria-causing polyuria. While 87. Answer: (D) Maintaining room temperature in the
clients with diabetes mellitus and diabetes insipidus also low-normal range. Graves’ disease causes signs and
have polyuria, they don’t have bone pain and increased symptoms of hypermetabolism, such as heat intolerance,
sleeping. Hypoparathyroidism is characterized by urinary diaphoresis, excessive thirst and appetite, and weight loss. To
frequency rather than polyuria. reduce heat intolerance and diaphoresis, the nurse should
keep the client’s room temperature in the low-normal range.
80. Answer: (C) “I’ll take two-thirds of the dose when I wake up To replace fluids lost via diaphoresis, the nurse should
and one-third in the late afternoon.” Hydrocortisone, a encourage, not restrict, intake of oral fluids. Placing extra
glucocorticoid, should be administered according to a blankets on the bed of a client with heat intolerance would
schedule that closely reflects the body’s own secretion of this cause discomfort. To provide needed energy and calories, the
hormone; therefore, two-thirds of the dose of hydrocortisone nurse should encourage the client to eat high-carbohydrate
should be taken in the morning and one-third in the late foods.
afternoon. This dosage schedule reduces adverse effects.
88. Answer: (A) Fracture of the distal radius. Colles’ fracture is
81. Answer: (C) High corticotropin and high cortisol levels. A a fracture of the distal radius, such as from a fall on an
corticotropin-secreting pituitary tumor would cause high outstretched hand. It’s most common in women. Colles’
corticotropin and high cortisol levels. A high corticotropin fracture doesn’t refer to a fracture of the olecranon, humerus,
level with a low cortisol level and a low corticotropin level or carpal scaphoid.
with a low cortisol level would be associated with
hypocortisolism. Low corticotropin and high cortisol levels 89. Answer: (B) Calcium and phosphorous. In osteoporosis,
would be seen if there was a primary defect in the adrenal bones lose calcium and phosphate salts, becoming porous,
glands. brittle, and abnormally vulnerable to fracture. Sodium and
potassium aren’t involved in the development of
82. Answer: (D) Performing capillary glucose testing every 4 osteoporosis.
hours. The nurse should perform capillary glucose testing
every 4 hours because excess cortisol may cause insulin 90. Answer: (A) Adult respiratory distress syndrome (ARDS).
resistance, placing the client at risk for hyperglycemia. Urine Severe hypoxia after smoke inhalation is typically related to
ketone testing isn’t indicated because the client does secrete ARDS. The other conditions listed aren’t typically associated
insulin and, therefore, isn’t at risk for ketosis. Urine specific with smoke inhalation and severe hypoxia.
gravity isn’t indicated because although fluid balance can be
compromised, it usually isn’t dangerously imbalanced. 91. Answer: (D) Fat embolism. Long bone fractures are
Temperature regulation may be affected by excess cortisol correlated with fat emboli, whichcause shortness of breath
and isn’t an accurate indicator of infection. and hypoxia. It’s unlikely the client has developed asthma or
bronchitis without a previous history. He could develop
83. Answer: (C) onset to be at 2:30 p.m. and its peak to be at 4 atelectasis but it typically doesn’t produce progressive
p.m.. Regular insulin, which is a short-acting insulin, has an hypoxia.
onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because
the nurse gave the insulin at 2 p.m., the expected onset would 92. Answer: (D) Spontaneous pneumothorax. A spontaneous
be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 pneumothorax occurs when the client’s lung collapses,
p.m. causing an acute decreased in the amount of functional lung
used in oxygenation. The sudden collapse was the cause of
84. Answer: (A) No increase in the thyroid-stimulating hormone his chest pain and shortness of breath. An asthma attack
(TSH) level after 30 minutes during the TSH stimulation test. would show wheezing breath sounds, and bronchitis would
In the TSH test, failure of the TSH level to rise after 30 have rhonchi. Pneumonia would have bronchial breath
minutes confirms hyperthyroidism. A decreased TSH level sounds over the area of consolidation.
indicates a pituitary deficiency of this hormone.
Below-normal levels of T3 and T4, as detected by 93. Answer: (C) Pneumothorax. From the trauma the client
radioimmunoassay, signal hypothyroidism. A below-normal experienced, it’s unlikely he has bronchitis, pneumonia, or
T4 level also occurs in malnutrition and liver disease and TB; rhonchi with bronchitis, bronchial breath sounds with
may result from administration of phenytoin and certain TB would be heard.
other drugs.
94. Answer: (C) Serous fluids fills the space and consolidates the
 region. Serous fluid fills the space and eventually
consolidates, preventing extensive mediastinal shift of the
heart and remaining lung. Air can’t be left in the space.
There’s no gel that can be placed in the pleural space. The
tissue from the other lung can’t cross the mediastinum,
although a temporary mediastinal shift exits until the space is
filled.

95. Answer: (A) Alveolar damage in the infracted area. The

infracted area produces alveolar damage that can lead to the
production of bloody sputum, sometimes in massive
amounts. Clot formation usually occurs in the legs. There’s a
loss of lung parenchyma and subsequent scar tissue
formation.

96. Answer: (D) Respiratory alkalosis. A client with massive

pulmonary embolism will have a large region and blow off
large amount of carbon dioxide, which crosses the unaffected
alveolar-capillary membrane more readily than does oxygen
and results in respiratory alkalosis.

97. Answer: (A) Air leak. Bubbling in the water seal chamber of
a chest drainage system stems from an air leak. In
pneumothorax an air leak can occur as air is pulled from the
pleural space. Bubbling doesn’t normally occur with either
adequate or inadequate suction or any preexisting bubbling
in the water seal chamber.

98. Answer: (B) 21. 3000 x 10 divided by 24 x 60.

99. Answer: (B) 2.4 ml. .05 mg/ 1 ml = .12mg/ x ml, .05x = .12,
x = 2.4 ml.

100.Answer: (D) “I should put on the stockings before getting out

of bed in the morning. Promote venous return by applying
external pressure on veins.
 A. Withhold the drug.
Care of Clients with
B. Record the client’s response.
Physiologic and Psychosocial
C. Encourage the client to tell the doctor.
Alterations (Part 3) D. Suggest that it takes awhile before seeing the
1. Mr. Marquez reports of losing his job, not being able to sleep results.
at night, and feeling upset with his wife. Nurse John responds to
the client, “You may want to talk about your employment 7. Dervid, an adolescent has a history of truancy from school,
situation in group today.” The Nurse is using which therapeutic running away from home and “barrowing” other people’s things
technique? without their permission. The adolescent denies stealing,
rationalizing instead that as long as no one was using the items,
A. Observations it was all right to borrow them. It is important for the nurse to
understand the psychodynamically, this behavior may be largely
B. Restating attributed to a developmental defect related to the:

C. Exploring A. Id

D. Focusing B. Ego

2. Tony refuses his evening dose of Haloperidol (Haldol), then C. Superego

becomes extremely agitated in the dayroom while other clients
are watching television. He begins cursing and throwing D. Oedipal complex
furniture. Nurse Oliver first action is to:
8. In preparing a female client for electroconvulsive therapy
A. Check the client’s medical record for an order for (ECT), Nurse Michelle knows that succinylcoline (Anectine)
an as-needed I.M. dose of medication for will be administered for which therapeutic effect?
agitation.
A. Short-acting anesthesia
B. Place the client in full leather restraints.
B. Decreased oral and respiratory secretions.
C. Call the attending physician and report the
behavior. C. Skeletal muscle paralysis.

D. Remove all other clients from the dayroom. D. Analgesia.

3. Tina who is manic, but not yet on medication, comes to the 9. Nurse Gina is aware that the dietary implications for a client
drug treatment center. The nurse would not let this client join the in manic phase of bipolar disorder is:
group session because:
A. Serve the client a bowl of soup, buttered French
A. The client is disruptive. bread, and apple slices.

B. The client is harmful to self. B. Increase calories, decrease fat, and decrease
protein.
C. The client is harmful to others.
C. Give the client pieces of cut-up steak, carrots, and
D. The client needs to be on medication first. an apple.

4. Dervid, an adolescent boy was admitted for substance abuse D. Increase calories, carbohydrates, and protein.
and hallucinations. The client’s mother asks Nurse Armando to
talk with his husband when he arrives at the hospital. The 10.What parental behavior toward a child during an admission
mother says that she is afraid of what the father might say to the procedure should cause Nurse Ron to suspect child abuse?
boy. The most appropriate nursing intervention would be to:
A. Flat affect
A. Inform the mother that she and the father can
B. Expressing guilt
work through this problem themselves.
C. Acting overly solicitous toward the child.
B. Refer the mother to the hospital social worker.
D. Ignoring the child.
C. Agree to talk with the mother and the father
together. 11.Nurse Lynnette notices that a female client with
obsessive-compulsive disorder washes her hands for long
D. Suggest that the father and son work things out.
periods each day. How should the nurse respond to this
5. What is Nurse John likely to note in a male client being compulsive behavior?
admitted for alcohol withdrawal?
A. By designating times during which the client can
A. Perceptual disorders. focus on the behavior.

