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Table of Contents
Part 1
Test
Nursing Practice I
Part 2
Nursing Practice I-V
Nursing Practice II
Part 3
Practice Test 1
Answers and Rationale
Practice Test 2
Answers and Rationale
Practice Test 3
Answers and Rationale
Practice Test 4
Answers and Rationale
Foundation of Nursing
Maternal and Child Health
Medical Surgical Nursing
Psychiatric Nursing
PART I
NURSING PRACTICE I
I.V
I.M
Oral
S.C
3. Dr. Garcia writes the following order for the client who has been recently
admitted Digoxin .125 mg P.O. once daily. To prevent a dosage error,
how should the nurse document this order onto the medication
administration record?
a.
b.
c.
d.
4. A newly admitted female client was diagnosed with deep vein thrombosis.
Which nursing diagnosis should receive the highest priority?
a.
b.
c.
d.
5. Nurse Betty is assigned to the following clients. The client that the nurse
would see first after endorsement?
a. A 34 year-old post operative appendectomy client of five hours who
is complaining of pain.
b. A 44 year-old myocardial infarction (MI) client who is complaining of
nausea.
c. A 26 year-old client admitted for dehydration whose intravenous
(IV) has infiltrated.
d. A 63 year-old post operatives abdominal hysterectomy client of
three days whose incisional dressing is saturated with
serosanguinous fluid.
6. Nurse Gail places a client in a four-point restraint following orders from the
physician. The client care plan should include:
a.
b.
c.
d.
9. Tony, a basketball player twist his right ankle while playing on the court
and seeks care for ankle pain and swelling. After the nurse applies ice to
the ankle for 30 minutes, which statement by Tony suggests that ice
application has been effective?
a. My ankle looks less swollen now.
b. My ankle feels warm.
Hypernatremia
Hyperkalemia
Hypokalemia
Hypervolemia
11. She finds out that some managers have benevolent-authoritative style of
management. Which of the following behaviors will she exhibit most likely?
a.
b.
c.
d.
12. Nurse Amy is aware that the following is true about functional nursing
a. Provides continuous, coordinated and comprehensive nursing
services.
b. One-to-one nurse patient ratio.
c. Emphasize the use of group collaboration.
d. Concentrates on tasks and activities.
13. Which type of medication order might read "Vitamin K 10 mg I.M. daily 3
days?"
a.
b.
c.
d.
Single order
Standard written order
Standing order
Stat order
14. A female client with a fecal impaction frequently exhibits which clinical
manifestation?
a.
b.
c.
d.
Increased appetite
Loss of urge to defecate
Hard, brown, formed stools
Liquid or semi-liquid stools
16. Which instruction should nurse Tom give to a male client who is having
external radiation therapy:
a.
b.
c.
d.
17. In assisting a female client for immediate surgery, the nurse In-charge is
aware that she should:
a.
b.
c.
d.
18. A male client is admitted and diagnosed with acute pancreatitis after a
holiday celebration of excessive food and alcohol. Which assessment
finding reflects this diagnosis?
a.
b.
c.
d.
19. Which dietary guidelines are important for nurse Oliver to implement in
caring for the client with burns?
a.
b.
c.
d.
20. Nurse Hazel will administer a unit of whole blood, which priority
information should the nurse have about the client?
a. Blood pressure and pulse rate.
22. A male client is being transferred to the nursing unit for admission after
receiving a radium implant for bladder cancer. The nurse in-charge would
take which priority action in the care of this client?
a.
b.
c.
d.
23. A newly admitted female client was diagnosed with agranulocytosis. The
nurse formulates which priority nursing diagnosis?
a.
b.
c.
d.
Constipation
Diarrhea
Risk for infection
Deficient knowledge
10
c. Democratic.
d. Situational
26. The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The
nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10
cc. How many ccs of KCl will be added to the IV solution?
a.
b.
c.
d.
.5 cc
5 cc
1.5 cc
2.5 cc
50 cc/ hour
55 cc/ hour
24 cc/ hour
66 cc/ hour
28. The nurse is aware that the most important nursing action when a client
returns from surgery is:
a.
b.
c.
d.
29. Which of the following vital sign assessments that may indicate
cardiogenic shock after myocardial infarction?
a.
b.
c.
d.
30. Which is the most appropriate nursing action in obtaining a blood pressure
measurement?
a. Take the proper equipment, place the client in a comfortable
position, and record the appropriate information in the clients chart.
b. Measure the clients arm, if you are not sure of the size of cuff to
use.
c. Have the client recline or sit comfortably in a chair with the forearm
at the level of the heart.
11
Assessment
Evaluation
Implementation
Planning and goals
32. Which of the following item is considered the single most important factor
in assisting the health professional in arriving at a diagnosis or
determining the persons needs?
a.
b.
c.
d.
Stage I
Stage II
Stage III
Stage IV
35. When the method of wound healing is one in which wound edges are not
surgically approximated and integumentary continuity is restored by
granulations, the wound healing is termed
a. Second intention healing
b. Primary intention healing
c. Third intention healing
12
Hypothermia
Hypertension
Distended neck veins
Tachycardia
0.75
0.6
0.5
0.25
38. A male client with diabetes mellitus is receiving insulin. Which statement
correctly describes an insulin unit?
a.
b.
c.
d.
40.1 C
38.9 C
48 C
38 C
40. The nurse is assessing a 48-year-old client who has come to the
physicians office for his annual physical exam. One of the first physical
signs of aging is:
a. Accepting limitations while developing assets.
b. Increasing loss of muscle tone.
c. Failing eyesight, especially close vision.
13
42. Nurse Trish must verify the clients identity before administering
medication. She is aware that the safest way to verify identity is to:
a. Check the clients identification band.
b. Ask the client to state his name.
c. State the clients name out loud and wait a client to repeat it.
d. Check the room number and the clients name on the bed.
43. The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8
hours. The I.V. tubing delivers 15 drops/ml. Nurse John should run the I.V.
infusion at a rate of:
a.
b.
c.
d.
30 drops/minute
32 drops/minute
20 drops/minute
18 drops/minute
45. A female client was recently admitted. She has fever, weight loss, and
watery diarrhea is being admitted to the facility. While assessing the client,
Nurse Hazel inspects the clients abdomen and notice that it is slightly
concave. Additional assessment should proceed in which order:
a.
b.
c.
d.
14
46. Nurse Betty is assessing tactile fremitus in a client with pneumonia. For
this examination, nurse Betty should use the:
a.
b.
c.
d.
Fingertips
Finger pads
Dorsal surface of the hand
Ulnar surface of the hand
47. Which type of evaluation occurs continuously throughout the teaching and
learning process?
a.
b.
c.
d.
Summative
Informative
Formative
Retrospective
48. A 45 year old client, has no family history of breast cancer or other risk
factors for this disease. Nurse John should instruct her to have
mammogram how often?
a.
b.
c.
d.
49. A male client has the following arterial blood gas values: pH 7.30; Pao2 89
mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on these values,
Nurse Patricia should expect which condition?
a.
b.
c.
d.
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
50. Nurse Len refers a female client with terminal cancer to a local hospice.
What is the goal of this referral?
a. To help the client find appropriate treatment options.
b. To provide support for the client and family in coping with terminal
illness.
c. To ensure that the client gets counseling regarding health care
costs.
d. To teach the client and family about cancer and its treatment.
15
51. When caring for a male client with a 3-cm stage I pressure ulcer on the
coccyx, which of the following actions can the nurse institute
independently?
a. Massaging the area with an astringent every 2 hours.
b. Applying an antibiotic cream to the area three times per day.
c. Using normal saline solution to clean the ulcer and applying a
protective dressing as necessary.
d. Using a povidone-iodine wash on the ulceration three times per
day.
52. Nurse Oliver must apply an elastic bandage to a clients ankle and calf. He
should apply the bandage beginning at the clients:
a.
b.
c.
d.
Knee
Ankle
Lower thigh
Foot
53. A 10 year old child with type 1 diabetes develops diabetic ketoacidosis
and receives a continuous insulin infusion. Which condition represents the
greatest risk to this child?
a.
b.
c.
d.
Hypernatremia
Hypokalemia
Hyperphosphatemia
Hypercalcemia
55. Nurse Michelle hears the alarm sound on the telemetry monitor. The nurse
quickly looks at the monitor and notes that a client is in a ventricular
tachycardia. The nurse rushes to the clients room. Upon reaching the
clients bedside, the nurse would take which action first?
a.
b.
c.
d.
16
56. Nurse Hazel is preparing to ambulate a female client. The best and the
safest position for the nurse in assisting the client is to stand:
a.
b.
c.
d.
57. Nurse Janah is monitoring the ongoing care given to the potential organ
donor who has been diagnosed with brain death. The nurse determines
that the standard of care had been maintained if which of the following
data is observed?
a.
b.
c.
d.
58. Nurse Amy has an order to obtain a urinalysis from a male client with an
indwelling urinary catheter. The nurse avoids which of the following, which
contaminate the specimen?
a.
b.
c.
d.
Wiping the port with an alcohol swab before inserting the syringe.
Aspirating a sample from the port on the drainage bag.
Clamping the tubing of the drainage bag.
Obtaining the specimen from the urinary drainage bag.
59. Nurse Meredith is in the process of giving a client a bed bath. In the
middle of the procedure, the unit secretary calls the nurse on the intercom
to tell the nurse that there is an emergency phone call. The appropriate
nursing action is to:
a. Immediately walk out of the clients room and answer the phone
call.
b. Cover the client, place the call light within reach, and answer the
phone call.
c. Finish the bed bath before answering the phone call.
d. Leave the clients door open so the client can be monitored and the
nurse can answer the phone call.
60. Nurse Janah is collecting a sputum specimen for culture and sensitivity
testing from a client who has a productive cough. Nurse Janah plans to
implement which intervention to obtain the specimen?
a. Ask the client to expectorate a small amount of sputum into the
emesis basin.