B. Impending coma. B. By urging the client to reduce the frequency of the

behavior as rapidly as possible.
C. Recent alcohol intake.
C. By calling attention to or attempting to prevent
D. Depression with mutism. the behavior.

6. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now D. By discouraging the client from verbalizing
complains that it “doesn’t help” and refuses to take it. What anxieties.
should the nurse say or do?
12.After seeking help at an outpatient mental health clinic, Ruby
who was raped while walking her dog is diagnosed with C. Depression and weight loss.
posttraumatic stress disorder (PTSD). Three months later, Ruby
returns to the clinic, complaining of fear, loss of control, and D. Withdrawal and failure to distinguish reality from
helpless feelings. Which nursing intervention is most fantasy.
appropriate for Ruby?
17.Which medications have been found to help reduce or
A. Recommending a high-protein, low-fat diet. eliminate panic attacks?

B. Giving sleep medication, as prescribed, to restore A. Antidepressants

a normal sleepwake cycle.
B. Anticholinergics
C. Allowing the client time to heal.
C. Antipsychotics
D. Exploring the meaning of the traumatic event with
the client. D. Mood stabilizers

13.Meryl, age 19, is highly dependent on her parents and fears 18.A client seeks care because she feels depressed and has
leaving home to go away to college. Shortly before the semester gained weight. To treat her atypical depression, the physician
starts, she complains that her legs are paralyzed and is rushed to prescribes tranylcypromine sulfate (Parnate), 10 mg by mouth
the emergency department. When physical examination rules twice per day. When this drug is used to treat atypical
out a physical cause for her paralysis, the physician admits her depression, what is its onset of action?
to the psychiatric unit where she is diagnosed with conversion
disorder. Meryl asks the nurse, “Why has this happened to me?” A. 1 to 2 days
What is the nurse’s best response?
B. 3 to 5 days
A. “You’ve developed this paralysis so you can stay
C. 6 to 8 days
with your parents. You must deal with this conflict
if you want to walk again.” D. 10 to 14 days
B. “It must be awful not to be able to move your 19. A 65 years old client is in the first stage of Alzheimer’s
legs. You may feel better if you realize the disease. Nurse Patricia should plan to focus this client’s care on:
problem is psychological, not physical.”
A. Offering nourishing finger foods to help maintain
C. “Your problem is real but there is no physical the client’s nutritional status.
basis for it. We’ll work on what is going on in
your life to find out why it’s happened.” B. Providing emotional support and individual
counseling.
D. “It isn’t uncommon for someone with your
personality to develop a conversion disorder C. Monitoring the client to prevent minor illnesses
during times of stress.” from turning into major problems.
14.Nurse Krina knows that the following drugs have been D. Suggesting new activities for the client and family
known to be effective in treating obsessive-compulsive disorder to do together.
(OCD):
20.The nurse is assessing a client who has just been admitted to
A. benztropine (Cogentin) and diphenhydramine the emergency department. Which signs would suggest an
(Benadryl). overdose of an antianxiety agent?
B. chlordiazepoxide (Librium) and diazepam A. Combativeness, sweating, and confusion
(Valium)
B. Agitation, hyperactivity, and grandiose ideation
C. fluvoxamine (Luvox) and clomipramine
(Anafranil) C. Emotional lability, euphoria, and impaired
memory
D. divalproex (Depakote) and lithium (Lithobid)
D. Suspiciousness, dilated pupils, and increased
15.Alfred was newly diagnosed with anxiety disorder. The blood pressure
physician prescribed buspirone (BuSpar). The nurse is aware
that the teaching instructions for newly prescribed buspirone 21.The nurse is caring for a client diagnosed with antisocial
should include which of the following? personality disorder. The client has a history of fighting, cruelty
to animals, and stealing. Which of the following traits would the
A. A warning about the drugs delayed therapeutic nurse be most likely to uncover during assessment?
effect, which is from 14 to 30 days.
A. History of gainful employment
B. A warning about the incidence of neuroleptic
malignant syndrome (NMS). B. Frequent expression of guilt regarding antisocial
behavior
C. A reminder of the need to schedule blood work in
1 week to check blood levels of the drug. C. Demonstrated ability to maintain close, stable
relationships
D. A warning that immediate sedation can occur with
a resultant drop in pulse. D. d. A low tolerance for frustration

16.Richard with agoraphobia has been symptom-free for 4 22.Nurse Amy is providing care for a male client undergoing
months. Classic signs and symptoms of phobias include: opiate withdrawal. Opiate withdrawal causes severe physical
discomfort and can be life-threatening. To minimize these
A. Insomnia and an inability to concentrate. effects, opiate users are commonly detoxified with:
B. Severe anxiety and fear. A. Barbiturates
 B. Amphetamines C. Emotional affect

C. Methadone D. Independence needs

D. Benzodiazepines 29. Nurse Mickey is caring for a client diagnosed with bulimia.
The most appropriate initial goal for a client diagnosed with
23.Nurse Cristina is caring for a client who experiences false bulimia is to:
sensory perceptions with no basis in reality. These perceptions
are known as: A. Avoid shopping for large amounts of food.

A. Delusions B. Control eating impulses.

B. Hallucinations C. Identify anxiety-causing situations

C. Loose associations D. Eat only three meals per day.

D. Neologisms 30.Rudolf is admitted for an overdose of amphetamines. When

assessing the client, the nurse should expect to see:
24. Nurse Marco is developing a plan of care for a client with
anorexia nervosa. Which action should the nurse include in the A. Tension and irritability
plan?
B. Slow pulse
A. Restricts visits with the family and friends until
the client begins to eat. C. Hypotension

B. Provide privacy during meals. D. Constipation

C. Set up a strict eating plan for the client. 31.Nicolas is experiencing hallucinations tells the nurse, “The
voices are telling me I’m no good.” The client asks if the nurse
D. Encourage the client to exercise, which will hears the voices. The most appropriate response by the nurse
reduce her anxiety. would be:

25.Tim is admitted with a diagnosis of delusions of grandeur. A. “It is the voice of your conscience, which only
The nurse is aware that this diagnosis reflects a belief that one you can control.”
is:
B. “No, I do not hear your voices, but I believe you
A. Highly important or famous. can hear them”.

B. Being persecuted C. “The voices are coming from within you and only
you can hear them.”
C. Connected to events unrelated to oneself
D. “Oh, the voices are a symptom of your illness;
D. Responsible for the evil in the world. don’t pay any attention to them.”

26.Nurse Jen is caring for a male client with manic depression. 32.The nurse is aware that the side effect of electroconvulsive
The plan of care for a client in a manic state would include: therapy that a client may experience:

A. Offering a high-calorie meals and strongly A. Loss of appetite

encouraging the client to finish all food.
B. Postural hypotension
B. Insisting that the client remain active through the
day so that he’ll sleep at night. C. Confusion for a time after treatment

C. Allowing the client to exhibit hyperactive, D. Complete loss of memory for a time
demanding, manipulative behavior without setting
limits. 33.A dying male client gradually moves toward resolution of
feelings regarding impending death. Basing care on the theory
D. Listening attentively with a neutral attitude and of Kubler-Ross, Nurse Trish plans to use nonverbal
avoiding power struggles. interventions when assessment reveals that the client is in the:

27.Ramon is admitted for detoxification after a cocaine A. Anger stage

overdose. The client tells the nurse that he frequently uses
cocaine but that he can control his use if he chooses. Which B. Denial stage
coping mechanism is he using?
C. Bargaining stage
A. Withdrawal
D. Acceptance stage
B. Logical thinking
34.The outcome that is unrelated to a crisis state is:
C. Repression
A. Learning more constructive coping skills
D. Denial
B. Decompensation to a lower level of functioning.
28.Richard is admitted with a diagnosis of schizotypal
personality disorder. Which signs would this client exhibit C. Adaptation and a return to a prior level of
during social situations? functioning.