17
18
65. Nurse Oliver is caring for a client with impaired mobility that occurred as a
result of a stroke. The client has right sided arm and leg weakness. The
nurse would suggest that the client use which of the following assistive
devices that would provide the best stability for ambulating?
a.
b.
c.
d.
Crutches
Single straight-legged cane
Quad cane
Walker
66. A male client with a right pleural effusion noted on a chest X-ray is being
prepared for thoracentesis. The client experiences severe dizziness when
sitting upright. To provide a safe environment, the nurse assists the client
to which position for the procedure?
a.
b.
c.
d.
67. Nurse John develops methods for data gathering. Which of the following
criteria of a good instrument refers to the ability of the instrument to yield
the same results upon its repeated administration?
a.
b.
c.
d.
Validity
Specificity
Sensitivity
Reliability
68. Harry knows that he has to protect the rights of human research subjects.
Which of the following actions of Harry ensures anonymity?
a.
b.
c.
d.
Descriptive- correlational
Experiment
Quasi-experiment
Historical
19
70. Nurse Ronald is aware that the best tool for data gathering is?
a.
b.
c.
d.
Interview schedule
Questionnaire
Use of laboratory data
Observation
71. Monica is aware that there are times when only manipulation of study
variables is possible and the elements of control or randomization are not
attendant. Which type of research is referred to this?
a.
b.
c.
d.
Field study
Quasi-experiment
Solomon-Four group design
Post-test only design
72. Cherry notes down ideas that were derived from the description of an
investigation written by the person who conducted it. Which type of
reference source refers to this?
a.
b.
c.
d.
Footnote
Bibliography
Primary source
Endnotes
73. When Nurse Trish is providing care to his patient, she must remember that
her duty is bound not to do doing any action that will cause the patient
harm. This is the meaning of the bioethical principle:
a.
b.
c.
d.
Non-maleficence
Beneficence
Justice
Solidarity
74. When a nurse in-charge causes an injury to a female patient and the injury
caused becomes the proof of the negligent act, the presence of the injury
is said to exemplify the principle of:
a.
b.
c.
d.
Force majeure
Respondeat superior
Res ipsa loquitor
Holdover doctrine
20
75. Nurse Myrna is aware that the Board of Nursing has quasi-judicial power.
An example of this power is:
a. The Board can issue rules and regulations that will govern the
practice of nursing
b. The Board can investigate violations of the nursing law and code of
ethics
c. The Board can visit a school applying for a permit in collaboration
with CHED
d. The Board prepares the board examinations
76. When the license of nurse Krina is revoked, it means that she:
a. Is no longer allowed to practice the profession for the rest of her life
b. Will never have her/his license re-issued since it has been revoked
c. May apply for re-issuance of his/her license based on certain
conditions stipulated in RA 9173
d. Will remain unable to practice professional nursing
77. Ronald plans to conduct a research on the use of a new method of pain
assessment scale. Which of the following is the second step in the
conceptualizing phase of the research process?
a.
b.
c.
d.
78. The leader of the study knows that certain patients who are in a
specialized research setting tend to respond psychologically to the
conditions of the study. This referred to as :
a.
b.
c.
d.
79. Mary finally decides to use judgment sampling on her research. Which of
the following actions of is correct?
a. Plans to include whoever is there during his study.
b. Determines the different nationality of patients frequently admitted
and decides to get representations samples from each.
c. Assigns numbers for each of the patients, place these in a fishbowl
and draw 10 from it.
21
Florence Nightingale
Madeleine Leininger
Albert Moore
Sr. Callista Roy
81. Marion is aware that the sampling method that gives equal chance to all
units in the population to get picked is:
a.
b.
c.
d.
Random
Accidental
Quota
Judgment
82. John plans to use a Likert Scale to his study to determine the:
a.
b.
c.
d.
83. Which of the following theory addresses the four modes of adaptation?
a.
b.
c.
d.
Madeleine Leininger
Sr. Callista Roy
Florence Nightingale
Jean Watson
84. Ms. Garcia is responsible to the number of personnel reporting to her. This
principle refers to:
a.
b.
c.
d.
Span of control
Unity of command
Downward communication
Leader
85. Ensuring that there is an informed consent on the part of the patient
before a surgery is done, illustrates the bioethical principle of:
a.
b.
c.
d.
Beneficence
Autonomy
Veracity
Non-maleficence
22
86. Nurse Reese is teaching a female client with peripheral vascular disease
about foot care; Nurse Reese should include which instruction?
a.
b.
c.
d.
87. A client is admitted with multiple pressure ulcers. When developing the
client's diet plan, the nurse should include:
a.
b.
c.
d.
88. The nurse prepares to administer a cleansing enema. What is the most
common client position used for this procedure?
a.
b.
c.
d.
Lithotomy
Supine
Prone
Sims left lateral
Independent
Dependent
Interdependent
Intradependent
23
a.
b.
c.
d.
Assessment
Diagnosis
Implementation
Evaluation
92. Nursing care for a female client includes removing elastic stockings once
per day. The Nurse Betty is aware that the rationale for this intervention?
a.
b.
c.
d.
93. Which nursing intervention takes highest priority when caring for a newly
admitted client who's receiving a blood transfusion?
a.
b.
c.
d.
Do nothing.
Invert the vial and let it stand for 3 to 5 minutes.
Shake the vial vigorously.
Roll the vial gently between the palms.
96. Which intervention should the nurse Trish use when administering oxygen
by face mask to a female client?
a. Secure the elastic band tightly around the client's head.
b. Assist the client to the semi-Fowler position if possible.
c. Apply the face mask from the client's chin up over the nose.
24
6 hours
4 hours
3 hours
2 hours
99. Nurse May is aware that the main advantage of using a floor stock system
is:
a.
b.
c.
d.
100. Nurse Oliver is assessing a client's abdomen. Which finding should the
nurse report as abnormal?
a.
b.
c.
d.
25
NURSING PRACTICE II
26
TEST II - Community Health Nursing and Care of the Mother and Child
1. May arrives at the health care clinic and tells the nurse that her last
menstrual period was 9 weeks ago. She also tells the nurse that a home
pregnancy test was positive but she began to have mild cramps and is
now having moderate vaginal bleeding. During the physical examination of
the client, the nurse notes that May has a dilated cervix. The nurse
determines that May is experiencing which type of abortion?
a.
b.
c.
d.
Inevitable
Incomplete
Threatened
Septic
2. Nurse Reese is reviewing the record of a pregnant client for her first
prenatal visit. Which of the following data, if noted on the clients record,
would alert the nurse that the client is at risk for a spontaneous abortion?
a.
b.
c.
d.
Age 36 years
History of syphilis
History of genital herpes
History of diabetes mellitus
3. Nurse Hazel is preparing to care for a client who is newly admitted to the
hospital with a possible diagnosis of ectopic pregnancy. Nurse Hazel
develops a plan of care for the client and determines that which of the
following nursing actions is the priority?
a.
b.
c.
d.
Monitoring weight
Assessing for edema
Monitoring apical pulse
Monitoring temperature
27
Ventilator assistance
CVP readings
EKG tracings
Continuous CPR
28
10. A trial for vaginal delivery after an earlier caesareans, would likely to be
given to a gravida, who had:
a. First low transverse cesarean was for active herpes type 2
infections; vaginal culture at 39 weeks pregnancy was positive.
b. First and second caesareans were for cephalopelvic disproportion.
c. First caesarean through a classic incision as a result of severe fetal
distress.
d. First low transverse caesarean was for breech position. Fetus in
this pregnancy is in a vertex presentation.
11. Nurse Ryan is aware that the best initial approach when trying to take a
crying toddlers temperature is:
a.
b.
c.
d.
12. Baby Tina a 3 month old infant just had a cleft lip and palate repair. What
should the nurse do to prevent trauma to operative site?
a.
b.
c.
d.
13. Which action should nurse Marian include in the care plan for a 2 month
old with heart failure?
a.
b.
c.
d.
14. Nurse Hazel is teaching a mother who plans to discontinue breast feeding
after 5 months. The nurse should advise her to include which foods in her
infants diet?
a.
b.
c.
d.
15. Mommy Linda is playing with her infant, who is sitting securely alone on
the floor of the clinic. The mother hides a toy behind her back and the
29
infant looks for it. The nurse is aware that estimated age of the infant
would be:
a.
b.
c.
d.
6 months
4 months
8 months
10 months
16. Which of the following is the most prominent feature of public health
nursing?
a. It involves providing home care to sick people who are not confined
in the hospital.
b. Services are provided free of charge to people within the
catchments area.
c. The public health nurse functions as part of a team providing a
public health nursing services.
d. Public health nursing focuses on preventive, not curative, services.
17. When the nurse determines whether resources were maximized in
implementing Ligtas Tigdas, she is evaluating
a.
b.
c.
d.
Effectiveness
Efficiency
Adequacy
Appropriateness
18. Vangie is a new B.S.N. graduate. She wants to become a Public Health
Nurse. Where should she apply?
a.
b.
c.
d.
Department of Health
Provincial Health Office
Regional Health Office
Rural Health Unit
19. Tony is aware the Chairman of the Municipal Health Board is:
a.
b.
c.
d.
Mayor
Municipal Health Officer
Public Health Nurse
Any qualified physician
20. Myra is the public health nurse in a municipality with a total population of
about 20,000. There are 3 rural health midwives among the RHU
personnel. How many more midwife items will the RHU need?
30
a.
b.
c.
d.
1
2
3
The RHU does not need any more midwife item.
Poliomyelitis
Measles
Rabies
Neonatal tetanus
23. May knows that the step in community organizing that involves training of
potential leaders in the community is:
a.
b.
c.
d.
Integration
Community organization
Community study
Core group formation
24. Beth a public health nurse takes an active role in community participation.
What is the primary goal of community organizing?
a. To educate the people regarding community health problems
b. To mobilize the people to resolve community health problems
c. To maximize the communitys resources in dealing with health
problems.
d. To maximize the communitys resources in dealing with health
problems.