A. Aggressive behavior D. A higher level of anxiety continuing for more than

3 months.
B. Paranoid thoughts
35.Miranda a psychiatric client is to be discharged with orders client state, “I will call my doctor immediately if I notice any:
for haloperidol (haldol) therapy. When developing a teaching
plan for discharge, the nurse should include cautioning the client A. Sensitivity to bright light or sun
against:
B. Fine hand tremors or slurred speech
A. Driving at night
C. Sexual dysfunction or breast enlargement
B. Staying in the sun
D. d. Inability to urinate or difficulty when urinating
C. Ingesting wines and cheeses
42.Nurse Mylene recognizes that the most important factor
D. Taking medications containing aspirin necessary for the establishment of trust in a critical care area is:

36.Jen a nursing student is anxious about the upcoming board A. Privacy

examination but is able to study intently and does not become
distracted by a roommate’s talking and loud music. The B. Respect
student’s ability to ignore distractions and to focus on studying
demonstrates: C. Empathy

A. Mild-level anxiety D. Presence

B. Panic-level anxiety 43.When establishing an initial nurse-client relationship, Nurse

Hazel should explore with the client the:
C. Severe-level anxiety
A. Client’s perception of the presenting problem.
D. Moderate-level anxiety
B. Occurrence of fantasies the client may experience.
37.When assessing a premorbid personality characteristics of a
client with a major depression, it would be unusual for the nurse C. Details of any ritualistic acts carried out by the
to find that this client demonstrated: client

A. Rigidity D. Client’s feelings when external; controls are

instituted.
B. Stubbornness
44.Tranylcypromine sulfate (Parnate) is prescribed for a
C. Diverse interest depressed client who has not responded to the tricyclic
antidepressants. After teaching the client about the medication,
D. Over meticulousness Nurse Marian evaluates that learning has occurred when the
client states, “I will avoid:
38.Nurse Krina recognizes that the suicidal risk for depressed
client is greatest: A. Citrus fruit, tuna, and yellow vegetables.”

A. As their depression begins to improve B. Chocolate milk, aged cheese, and yogurt’”

B. When their depression is most severe C. Green leafy vegetables, chicken, and milk.”

C. Before nay type of treatment is started D. Whole grains, red meats, and carbonated soda.”

D. As they lose interest in the environment 45.Nurse John is a aware that most crisis situations should
resolve in about:
39.Nurse Kate would expect that a client with vascular dementis
would experience: A. 1 to 2 weeks

A. Loss of remote memory related to anoxia B. 4 to 6 weeks

B. Loss of abstract thinking related to emotional state C. 4 to 6 months

C. Inability to concentrate related to decreased D. 6 to 12 months

stimuli
46. Nurse Judy knows that statistics show that in adolescent
D. Disturbance in recalling recent events related to suicide behavior:
cerebral hypoxia.
A. Females use more dramatic methods than males
40.Josefina is to be discharged on a regimen of lithium
carbonate. In the teaching plan for discharge the nurse should B. Males account for more attempts than do females
include:
C. Females talk more about suicide before
A. Advising the client to watch the diet carefully attempting it

B. Suggesting that the client take the pills with milk D. Males are more likely to use lethal methods than
are females
C. Reminding the client that a CBC must be done
once a month. 47. Dervid with paranoid schizophrenia repeatedly uses
profanity during an activity therapy session. Which response by
D. Encouraging the client to have blood levels the nurse would be most appropriate?
checked as ordered.
A. “Your behavior won’t be tolerated. Go to your
41.The psychiatrist orders lithium carbonate 600 mg p.o t.i.d for room immediately.”
a female client. Nurse Katrina would be aware that the teaching
about the side effects of this drug were understood when the B. “You’re just doing this to get back at me for
 making you come to therapy.” by mouth immediately. Before administering the dose, the nurse
verifies the dosage ordered. What is the usual minimum dose of
C. “Your cursing is interrupting the activity. Take activated charcoal?
time out in your room for 10 minutes.”
A. 5 g mixed in 250 ml of water
D. “I’m disappointed in you. You can’t control
yourself even for a few minutes.” B. 15 g mixed in 500 ml of water

48.Nurse Maureen knows that the nonantipsychotic medication C. 30 g mixed in 250 ml of water
used to treat some clients with schizoaffective disorder is:
D. 60 g mixed in 500 ml of water
A. phenelzine (Nardil)
54.What herbal medication for depression, widely used in
B. chlordiazepoxide (Librium) Europe, is now being prescribed in the United States?

C. lithium carbonate (Lithane) A. Ginkgo biloba

D. imipramine (Tofranil) B. Echinacea

49.Which information is most important for the nurse Trinity to C. St. John’s wort
include in a teaching plan for a male schizophrenic client taking
clozapine (Clozaril)? D. Ephedra

A. Monthly blood tests will be necessary. 55.Cely with manic episodes is taking lithium. Which
electrolyte level should the nurse check before administering
B. Report a sore throat or fever to the physician this medication?
immediately.
A. Calcium
C. Blood pressure must be monitored for
hypertension. B. Sodium

D. Stop the medication when symptoms subside. C. Chloride

50.Ricky with chronic schizophrenia takes neuroleptic D. Potassium

medication is admitted to the psychiatric unit. Nursing
assessment reveals rigidity, fever, hypertension, and diaphoresis. 56.Nurse Josefina is caring for a client who has been diagnosed
These findings suggest which lifethreatening reaction: with delirium. Which statement about delirium is true?

A. Tardive dyskinesia. A. It’s characterized by an acute onset and lasts about

1 month.
B. Dystonia.
B. It’s characterized by a slowly evolving onset and
C. Neuroleptic malignant syndrome. lasts about 1 week.

D. Akathisia. C. It’s characterized by a slowly evolving onset and

lasts about 1 month.
51.Which nursing intervention would be most appropriate if a
male client develop orthostatic hypotension while taking D. It’s characterized by an acute onset and lasts hours
amitriptyline (Elavil)? to a number of days.

A. Consulting with the physician about substituting a 57.Edward, a 66 year old client with slight memory impairment
different type of antidepressant. and poor concentration is diagnosed with primary degenerative
dementia of the Alzheimer’s type. Early signs of this dementia
B. Advising the client to sit up for 1 minute before include subtle personality changes and withdrawal from social
getting out of bed. interactions. To assess for progression to the middle stage of
Alzheimer’s disease, the nurse should observe the client for:
C. Instructing the client to double the dosage until
the problem resolves. A. Occasional irritable outbursts.

D. Informing the client that this adverse reaction B. Impaired communication.

should disappear within 1 week.
C. Lack of spontaneity.
52.Mr. Cruz visits the physician’s office to seek treatment for
depression, feelings of hopelessness, poor appetite, insomnia, D. Inability to perform self-care activities.
fatigue, low selfesteem, poor concentration, and difficulty
making decisions. The client states that these symptoms began 58.Isabel with a diagnosis of depression is started on imipramine
at least 2 years ago. Based on this report, the nurse Tyfany (Tofranil), 75 mg by mouth at bedtime. The nurse should tell the
suspects: client that:

A. Cyclothymic disorder. A. This medication may be habit forming and will be

discontinued as soon as the client feels better.
B. Atypical affective disorder.
B. This medication has no serious adverse effects.
C. Major depression.
C. The client should avoid eating such foods as aged
D. Dysthymic disorder. cheeses, yogurt, and chicken livers while taking
the medication.
53. After taking an overdose of phenobarbital (Barbita), Mario
is admitted to the emergency department. Dr. Trinidad D. This medication may initially cause tiredness,
prescribes activated charcoal (Charcocaps) to be administered which should become less bothersome over time.
59.Kathleen is admitted to the psychiatric clinic for treatment of 1 hour after the release of two of the extremity
anorexia nervosa. To promote the client’s physical health, the restraints.
nurse should plan to:
D. The administered medication has taken effect.
A. Severely restrict the client’s physical activities.
65.Nurse Irish is aware that Ritalin is the drug of choice for a
B. Weigh the client daily, after the evening meal. child with ADHD. The side effects of the following may be
noted by the nurse:
C. Monitor vital signs, serum electrolyte levels, and
acid-base balance. A. Increased attention span and concentration

D. Instruct the client to keep an accurate record of B. Increase in appetite

food and fluid intake.
C. Sleepiness and lethargy
60.Celia with a history of polysubstance abuse is admitted to the
facility. She complains of nausea and vomiting 24 hours after D. Bradycardia and diarrhea
admission. The nurse assesses the client and notes piloerection,
pupillary dilation, and lacrimation. The nurse suspects that the 66.Kitty, a 9 year old child has very limited vocabulary and
client is going through which of the following withdrawals? interaction skills. She has an I.Q. of 45. She is diagnosed to have
Mental retardation of this classification:
A. Alcohol withdrawal
A. Profound
B. Cannibis withdrawal
B. Mild
C. Cocaine withdrawal
C. Moderate
D. Opioid withdrawal
D. Severe
61.Mr. Garcia, an attorney who throws books and furniture
around the office after losing a case is referred to the psychiatric 67.The therapeutic approach in the care of Armand an autistic
nurse in the law firm’s employee assistance program. Nurse child include the following EXCEPT:
Beatriz knows that the client’s behavior most likely represents
the use of which defense mechanism? A. Engage in diversionary activities when acting -out

A. Regression B. Provide an atmosphere of acceptance

B. Projection C. Provide safety measures

C. Reaction-formation D. Rearrange the environment to activate the child

D. Intellectualization 68.Jeremy is brought to the emergency room by friends who

state that he took something an hour ago. He is actively
62.Nurse Anne is caring for a client who has been treated long hallucinating, agitated, with irritated nasal septum.
term with antipsychotic medication. During the assessment,
Nurse Anne checks the client for tardive dyskinesia. If tardive A. Heroin
dyskinesia is present, Nurse Anne would most likely observe:
B. Cocaine
A. Abnormal movements and involuntary
C. LSD
movements of the mouth, tongue, and face.
D. Marijuana
B. Abnormal breathing through the nostrils
accompanied by a “thrill.” 69.Nurse Pauline is aware that Dementia unlike delirium is
characterized by:
C. Severe headache, flushing, tremors, and ataxia.
A. Slurred speech
D. Severe hypertension, migraine headache,
B. Insidious onset
63.Dennis has a lithium level of 2.4 mEq/L. The nurse
immediately would assess the client for which of the following C. Clouding of consciousness
signs or symptoms?
D. Sensory perceptual change
A. Weakness
70.A 35 year old female has intense fear of riding an elevator.
B. Diarrhea She claims “ As if I will die inside.” The client is suffering
from:
C. Blurred vision
A. Agoraphobia
D. Fecal incontinence
B. Social phobia
64.Nurse Jannah is monitoring a male client who has been
placed inrestraints because of violent behavior. Nurse C. Claustrophobia
determines that it will be safe to remove the restraints when:
D. Xenophobia
A. The client verbalizes the reasons for the violent
behavior. 71.Nurse Myrna develops a counter-transference reaction. This
is evidenced by:
B. The client apologizes and tells the nurse that it
will never happen again. A. Revealing personal information to the client
C. No acts of aggression have been observed within
 B. Focusing on the feelings of the client. 78.An 83year-old male client is in extended care facility is
anxious most of the time and frequently complains of a number
C. Confronting the client about discrepancies in of vague symptoms that interfere with his ability to eat. These
verbal or non-verbal behavior symptoms indicate which of the following disorders?

D. The client feels angry towards the nurse who A. Conversion disorder
resembles his mother.
B. Hypochondriasis
72.Tristan is on Lithium has suffered from diarrhea and
vomiting. What should the nurse in-charge do first: C. Severe anxiety

A. Recognize this as a drug interaction D. Sublimation

B. Give the client Cogentin 79. Charina, a college student who frequently visited the health
center during the past year with multiple vague complaints of GI
C. Reassure the client that these are common side symptoms before course examinations. Although physical
effects of lithium therapy causes have been eliminated, the student continues to express
her belief that she has a serious illness. These symptoms are
D. Hold the next dose and obtain an order for a stat typically of which of the following disorders?
serum lithium level
A. Conversion disorder
73.Nurse Sarah ensures a therapeutic environment for all the
client. Which of the following best describes a therapeutic B. Depersonalization
milieu?
C. Hypochondriasis
A. A therapy that rewards adaptive behavior
D. Somatization disorder
B. A cognitive approach to change behavior
80. Nurse Daisy is aware that the following pharmacologic
C. A living, learning or working environment. agents are sedative hypnotic medication is used to induce sleep
for a client experiencing a sleep disorder is:
D. A permissive and congenial environment
A. Triazolam (Halcion)
74.Anthony is very hostile toward one of the staff for no
apparent reason. He is manifesting: B. Paroxetine (Paxil)\

A. Splitting C. Fluoxetine (Prozac)

B. Transference D. Risperidone (Risperdal)
C. Countertransference 81. Aldo, with a somatoform pain disorder may obtain
secondary gain. Which of the following statement refers to a
D. Resistance secondary gain?
75.Marielle, 17 years old was sexually attacked while on her A. It brings some stability to the family
way home from school. She is brought to the hospital by her
mother. Rape is an example of which type of crisis: B. It decreases the preoccupation with the physical
illness
A. Situational
C. It enables the client to avoid some unpleasant
B. Adventitious activity
C. Developmental D. It promotes emotional support or attention for the
client
D. Internal
82. Dervid is diagnosed with panic disorder with agoraphobia is
76. Nurse Greta is aware that the following is classified as an talking with the nurse in-charge about the progress made in
Axis I disorder by the Diagnosis and Statistical Manual of treatment. Which of the following statements indicates a
Mental Disorders, Text Revision (DSM-IV-TR) is: positive client response?
A. Obesity A. “I went to the mall with my friends last Saturday”
B. Borderline personality disorder B. “I’m hyperventilating only when I have a panic
attack”
C. Major depression
C. “Today I decided that I can stop taking my
D. Hypertension
medication”
77.Katrina, a newly admitted is extremely hostile toward a staff
D. “Last night I decided to eat more than a bowl of
member she has just met, without apparent reason. According to
cereal”
Freudian theory, the nurse should suspect that the client is
experiencing which of the following phenomena? 83. The effectiveness of monoamine oxidase (MAO) inhibitor
drug therapy in client with posttraumatic stress disorder can be
A. Intellectualization
demonstrated by which of the following client self –reports?
B. Transference
A. “I’m sleeping better and don’t have nightmares”
C. Triangulation
B. “I’m not losing my temper as much”
D. Splitting
C. “I’ve lost my craving for alcohol”
 D. “I’ve lost my phobia for water” D. The client is experiencing visual hallucination

84. Mark, with a diagnosis of generalized anxiety disorder wants 90. Which of the following descriptions of a client’s experience
to stop taking his lorazepam (Ativan). Which of the following and behavior can be assessed as an illusion?
important facts should nurse Betty discuss with the client about
discontinuing the medication? A. The client tries to hit the nurse when vital signs
must be taken
A. Stopping the drug may cause depression
B. The client says, “I keep hearing a voice telling me
B. Stopping the drug increases cognitive abilities to run away”

C. Stopping the drug decreases sleeping difficulties C. The client becomes anxious whenever the nurse
leaves the bedside
D. Stopping the drug can cause withdrawal
symptoms D. The client looks at the shadow on a wall and tells
the nurse she sees frightening faces on the wall.
85. Jennifer, an adolescent who is depressed and reported by his
parents as having difficulty in school is brought to the 91. During conversation of Nurse John with a client, he observes
community mental health center to be evaluated. Which of the that the client shift from one topic to the next on a regular basis.
following other health problems would the nurse suspect? Which of the following terms describes this disorder?

A. Anxiety disorder A. Flight of ideas

B. Behavioral difficulties B. Concrete thinking

C. Cognitive impairment C. Ideas of reference

D. Labile moods D. Loose association

86. Ricardo, an outpatient in psychiatric facility is diagnosed 92. Francis tells the nurse that her coworkers are sabotaging the
with dysthymic disorder. Which of the following statement computer. When the nurse asks questions, the client becomes
about dysthymic disorder is true? argumentative. This behavior shows personality traits associated
with which of the following personality disorder?
A. It involves a mood range from moderate
depression to hypomania A. Antisocial

B. It involves a single manic depression B. Histrionic

C. It’s a form of depression that occurs in the fall and C. Paranoid

winter
D. Schizotypal
D. It’s a mood disorder similar to major depression
but of mild to moderate severity 93. Which of the following interventions is important for a Cely
experiencing with paranoid personality disorder taking
87. The nurse is aware that the following ways in vascular olanzapine (Zyprexa)?
dementia different from Alzheimer’s disease is:
A. Explain effects of serotonin syndrome
A. Vascular dementia has more abrupt onset
B. Teach the client to watch for extrapyramidal
B. The duration of vascular dementia is usually brief adverse reaction

C. Personality change is common in vascular C. Explain that the drug is less affective if the client
dementia smokes

D. The inability to perform motor activities occurs in D. Discuss the need to report paradoxical effects
vascular dementia such as euphoria

88. Loretta, a newly admitted client was diagnosed with 94. Nurse Alexandra notices other clients on the unit avoiding a
delirium and has history of hypertension and anxiety. She had client diagnosed with antisocial personality disorder. When
been taking digoxin, furosemide (Lasix), and diazepam (Valium) discussing appropriate behavior in group therapy, which of the
for anxiety. This client’s impairment may be related to which of following comments is expected about this client by his peers?
the following conditions?
A. Lack of honesty
A. Infection
B. Belief in superstition
B. Metabolic acidosis
C. Show of temper tantrums
C. Drug intoxication
D. Constant need for attention
D. Hepatic encephalopathy
95. Tommy, with dependent personality disorder is working to
89. Nurse Ron enters a client’s room, the client says, “They’re increase his selfesteem. Which of the following statements by
crawling on my sheets! Get them off my bed!” Which of the the Tommy shows teaching was successful?
following assessment is the most accurate?
A. “I’m not going to look just at the negative things
A. The client is experiencing aphasia about myself”

B. The client is experiencing dysarthria B. “I’m most concerned about my level of

competence and progress”
C. The client is experiencing a flight of ideas
 C. “I’m not as envious of the things other people
have as I used to be”

D. “I find I can’t stop myself from taking over things

other should be doing”

96. Norma, a 42-year-old client with a diagnosis of chronic

undifferentiated schizophrenia lives in a rooming house that has
a weekly nursing clinic. She scratches while she tells the nurse
she feels creatures eating away at her skin. Which of the
following interventions should be done first?