31
Pre-pathogenesis
Pathogenesis
Prodromal
Terminal
26. The nurse is caring for a primigravid client in the labor and delivery area.
Which condition would place the client at risk for disseminated
intravascular coagulation (DIC)?
a.
b.
c.
d.
27. A fullterm client is in labor. Nurse Betty is aware that the fetal heart rate
would be:
a.
b.
c.
d.
80 to 100 beats/minute
100 to 120 beats/minute
120 to 160 beats/minute
160 to 180 beats/minute
28. The skin in the diaper area of a 7 month old infant is excoriated and red.
Nurse Hazel should instruct the mother to:
a.
b.
c.
d.
29. Nurse Carla knows that the common cardiac anomalies in children with
Down Syndrome (tri-somy 21) is:
a.
b.
c.
d.
30. Malou was diagnosed with severe preeclampsia is now receiving I.V.
magnesium sulfate. The adverse effects associated with magnesium
sulfate is:
a. Anemia
32
Menorrhagia
Metrorrhagia
Dyspareunia
Amenorrhea
32. Jannah is admitted to the labor and delivery unit. The critical laboratory
result for this client would be:
a.
b.
c.
d.
Oxygen saturation
Iron binding capacity
Blood typing
Serum Calcium
33. Nurse Gina is aware that the most common condition found during the
second-trimester of pregnancy is:
a.
b.
c.
d.
Metabolic alkalosis
Respiratory acidosis
Mastitis
Physiologic anemia
Placenta previa
Abruptio placentae
Premature labor
Sexually transmitted disease
33
Drooling
Muffled voice
Restlessness
Low-grade fever
40. How should Nurse Michelle guide a child who is blind to walk to the
playroom?
a. Without touching the child, talk continuously as the child walks
down the hall.
b. Walk one step ahead, with the childs hand on the nurses elbow.
c. Walk slightly behind, gently guiding the child forward.
d. Walk next to the child, holding the childs hand.
34
42. The reason nurse May keeps the neonate in a neutral thermal
environment is that when a newborn becomes too cool, the neonate
requires:
a.
b.
c.
d.
43. Before adding potassium to an infants I.V. line, Nurse Ron must be sure
to assess whether this infant has:
a.
b.
c.
d.
44. Nurse Carla should know that the most common causative factor of
dermatitis in infants and younger children is:
a.
b.
c.
d.
Baby oil
Baby lotion
Laundry detergent
Powder with cornstarch
45. During tube feeding, how far above an infants stomach should the nurse
hold the syringe with formula?
a.
b.
c.
d.
6 inches
12 inches
18 inches
24 inches
35
48. Myrna a public health nurse knows that to determine possible sources of
sexually transmitted infections, the BEST method that may be undertaken
is:
a.
b.
c.
d.
Contact tracing
Community survey
Mass screening tests
Interview of suspects
49. A 33-year old female client came for consultation at the health center with
the chief complaint of fever for a week. Accompanying symptoms were
muscle pains and body malaise. A week after the start of fever, the client
noted yellowish discoloration of his sclera. History showed that he waded
in flood waters about 2 weeks before the onset of symptoms. Based on
her history, which disease condition will you suspect?
a.
b.
c.
d.
Hepatitis A
Hepatitis B
Tetanus
Leptospirosis
50. Mickey a 3-year old client was brought to the health center with the chief
complaint of severe diarrhea and the passage of rice water stools. The
client is most probably suffering from which condition?
a. Giardiasis
b. Cholera
c. Amebiasis
36
d. Dysentery
51. The most prevalent form of meningitis among children aged 2 months to 3
years is caused by which microorganism?
a.
b.
c.
d.
Hemophilus influenzae
Morbillivirus
Steptococcus pneumoniae
Neisseria meningitidis
52. The student nurse is aware that the pathognomonic sign of measles is
Kopliks spot and you may see Kopliks spot by inspecting the:
a.
b.
c.
d.
Nasal mucosa
Buccal mucosa
Skin on the abdomen
Skin on neck
53. Angel was diagnosed as having Dengue fever. You will say that there is
slow capillary refill when the color of the nailbed that you pressed does not
return within how many seconds?
a.
b.
c.
d.
3 seconds
6 seconds
9 seconds
10 seconds
Mastoiditis
Severe dehydration
Severe pneumonia
Severe febrile disease
45 infants
50 infants
55 infants
65 infants
37
56. The community nurse is aware that the biological used in Expanded
Program on Immunization (EPI) should NOT be stored in the freezer?
a.
b.
c.
d.
DPT
Oral polio vaccine
Measles vaccine
MMR
Use of molluscicides
Building of foot bridges
Proper use of sanitary toilets
Use of protective footwear, such as rubber boots
58. Several clients is newly admitted and diagnosed with leprosy. Which of the
following clients should be classified as a case of multibacillary leprosy?
a.
b.
c.
d.
Macular lesions
Inability to close eyelids
Thickened painful nerves
Sinking of the nosebridge
60. Marie brought her 10 month old infant for consultation because of fever,
started 4 days prior to consultation. In determining malaria risk, what will
you do?
a.
b.
c.
d.