A. Talk about his hallucinations and fears

B. Refer him for anticholinergic adverse reactions

C. Assess for possible physical problems such as

rash

D. Call his physician to get his medication increased

to control his psychosis

97. Ivy, who is on the psychiatric unit is copying and imitating

the movements of her primary nurse. During recovery, she says,
“I thought the nurse was my mirror. I felt connected only when I
saw my nurse.” This behavior is known by which of the
following terms?

A. Modeling

B. Echopraxia

C. Ego-syntonicity

D. Ritualism

98. Jun approaches the nurse and tells that he hears a voice
telling him that he’s evil and deserves to die. Which of the
following terms describes the client’s perception?

A. Delusion

B. Disorganized speech

C. Hallucination

D. Idea of reference

99. Mike is admitted to a psychiatric unit with a diagnosis of

undifferentiated schizophrenia. Which of the following defense
mechanisms is probably used by mike?

A. Projection

B. Rationalization

C. Regression

D. Repression

100. Rocky has started taking haloperidol (Haldol). Which of

the following instructions is most appropriate for Ricky before
taking haloperidol?

A. Should report feelings of restlessness or agitation

at once

B. Use a sunscreen outdoors on a year-round basis

C. Be aware you’ll feel increased energy taking this

drug

D. This drug will indirectly control essential

hypertension
 avoid dependence; sleep medication is rarely appropriate. A
Care of Clients with special diet isn’t indicated unless the client also has an eating
disorder or a nutritional problem.
Physiologic and Psychosocial
13. Answer: (C) “Your problem is real but there is no physical
Alterations (Part 3) basis for it. We’ll work on what is going on in your life to
find out why it’s happened.” The nurse must be honest with
1. Answer: (D) Focusing. The nurse is using focusing by the client by telling her that the paralysis has no physiologic
suggesting that the client discuss a specific issue. The nurse cause while also conveying empathy and acknowledging that
didn’t restate the question, make observation, or ask further her symptoms are real. The client will benefit from
question (exploring). psychiatric treatment, which will help her understand the
underlying cause of her symptoms. After the psychological
2. Answer: (D) Remove all other clients from the dayroom. The conflict is resolved, her symptoms will disappear. Saying that
nurse’s first priority is to consider the safety of the clients in it must be awful not to be able to move her legs wouldn’t
the therapeutic setting. The other actions are appropriate answer the client’s question; knowing that the cause is
responses after ensuring the safety of other clients. psychological wouldn’t necessarily make her feel better.
Telling her that she has developed paralysis to avoid leaving
3. Answer: (A) The client is disruptive. Group activity provides her parents or that her personality caused her disorder
too much stimulation, which the client will not be able to wouldn’t help her understand and resolve the underlying
handle (harmful to self) and as a result will be disruptive to conflict.
others.
14. Answer: (C) fluvoxamine (Luvox) and clomipramine
4. Answer: (C) Agree to talk with the mother and the father (Anafranil). The antidepressants fluvoxamine and
together. By agreeing to talk with both parents, the nurse can clomipramine have been effective in the treatment of OCD.
provide emotional support and further assess and validate the Librium and Valium may be helpful in treating anxiety
family’s needs. related to OCD but aren’t drugs of choice to treat the illness.
The other medications mentioned aren’t effective in the
5. Answer: (A) Perceptual disorders. Frightening visual treatment of OCD.
hallucinations are especially common in clients experiencing
alcohol withdrawal. 15. Answer: (A) A warning about the drugs delayed therapeutic
effect, which is from 14 to 30 days. The client should be
6. Answer: (D) Suggest that it takes awhile before seeing the informed that the drug’s therapeutic effect might not be
results. The client needs a specific response; that it takes 2 to reached for 14 to 30 days. The client must be instructed to
3 weeks (a delayed effect) until the therapeutic blood level is continue taking the drug as directed. Blood level checks
reached. aren’t necessary. NMS hasn’t been reported with this drug,
but tachycardia is frequently reported.
7. Answer: (C) Superego. This behavior shows a weak sense of
moral consciousness. According to Freudian theory, 16. Answer: (B) Severe anxiety and fear. Phobias cause severe
personality disorders stem from a weak superego. anxiety (such as a panic attack) that is out of proportion to
the threat of the feared object or situation. Physical signs and
8. Answer: (C) Skeletal muscle paralysis. Anectine is a
symptoms of phobias include profuse sweating, poor motor
depolarizing muscle relaxant causing paralysis. It is used to
control, tachycardia, and elevated blood pressure. Insomnia,
reduce the intensity of muscle contractions during the
an inability to concentrate, and weight loss are common in
convulsive stage, thereby reducing the risk of bone fractures
depression. Withdrawal and failure to distinguish reality
or dislocation.
from fantasy occur in schizophrenia.
9. Answer: (D) Increase calories, carbohydrates, and
17. Answer: (A) Antidepressants. Tricyclic and monoamine
protein.This client increased protein for tissue building and
oxidase (MAO) inhibitor antidepressants have been found to
increased calories to replace what is burned up (usually via
be effective in treating clients with panic attacks. Why these
carbohydrates).
drugs help control panic attacks isn’t clearly understood.
10. Answer: (C) Acting overly solicitous toward the child. This Anticholinergic agents, which are smooth-muscle relaxants,
behavior is an example of reaction formation, a coping relieve physical symptoms of anxiety but don’t relieve the
mechanism. anxiety itself. Antipsychotic drugs are inappropriate because
clients who experience panic attacks aren’t psychotic. Mood
11. Answer: (A) By designating times during which the client stabilizers aren’t indicated because panic attacks are rarely
can focus on the behavior. The nurse should designate times associated with mood changes.
during which the client can focus on the compulsive
behavior or obsessive thoughts. The nurse should urge the 18. Answer: (B) 3 to 5 days. Monoamine oxidase inhibitors,
client to reduce the frequency of the compulsive behavior such as tranylcypromine, have an onset of action of
gradually, not rapidly. She shouldn’t call attention to or try to approximately 3 to 5 days. A full clinical response may be
prevent the behavior. Trying to prevent the behavior may delayed for 3 to 4 weeks. The therapeutic effects may
cause pain and terror in the client. The nurse should continue for 1 to 2 weeks after discontinuation.
encourage the client to verbalize anxieties to help distract
19. Answer: (B) Providing emotional support and individual
attention from the compulsive behavior.
counseling. Clients in the first stage of Alzheimer’s disease
12. Answer: (D) Exploring the meaning of the traumatic event are aware that something is happening to them and may
with the client. The client with PTSD needs encouragement become overwhelmed and frightened. Therefore, nursing
to examine and understand the meaning of the traumatic care typically focuses on providing emotional support and
event and consequent losses. Otherwise, symptoms may individual counseling. The other options are appropriate
worsen and the client may become depressed or engage in during the second stage of Alzheimer’s disease, when the
self-destructive behavior such as substance abuse. The client client needs continuous monitoring to prevent minor
must explore the meaning of the event and won’t heal illnesses from progressing into major problems and when
without this, no matter how much time passes. Behavioral maintaining adequate nutrition may become a challenge.
techniques, such as relaxation therapy, may help decrease the During this stage, offering nourishing finger foods helps
client’s anxiety and induce sleep. The physician may clients to feed themselves and maintain adequate nutrition.
prescribe antianxiety agents or antidepressants cautiously to
20. Answer: (C) Emotional lability, euphoria, and impaired
 memory. Signs of antianxiety agent overdose include uncommon, although these clients may experience agitation
emotional lability, euphoria, and impaired memory. with anxiety. Their behavior is emotionally cold with a
Phencyclidine overdose can cause combativeness, sweating, flattened affect, regardless of the situation. These clients
and confusion. Amphetamine overdose can result in demonstrate a reduced capacity for close or dependent
agitation, hyperactivity, and grandiose ideation. relationships.
Hallucinogen overdose can produce suspiciousness, dilated
pupils, and increased blood pressure. 29. Answer: (C) Identify anxiety-causing situations. Bulimic
behavior is generally a maladaptive coping response to stress
21. Answer: (D) A low tolerance for frustration. Clients with an and underlying issues. The client must identify
antisocial personality disorder exhibit a low tolerance for anxiety-causing situations that stimulate the bulimic behavior
frustration, emotional immaturity, and a lack of impulse and then learn new ways of coping with the anxiety.
control. They commonly have a history of unemployment,
miss work repeatedly, and quit work without other plans for 30. Answer: (A) Tension and irritability. An amphetamine is a
employment. They don’t feel guilt about their behavior and nervous system stimulant that is subject to abuse because of
commonly perceive themselves as victims. They also display its ability to produce wakefulness and euphoria. An overdose
a lack of responsibility for the outcome of their actions. increases tension and irritability. Options B and C are
Because of a lack of trust in others, clients with antisocial incorrect because amphetamines stimulate norepinephrine,
personality disorder commonly have difficulty developing which increase the heart rate and blood flow. Diarrhea is a
stable, close relationships. common adverse effect so option D in is incorrect.

22. Answer: (C) Methadone. Methadone is used to detoxify 31. Answer: (B) “No, I do not hear your voices, but I believe you
opiate users because it binds with opioid receptors at many can hear them”. The nurse, demonstrating knowledge and
sites in the central nervous system but doesn’t have the same understanding, accepts the client’s perceptions even though
deterious effects as other opiates, such as cocaine, heroin, they are hallucinatory.
and morphine. Barbiturates, amphetamines, and
benzodiazepines are highly addictive and would require 32. Answer: (C) Confusion for a time after treatment. The
detoxification treatment. electrical energy passing through the cerebral cortex during
ECT results in a temporary state of confusion after treatment.
23. Answer: (B) Hallucinations. Hallucinations are visual,
auditory, gustatory, tactile, or olfactory perceptions that have 33. Answer: (D) Acceptance stage. Communication and
no basis in reality. Delusions are false beliefs, rather than intervention during this stage are mainly nonverbal, as when
perceptions, that the client accepts as real. Loose associations the client gestures to hold the nurse’s hand.
are rapid shifts among unrelated ideas. Neologisms are
bizarre words that have meaning only to the client. 34. Answer: (D) A higher level of anxiety continuing for more
than 3 months. This is not an expected outcome of a crisis
24. Answer: (C) Set up a strict eating plan for the client. because by definition a crisis would be resolved in 6 weeks.
Establishing a consistent eating plan and monitoring the
client’s weight are very important in this disorder. The family 35. Answer: (B) Staying in the sun. Haldol causes
and friends should be included in the client’s care. The client photosensitivity. Severe sunburn can occur on exposure to
should be monitored during meals-not given privacy. the sun.
Exercise must be limited and supervised.
36. Answer: (D) Moderate-level anxiety. A moderately anxious
25. Answer: (A) Highly important or famous. A delusion of person can ignore peripheral events and focuses on central
grandeur is a false belief that one is highly important or concerns.
famous. A delusion of persecution is a false belief that one is
37. Answer: (C) Diverse interest. Before onset of depression,
being persecuted. A delusion of reference is a false belief
these clients usually have very narrow, limited interest.
that one is connected to events unrelated to oneself or a
belief that one is responsible for the evil in the world. 38. Answer: (A) As their depression begins to improve. At this
point the client may have enough energy to plan and execute
26. Answer: (D) Listening attentively with a neutral attitude and
an attempt.
avoiding power struggles. The nurse should listen to the
client’s requests, express willingness to seriously consider 39. Answer: (D) Disturbance in recalling recent events related to
the request, and respond later. The nurse should encourage cerebral hypoxia. Cell damage seems to interfere with
the client to take short daytime naps because he expends so registering input stimuli, which affects the ability to register
much energy. The nurse shouldn’t try to restrain the client and recall recent events; vascular dementia is related to
when he feels the need to move around as long as his activity multiple vascular lesions of the cerebral cortex and
isn’t harmful. High calorie finger foods should be offered to subcortical structure.
supplement the client’s diet, if he can’t remain seated long
enough to eat a complete meal. The nurse shouldn’t be 40. Answer: (D) Encouraging the client to have blood levels
forced to stay seated at the table to finish a meal. The nurse checked as ordered. Blood levels must be checked monthly
should set limits in a calm, clear, and self-confident tone of or bimonthly when the client is on maintenance therapy
voice. because there is only a small range between therapeutic and
toxic levels.
27. Answer: (D) Denial. Denial is unconscious defense
mechanism in which emotional conflict and anxiety is 41. Answer: (B) Fine hand tremors or slurred speech. These are
avoided by refusing to acknowledge feelings, desires, common side effects of lithium carbonate.
impulses, or external facts that are consciously intolerable.
Withdrawal is a common response to stress, characterized by 42. Answer: (D) Presence. The constant presence of a nurse
apathy. Logical thinking is the ability to think rationally and provides emotional support because the client knows that
make responsible decisions, which would lead the client someone is attentive and available in case of an emergency.
admitting the problem and seeking help. Repression is
suppressing past events from the consciousness because of 43. Answer: (A) Client’s perception of the presenting problem.
guilty association. The nurse can be most therapeutic by starting where the
client is, because it is the client’s concept of the problem that
28. Answer: (B) Paranoid thoughts. Clients with schizotypal serves as the starting point of the relationship.
personality disorder experience excessive social anxiety that
can lead to paranoid thoughts. Aggressive behavior is 44. Answer: (B) Chocolate milk, aged cheese, and yogurt’.
 These high-tyramine foods, when ingested in the presence of of normal mood that last a few days to a few weeks.
an MAO inhibitor, cause a severe hypertensive response. Cyclothymic disorder is a chronic mood disturbance of at
least 2 years’ duration marked by numerous periods of
45. Answer: (B) 4 to 6 weeks. Crisis is self-limiting and lasts depression and hypomania. Atypical affective disorder is
from 4 to 6 weeks. characterized by manic signs and symptoms. Major
depression is a recurring, persistent sadness or loss of interest
46. Answer: (D) Males are more likely to use lethal methods or pleasure in almost all activities, with signs and symptoms
than are females. This finding is supported by research; recurring for at least 2 weeks.
females account for 90% of suicide attempts but males are
three times more successful because of methods used. 53. Answer: (C) 30 g mixed in 250 ml of water. The usual adult
dosage of activated charcoal is 5 to 10 times the estimated
47. Answer: (C) “Your cursing is interrupting the activity. Take weight of the drug or chemical ingested, or a minimum dose
time out in your room for 10 minutes.” The nurse should set of 30 g, mixed in 250 ml of water. Doses less than this will
limits on client behavior to ensure a comfortable be ineffective; doses greater than this can increase the risk of
environment for all clients. The nurse should accept hostile adverse reactions, although toxicity doesn’t occur with
or quarrelsome client outbursts within limits without activated charcoal, even at the maximum dose.
becoming personally offended, as in option A. Option B is
incorrect because it implies that the client’s actions reflect 54. Answer: (C) St. John’s wort. St. John’s wort has been found
feelings toward the staff instead of the client’s own misery. to have serotonin-elevating properties, similar to prescription
Judgmental remarks, such as option D, may decrease the antidepressants. Ginkgo biloba is prescribed to enhance
client’s self-esteem. mental acuity. Echinacea has immune-stimulating properties.
Ephedra is a naturally occurring stimulant that is similar to
48. Answer: (C) lithium carbonate (Lithane). Lithium carbonate, ephedrine.
an antimania drug, is used to treat clients with cyclical
schizoaffective disorder, a psychotic disorder once classified 55. Answer: (B) Sodium. Lithium is chemically similar to
under schizophrenia that causes affective symptoms, sodium. If sodium levels are reduced, such as from sweating
including maniclike activity. Lithium helps control the or diuresis, lithium will be reabsorbed by the kidneys,
affective component of this disorder. Phenelzine is a increasing the risk of toxicity. Clients taking lithium
monoamine oxidase inhibitor prescribed for clients who shouldn’t restrict their intake of sodium and should drink
don’t respond to other antidepressant drugs such as adequate amounts of fluid each day. The other electrolytes
imipramine. Chlordiazepoxide, an antianxiety agent, are important for normal body functions but sodium is most
generally is contraindicated in psychotic clients. Imipramine, important to the absorption of lithium.
primarily considered an antidepressant agent, is also used to
treat clients with agoraphobia and that undergoing cocaine 56. Answer: (D) It’s characterized by an acute onset and lasts
detoxification. hours to a number of days. Delirium has an acute onset and
typically can last from several hours to several days.
49. Answer: (B) Report a sore throat or fever to the physician
immediately. A sore throat and fever are indications of an 57. Answer: (B) Impaired communication. Initially, memory
infection caused by agranulocytosis, a potentially impairment may be the only cognitive deficit in a client with
life-threatening complication of clozapine. Because of the Alzheimer’s disease. During the early stage of this disease,
risk of agranulocytosis, white blood cell (WBC) counts are subtle personality changes may also be present. However,
necessary weekly, not monthly. If the WBC count drops other than occasional irritable outbursts and lack of
below 3,000/μl, the medication must be stopped. spontaneity, the client is usually cooperative and exhibits
Hypotension may occur in clients taking this medication. socially appropriate behavior. Signs of advancement to the
Warn the client to stand up slowly to avoid dizziness from middle stage of Alzheimer’s disease include exacerbated
orthostatic hypotension. The medication should be cognitive impairment with obvious personality changes and
continued, even when symptoms have been controlled. If the impaired communication, such as inappropriate
medication must be stopped, it should be slowly tapered over conversation, actions, and responses. During the late stage,
1 to 2 weeks and only under the supervision of a physician. the client can’t perform self-care activities and may become
mute.
50. Answer: (C) Neuroleptic malignant syndrome. The client’s
signs and symptoms suggest neuroleptic malignant 58. Answer: (D) This medication may initially cause tiredness,
syndrome, a life-threatening reaction to neuroleptic which should become less bothersome over time. Sedation is
medication that requires immediate treatment. Tardive a common early adverse effect of imipramine, a tricyclic
dyskinesia causes involuntary movements of the tongue, antidepressant, and usually decreases as tolerance develops.
mouth, facial muscles, and arm and leg muscles. Dystonia is Antidepressants aren’t habit forming and don’t cause
characterized by cramps and rigidity of the tongue, face, physical or psychological dependence. However, after a long
neck, and back muscles. Akathisia causes restlessness, course of high-dose therapy, the dosage should be decreased
anxiety, and jitteriness. gradually to avoid mild withdrawal symptoms. Serious
adverse effects, although rare, include myocardial infarction,
51. Answer: (B) Advising the client to sit up for 1 minute before heart failure, and tachycardia. Dietary restrictions, such as
getting out of bed. To minimize the effects of avoiding aged cheeses, yogurt, and chicken livers, are
amitriptyline-induced orthostatic hypotension, the nurse necessary for a client taking a monoamine oxidase inhibitor,
should advise the client to sit up for 1 minute before getting not a tricyclic antidepressant.
out of bed. Orthostatic hypotension commonly occurs with
tricyclic antidepressant therapy. In these cases, the dosage 59. Answer: (C) Monitor vital signs, serum electrolyte levels,
may be reduced or the physician may prescribe nortriptyline, and acid-base balance. An anorexic client who requires
another tricyclic antidepressant. Orthostatic hypotension hospitalization is in poor physical condition from starvation
disappears only when the drug is discontinued. and may die as a result of arrhythmias, hypothermia,
malnutrition, infection, or cardiac abnormalities secondary to
52. Answer: (D) Dysthymic disorder. Dysthymic disorder is electrolyte imbalances. Therefore, monitoring the client’s
marked by feelings of depression lasting at least 2 years, vital signs, serum electrolyte level, and acid base balance is
accompanied by at least two of the following symptoms: crucial. Option A may worsen anxiety. Option B is incorrect
sleep disturbance, appetite disturbance, low energy or because a weight obtained after breakfast is more accurate
fatigue, low selfesteem, poor concentration, difficulty than one obtained after the evening meal. Option D would
making decisions, and hopelessness. These symptoms may reward the client with attention for not eating and reinforce
be relatively continuous or separated by intervening periods the control issues that are central to the underlying
 psychological problem; also, the client may record food and 70. Answer: (C) Claustrophobia. Claustrophobia is fear of closed
fluid intake inaccurately. space. A. Agoraphobia is fear of open space or being a
situation where escape is difficult. B. Social phobia is fear of
60. Answer: (D) Opioid withdrawal. The symptoms listed are performing in the presence of others in a way that will be
specific to opioid withdrawal. Alcohol withdrawal would humiliating or embarrassing. D. Xenophobia is fear of
show elevated vital signs. There is no real withdrawal from strangers.
cannibis. Symptoms of cocaine withdrawal include
depression, anxiety, and agitation. 71. Answer: (A) Revealing personal information to the client.
Counter-transference is an emotional reaction of the nurse on
61. Answer: (A) Regression. An adult who throws temper the client based on her unconscious needs and conflicts. B
tantrums, such as this one, is displaying regressive behavior, and C. These are therapeutic approaches. D. This is