61. Susie brought her 4 years old daughter to the RHU because of cough and
colds. Following the IMCI assessment guide, which of the following is a
danger sign that indicates the need for urgent referral to a hospital?
38
a.
b.
c.
d.
Inability to drink
High grade fever
Signs of severe dehydration
Cough for more than 30 days
62. Jimmy a 2-year old child revealed baggy pants. As a nurse, using the
IMCI guidelines, how will you manage Jimmy?
a. Refer the child urgently to a hospital for confinement.
b. Coordinate with the social worker to enroll the child in a feeding
program.
c. Make a teaching plan for the mother, focusing on menu planning for
her child.
d. Assess and treat the child for health problems like infections and
intestinal parasitism.
63. Gina is using Oresol in the management of diarrhea of her 3-year old
child. She asked you what to do if her child vomits. As a nurse you will tell
her to:
a.
b.
c.
d.
64. Nikki a 5-month old infant was brought by his mother to the health center
because of diarrhea for 4 to 5 times a day. Her skin goes back slowly after
a skin pinch and her eyes are sunken. Using the IMCI guidelines, you will
classify this infant in which category?
a.
b.
c.
d.
No signs of dehydration
Some dehydration
Severe dehydration
The data is insufficient.
65. Chris a 4-month old infant was brought by her mother to the health center
because of cough. His respiratory rate is 42/minute. Using the Integrated
Management of Child Illness (IMCI) guidelines of assessment, his
breathing is considered as:
a.
b.
c.
d.
Fast
Slow
Normal
Insignificant
39
66. Maylene had just received her 4th dose of tetanus toxoid. She is aware
that her baby will have protection against tetanus for
a.
b.
c.
d.
1 year
3 years
5 years
Lifetime
67. Nurse Ron is aware that unused BCG should be discarded after how
many hours of reconstitution?
a.
b.
c.
d.
2 hours
4 hours
8 hours
At the end of the day
68. The nurse explains to a breastfeeding mother that breast milk is sufficient
for all of the babys nutrient needs only up to:
a.
b.
c.
d.
5 months
6 months
1 year
2 years
69. Nurse Ron is aware that the gestational age of a conceptus that is
considered viable (able to live outside the womb) is:
a.
b.
c.
d.
8 weeks
12 weeks
24 weeks
32 weeks
70. When teaching parents of a neonate the proper position for the neonates
sleep, the nurse Patricia stresses the importance of placing the neonate
on his back to reduce the risk of which of the following?
a.
b.
c.
d.
Aspiration
Sudden infant death syndrome (SIDS)
Suffocation
Gastroesophageal reflux (GER)
40
c. Decreased temperature
d. Increased activity level
72. Baby Jenny who is small-for-gestation is at increased risk during the
transitional period for which complication?
a.
b.
c.
d.
73. Marjorie has just given birth at 42 weeks gestation. When the nurse
assessing the neonate, which physical finding is expected?
a.
b.
c.
d.
74. After reviewing the Myrnas maternal history of magnesium sulfate during
labor, which condition would nurse Richard anticipate as a potential
problem in the neonate?
a.
b.
c.
d.
Hypoglycemia
Jitteriness
Respiratory depression
Tachycardia
75. Which symptom would indicate the Baby Alexandra was adapting
appropriately to extra-uterine life without difficulty?
a.
b.
c.
d.
Nasal flaring
Light audible grunting
Respiratory rate 40 to 60 breaths/minute
Respiratory rate 60 to 80 breaths/minute
76. When teaching umbilical cord care for Jennifer a new mother, the nurse
Jenny would include which information?
a.
b.
c.
d.
41
a.
b.
c.
d.
Simian crease
Conjunctival hemorrhage
Cystic hygroma
Bulging fontanelle
78. Dr. Esteves decides to artificially rupture the membranes of a mother who
is on labor. Following this procedure, the nurse Hazel checks the fetal
heart tones for which the following reasons?
a.
b.
c.
d.
79. Which of the following would be least likely to indicate anticipated bonding
behaviors by new parents?
a.
b.
c.
d.
82. A neonate begins to gag and turns a dusky color. What should the nurse
do first?
42
a.
b.
c.
d.
83. When
a client states that her "water broke," which of the following actions
would be inappropriate for the nurse to do?
a.
b.
c.
d.
84. A baby girl is born 8 weeks premature. At birth, she has no spontaneous
respirations but is successfully resuscitated. Within several hours she develops
respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. She's
diagnosed with respiratory distress syndrome, intubated, and placed on a
ventilator. Which nursing action should be included in the baby's plan of care to
prevent retinopathy of prematurity?
a.
b.
c.
d.
86. Nurse John is knowledgeable that usually individual twins will grow
appropriately and at the same rate as singletons until how many weeks?
a. 16 to 18 weeks
b. 18 to 22 weeks
c.
30 to 32 weeks
d. 38 to 40 weeks
87. Which of the following classifications applies to monozygotic twins for whom
the cleavage of the fertilized ovum occurs more than 13 days after fertilization?
a. conjoined twins
b. diamniotic dichorionic twins
43
Amniocentesis
Digital or speculum examination
External fetal monitoring
Ultrasound
89. Nurse Arnold knows that the following changes in respiratory functioning
during pregnancy is considered normal:
a.
b.
c.
d.