or behavior that is appropriate at a younger age. In transference reaction where a client has an emotional
projection, the client blames someone or something other reaction towards the nurse based on her past.
than the source. In reaction formation, the client acts in
opposition to his feelings. In intellectualization, the client 72. Answer: (D) Hold the next dose and obtain an order for a stat
overuses rational explanations orabstract thinking to decrease serum lithium level. Diarrhea and vomiting are
the significance of a feeling or event. manifestations of Lithium toxicity. The next dose of lithium
should be withheld and test is done to validate the
62. Answer: (A) Abnormal movements and involuntary observation. A. The manifestations are not due to drug
movements of the mouth, tongue, and face. Tardive interaction. B. Cogentin is used to manage the extra
dyskinesia is a severe reaction associated with long term use pyramidal symptom side effects of antipsychotics. C. The
of antipsychotic medication. The clinical manifestations common side effects of Lithium are fine hand tremors,
include abnormal movements (dyskinesia) and involuntary nausea, polyuria and polydipsia.
movements of the mouth, tongue (fly catcher tongue), and
face. 73. Answer: (C) A living, learning or working environment. A
therapeutic milieu refers to a broad conceptual approach in
63. Answer: (C) Blurred vision. At lithium levels of 2 to 2.5 which all aspects of the environment are channeled to
mEq/L the client will experienced blurred vision, muscle provide a therapeutic environment for the client. The six
twitching, severe hypotension, and persistent nausea and environmental elements include structure, safety, norms;
vomiting. With levels between 1.5 and 2 mEq/L the client limit setting, balance and unit modification. A. Behavioral
experiencing vomiting, diarrhea, muscle weakness, ataxia, approach in psychiatric care is based on the premise that
dizziness, slurred speech, and confusion. At lithium levels of behavior can be learned or unlearned through the use of
2.5 to 3 mEq/L or higher, urinary and fecal incontinence reward and punishment. B. Cognitive approach to change
occurs, as well as seizures, cardiac dysrythmias, peripheral behavior is done by correcting distorted perceptions and
vascular collapse, and death. irrational beliefs to correct maladaptive behaviors. D. This is
not congruent with therapeutic milieu.
64. Answer: (C) No acts of aggression have been observed
within 1 hour after the release of two of the extremity 74. Answer: (B) Transference. Transference is a positive or
restraints. The best indicator that the behavior is controlled, negative feeling associated with a significant person in the
if the client exhibits no signs of aggression after partial client’s past that are unconsciously assigned to another A.
release of restraints. Options A, B, and D do not ensure that Splitting is a defense mechanism commonly seen in a client
the client has controlled the behavior. with personality disorder in which the world is perceived as
all good or all bad C. Countert-transference is a phenomenon
65. Answer: (A) increased attention span and concentration. The where the nurse shifts feelings assigned to someone in her
medication has a paradoxic effect that decrease hyperactivity past to the patient D. Resistance is the client’s refusal to
and impulsivity among children with ADHD. B, C, D. Side submit himself to the care of the nurse
effects of Ritalin include anorexia, insomnia, diarrhea and
irritability. 75. Answer: (B) Adventitious. Adventitious crisis is a crisis
involving a traumatic event. It is not part of everyday life. A.
66. Answer: (C) Moderate. The child with moderate mental Situational crisis is from an external source that upset ones
retardation has an I.Q. of 35- 50 Profound Mental retardation psychological equilibrium C and D. Are the same. They are
has an I.Q. of below 20; Mild mental retardation 50-70 and transitional or developmental periods in life
Severe mental retardation has an I.Q. of 20-35.
76. Answer: (C) Major depression. The DSM-IV-TR classifies
67. Answer: (D) Rearrange the environment to activate the child. major depression as an Axis I disorder. Borderline
The child with autistic disorder does not want change. personality disorder as an Axis II; obesity and hypertension,
Maintaining a consistent environment is therapeutic. A. Axis III.
Angry outburst can be re-channeling through safe activities.
B. Acceptance enhances a trusting relationship. C. Ensure 77. Answer: (B) Transference. Transference is the unconscious
safety from self-destructive behaviors like head banging and assignment of negative or positive feelings evoked by a
hair pulling. significant person in the client’s past to another person.
Intellectualization is a defense mechanism in which the client
68. Answer: (B) cocaine. The manifestations indicate avoids dealing with emotions by focusing on facts.
intoxication with cocaine, a CNS stimulant. A. Intoxication Triangulation refers to conflicts involving three family
with heroine is manifested by euphoria then impairment in members. Splitting is a defense mechanism commonly seen
judgment, attention and the presence of papillary in clients with personality disorder in which the world is
constriction. C. Intoxication with hallucinogen like LSD is perceived as all good or all bad.
manifested by grandiosity, hallucinations, synesthesia and
increase in vital signs D. Intoxication with Marijuana, a 78. Answer: (B) Hypochondriasis. Complains of vague physical
cannabinoid is manifested by sensation of slowed time, symptoms that have no apparent medical causes are
conjunctival redness, social withdrawal, impaired judgment characteristic of clients with hypochondriasis. In many cases,
and hallucinations. the GI system is affected. Conversion disorders are
characterized by one or more neurologic symptoms. The
69. Answer: (B) insidious onset. Dementia has a gradual onset client’s symptoms don’t suggest severe anxiety. A client
and progressive deterioration. It causes pronounced memory experiencing sublimation channels maladaptive feelings or
and cognitive disturbances. A,C and D are all characteristics impulses into socially acceptable behavior
of delirium.
79. Answer: (C) Hypochondriasis. Hypochodriasis in this case is duration of delirium is usually brief. The inability to carry
shown by the client’s belief that she has a serious illness, out motor activities is common in Alzheimer’s disease.
although pathologic causes have been eliminated. The
disturbance usually lasts at lease 6 with identifiable life 88. Answer: (C) Drug intoxication. This client was taking
stressor such as, in this case, course examinations. several medications that have a propensity for producing
Conversion disorders are characterized by one or more delirium; digoxin (a digitalis glycoxide), furosemide (a
neurologic symptoms. Depersonalization refers to persistent thiazide diuretic), and diazepam (a benzodiazepine).
recurrent episodes of feeling detached from one’s self or Sufficient supporting data don’t exist to suspect the other
body. Somatoform disorders generally have a chronic course options as causes.
with few remissions.
89. Answer: (D) The client is experiencing visual hallucination.
80. Answer: (A) Triazolam (Halcion). Triazolam is one of a The presence of a sensory stimulus correlates with the
group of sedative hypnotic medication that can be used for a definition of a hallucination, which is a false sensory
limited time because of the risk of dependence. Paroxetine is perception. Aphasia refers to a communication problem.
a scrotonin-specific reutake inhibitor used for treatment of Dysarthria is difficulty in speech production. Flight of ideas
depression panic disorder, and obsessive-compulsive is rapid shifting from one topic to another.
disorder. Fluoxetine is a scrotonin-specific reuptake inhibitor
used for depressive disorders and obsessive-compulsive 90. Answer: (D) The client looks at the shadow on a wall and
disorders. Risperidome is indicated for psychotic disorders. tells the nurse she sees frightening faces on the wall. Minor
memory problems are distinguished from dementia by their
81. Answer: (D) It promotes emotional support or attention for minor severity and their lack of significant interference with
the client. Secondary gain refers to the benefits of the illness the client’s social or occupational lifestyle. Other options
that allow the client to receive emotional support or would be included in the history data but don’t directly
attention. Primary gain enables the client to avoid some correlate with the client’s lifestyle.
unpleasant activity. A dysfunctional family may disregard
the real issue, although some conflict is relieved. 91. Answer: (D) Loose association. Loose associations are
Somatoform pain disorder is a preoccupation with pain in the conversations that constantly shift in topic. Concrete thinking
absence of physical disease. implies highly definitive thought processes. Flight of ideas is
characterized by conversation that’s disorganized from the
82. Answer: (A) “I went to the mall with my friends last onset. Loose associations don’t necessarily start in a
Saturday”. Clients with panic disorder tent to be socially cogently, then becomes loose.
withdrawn. Going to the mall is a sign of working on
avoidance behaviors. Hyperventilating is a key symptom of 92. Answer: (C) Paranoid. Because of their suspiciousness,
panic disorder. Teaching breathing control is a major paranoid personalities ascribe malevolent activities to others
intervention for clients with panic disorder. The client taking and tent to be defensive, becoming quarrelsome and
medications for panic disorder; such as tricylic argumentative. Clients with antisocial personality disorder
antidepressants and benzodiazepines, must be weaned off can also be antagonistic and argumentative but are less
these drugs. Most clients with panic disorder with suspicious than paranoid personalities. Clients with histrionic
agoraphobia don’t have nutritional problems. personality disorder are dramatic, not suspicious and
argumentative. Clients with schizoid personality disorder are
83. Answer: (A) “I’m sleeping better and don’t have nightmares” usually detached from other and tend to have eccentric
MAO inhibitors are used to treat sleep problems, nightmares, behavior.
and intrusive daytime thoughts in individual with
posttraumatic stress disorder. MAO inhibitors aren’t used to 93. Answer: (C) Explain that the drug is less affective if the
help control flashbacks or phobias or to decrease the craving client smokes. Olanzapine (Zyprexa) is less effective for
for alcohol. clients who smoke cigarettes. Serotonin syndrome occurs
with clients who take a combination of antidepressant
84. Answer: (D) Stopping the drug can cause withdrawal medications. Olanzapine doesn’t cause euphoria, and
symptoms. Stopping antianxiety drugs such as extrapyramidal adverse reactions aren’t a problem. However,
benzodiazepines can cause the client to have withdrawal the client should be aware of adverse effects such as tardive
symptoms. Stopping a benzodiazepine doesn’t tend to cause dyskinesia.
depression, increase cognitive abilities, or decrease sleeping
difficulties. 94. Answer: (A) Lack of honesty. Clients with antisocial
personality disorder tent to engage in acts of dishonesty,
85. Answer: (B) Behavioral difficulties. Adolescents tend to shown by lying. Clients with schizotypal personality disorder
demonstrate severe irritability and behavioral problems tend to be superstitious. Clients with histrionic personality
rather than simply a depressed mood. Anxiety disorder is disorders tend to overreact to frustrations and
more commonly associated with small children rather than disappointments, have temper tantrums, and seek attention.
with adolescents. Cognitive impairment is typically
associated with delirium or dementia. Labile mood is more 95. Answer: (A) “I’m not going to look just at the negative
characteristic of a client with cognitive impairment or bipolar things about myself”. As the clients makes progress on
disorder. improving self-esteem, selfblame and negative self
evaluation will decrease. Clients with dependent personality
86. Answer: (D) It’s a mood disorder similar to major depression disorder tend to feel fragile and inadequate and would be
but of mild to moderate severity. Dysthymic disorder is a extremely unlikely to discuss their level of competence and
mood disorder similar to major depression but it remains progress. These clients focus on self and aren’t envious or
mild to moderate in severity. Cyclothymic disorder is a mood jealous. Individuals with dependent personality disorders
disorder characterized by a mood range from moderate don’t take over situations because they see themselves as
depression to hypomania. Bipolar I disorder is characterized inept and inadequate.
by a single manic episode with no past major depressive
episodes. Seasonalaffective disorder is a form of depression 96. Answer: (C) Assess for possible physical problems such as
occurring in the fall and winter. rash. Clients with schizophrenia generally have poor visceral
recognition because they live so fully in their fantasy world.
87. Answer: (A) Vascular dementia has more abrupt onset. They need to have as in-depth assessment of physical
Vascular dementia differs from Alzheimer’s disease in that it complaints that may spill over into their delusional
has a more abrupt onset and runs a highly variable course. symptoms. Talking with the client won’t provide as
Personally change is common in Alzheimer’s disease. The assessment of his itching, and itching isn’t as adverse
 reaction of antipsychotic drugs, calling the physician to get
the client’s medication increased doesn’t address his physical
complaints.