90. Emily has gestational diabetes and it is usually managed by which of the
following therapy?
a.
b.
c.
d.
Diet
Long-acting insulin
Oral hypoglycemic
Oral hypoglycemic drug and insulin
Hemorrhage
Hypertension
Hypomagnesemia
Seizure
92. Cammile with sickle cell anemia has an increased risk for having a sickle cell
crisis during pregnancy. Aggressive management of a sickle cell crisis includes
which of the following measures?
a.
b.
c.
d.
Antihypertensive agents
Diuretic agents
I.V. fluids
Acetaminophen (Tylenol) for pain
44
93. Which of the following drugs is the antidote for magnesium toxicity?
a.
b.
c.
d.
94. Marlyn is screened for tuberculosis during her first prenatal visit. An
intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is
given. She is considered to have a positive test for which of the following results?
a. An indurated wheal under 10 mm in diameter appears in 6 to 12 hours.
b. An indurated wheal over 10 mm in diameter appears in 48 to 72 hours.
c. A flat circumcised area under 10 mm in diameter appears in 6 to 12
hours.
d. A flat circumcised area over 10 mm in diameter appears in 48 to 72
hours.
95. Dianne, 24 year-old is 27 weeks pregnant arrives at her physicians office
with complaints of fever, nausea, vomiting, malaise, unilateral flank pain, and
costovertebral angle tenderness. Which of the following diagnoses is most likely?
a.
b.
c.
d.
Asymptomatic bacteriuria
Bacterial vaginosis
Pyelonephritis
Urinary tract infection (UTI)
45
d. Standing position
98. Celeste who used heroin during her pregnancy delivers a neonate. When
assessing the neonate, the nurse Lhynnette expects to find:
a.
b.
c.
d.
99. The uterus returns to the pelvic cavity in which of the following time frames?
a.
b.
c.
d.
100. Maureen, a primigravida client, age 20, has just completed a difficult,
forceps-assisted delivery of twins. Her labor was unusually long and required
oxytocin (Pitocin) augmentation. The nurse who's caring for her should stay alert
for:
a.
b.
c.
d.
Uterine inversion
Uterine atony
Uterine involution
Uterine discomfort
46
47
Green liquid
Solid formed
Loose, bloody
Semiformed
2. Where would nurse Kristine place the call light for a male client with a
right-sided brain attack and left homonymous hemianopsia?
a.
b.
c.
d.
48
10. While monitoring a male client several hours after a motor vehicle
accident, which assessment data suggest increasing intracranial
pressure?
a. Blood pressure is decreased from 160/90 to 110/70.
b. Pulse is increased from 87 to 95, with an occasional skipped beat.
c. The client is oriented when aroused from sleep, and goes back to
sleep immediately.
d. The client refuses dinner because of anorexia.
11. Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the
following symptoms may appear first?
a. Altered mental status and dehydration
49
Acute asthma
Bronchial pneumonia
Chronic obstructive pulmonary disease (COPD)
Emphysema
14. Marichu was given morphine sulfate for pain. She is sleeping and her
respiratory rate is 4 breaths/minute. If action isnt taken quickly, she might have
which of the following reactions?
a.
b.
c.
d.
Asthma attack
Respiratory arrest
Seizure
Wake up on his own
15. A 77-year-old male client is admitted for elective knee surgery. Physical
examination reveals shallow respirations but no sign of respiratory distress.
Which of the following is a normal physiologic change related to aging?
a.
b.
c.
d.
16. Nurse John is caring for a male client receiving lidocaine I.V. Which factor is
the most relevant to administration of this medication?
a. Decrease in arterial oxygen saturation (SaO2) when measured with a
pulse oximeter.
b. Increase in systemic blood pressure.
50
18. Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter. The
nurse should treat excess hair at the site by:
a.
b.
c.
d.
19. Nurse Michelle is caring for an elderly female with osteoporosis. When
teaching the client, the nurse should include information about which major
complication:
a.
b.
c.
d.
Bone fracture
Loss of estrogen
Negative calcium balance
Dowagers hump
20. Nurse Len is teaching a group of women to perform BSE. The nurse should
explain that the purpose of performing the examination is to discover:
a.
b.
c.
d.
Cancerous lumps
Areas of thickness or fullness
Changes from previous examinations.
Fibrocystic masses
21. When caring for a female client who is being treated for hyperthyroidism, it is
important to:
a. Provide extra blankets and clothing to keep the client warm.
b. Monitor the client for signs of restlessness, sweating, and excessive
weight loss during thyroid replacement therapy.
c. Balance the clients periods of activity and rest.
d. Encourage the client to be active to prevent constipation.
51
23. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client
following a:
a.
b.
c.
d.
Laminectomy
Thoracotomy
Hemorrhoidectomy
Cystectomy.
24. A 55-year old client underwent cataract removal with intraocular lens implant.
Nurse Oliver is giving the client discharge instructions. These instructions should
include which of the following?
a.
b.
c.
d.