97. Answer: (B) Echopraxia. Echopraxia is the copying of

another’s behaviors and is the result of the loss of ego
boundaries. Modeling is the conscious copying of someone’s
behaviors. Ego-syntonicity refers to behaviors that
correspond with the individual’s sense of self. Ritualism
behaviors are repetitive and compulsive.

98. Answer: (C) Hallucination. Hallucinations are sensory

experiences that are misrepresentations of reality or have no
basis in reality. Delusions are beliefs not based in reality.
Disorganized speech is characterized by jumping from one
topic to the next or using unrelated words. An idea of
reference is a belief that an unrelated situation holds special
meaning for the client.

99. Answer: (C) Regression. Regression, a return to earlier

behavior to reduce anxiety, is the basic defense mechanism
in schizophrenia. Projection is a defense mechanism in
which one blames others and attempts to justify actions; it’s
used primarily by people with paranoid schizophrenia and
delusional disorder. Rationalization is a defense mechanism
used to justify one’s action. Repression is the basic defense
mechanism in the neuroses; it’s an involuntary exclusion of
painful thoughts, feelings, or experiences from awareness.

100.Answer: (A) Should report feelings of restlessness or

agitation at once. Agitation and restlessness are adverse
effect of haloperidol and can be treated with antocholinergic
drugs. Haloperidol isn’t likely to cause photosensitivity or
control essential hypertension. Although the client may
experience increased concentration and activity, these effects
are due to a decreased in symptoms, not the drug itself.