26. A male client undergone a colon resection. While turning him, wound
dehiscence with evisceration occurs. Nurse Trish first response is to:
a.
b.
c.
d.
27. Nurse Audrey is caring for a client who has suffered a severe
cerebrovascular accident. During routine assessment, the nurse notices CheyneStrokes respirations. Cheyne-strokes respirations are:
a. A progressively deeper breaths followed by shallower breaths with
apneic periods.
52
Tracheal
Fine crackles
Coarse crackles
Friction rubs
29. The nurse is caring for Kenneth experiencing an acute asthma attack. The
client stops wheezing and breath sounds arent audible. The reason for this
change is that:
a.
b.
c.
d.
30. Mike with epilepsy is having a seizure. During the active seizure phase, the
nurse should:
a. Place the client on his back remove dangerous objects, and insert a
bite block.
b. Place the client on his side, remove dangerous objects, and insert a
bite block.
c. Place the client o his back, remove dangerous objects, and hold down
his arms.
d. Place the client on his side, remove dangerous objects, and protect his
head.
31. After insertion of a cheat tube for a pneumothorax, a client becomes
hypotensive with neck vein distention, tracheal shift, absent breath sounds, and
diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred.
What cause of tension pneumothorax should the nurse check for?
a.
b.
c.
d.
32. Nurse Maureen is talking to a male client, the client begins choking on his
lunch. Hes coughing forcefully. The nurse should:
53
a. Stand him up and perform the abdominal thrust maneuver from behind.
b. Lay him down, straddle him, and perform the abdominal thrust
maneuver.
c. Leave him to get assistance
d. Stay with him but not intervene at this time.
33. Nurse Ron is taking a health history of an 84 year old client. Which
information will be most useful to the nurse for planning care?
a.
b.
c.
d.
34. When performing oral care on a comatose client, Nurse Krina should:
a. Apply lemon glycerin to the clients lips at least every 2 hours.
b. Brush the teeth with client lying supine.
c. Place the client in a side lying position, with the head of the bed
lowered.
d. Clean the clients mouth with hydrogen peroxide.
35. A 77-year-old male client is admitted with a diagnosis of dehydration and
change in mental status. Hes being hydrated with L.V. fluids. When the nurse
takes his vital signs, she notes he has a fever of 103F (39.4C) a cough
producing yellow sputum and pleuritic chest pain. The nurse suspects this client
may have which of the following conditions?
a.
b.
c.
d.
36. Nurse Oliver is working in a out patient clinic. He has been alerted that there
is an outbreak of tuberculosis (TB). Which of the following clients entering the
clinic today most likely to have TB?
a.
b.
c.
d.
37. Virgie with a positive Mantoux test result will be sent for a chest X-ray. The
nurse is aware that which of the following reasons this is done?
a. To confirm the diagnosis
54
Beta-adrenergic blockers
Bronchodilators
Inhaled steroids
Oral steroids
39. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two
packs of cigarettes per day has a chronic cough producing thick sputum,
peripheral edema and cyanotic nail beds. Based on this information, he most
likely has which of the following conditions?
a.
b.
c.
d.
41. After several days of admission, Francis becomes disoriented and complains
of frequent headaches. The nurse in-charge first action would be:
a.
b.
c.
d.
42. During routine care, Francis asks the nurse, How can I be anemic if this
disease causes increased my white blood cell production? The nurse in-charge
best response would be that the increased number of white blood cells (WBC) is:
55
a.
b.
c.
d.
Predominance of lymhoblasts
Leukocytosis
Abnormal blast cells in the bone marrow
Elevated thrombocyte counts
44. Robert, a 57-year-old client with acute arterial occlusion of the left leg
undergoes an emergency embolectomy. Six hours later, the nurse isnt able to
obtain pulses in his left foot using Doppler ultrasound. The nurse immediately
notifies the physician, and asks her to prepare the client for surgery. As the nurse
enters the clients room to prepare him, he states that he wont have any more
surgery. Which of the following is the best initial response by the nurse?
a.
b.
c.
d.
45. During the endorsement, which of the following clients should the on-duty
nurse assess first?
a. The 58-year-old client who was admitted 2 days ago with heart failure,
blood pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/
minute.
b. The 89-year-old client with end-stage right-sided heart failure, blood
pressure of 78/50 mm Hg, and a do not resuscitate order
c. The 62-year-old client who was admitted 1 day ago with
thrombophlebitis and is receiving L.V. heparin
d. The 75-year-old client who was admitted 1 hour ago with new-onset
atrial fibrillation and is receiving L.V. dilitiazem (Cardizem)
46. Honey, a 23-year old client complains of substernal chest pain and states
that her heart feels like its racing out of the chest. She reports no history of
cardiac disorders. The nurse attaches her to a cardiac monitor and notes sinus
tachycardia with a rate of 136beats/minutes. Breath sounds are clear and the
respiratory rate is 26 breaths/minutes. Which of the following drugs should the
nurse question the client about using?
a. Barbiturates
56
b. Opioids
c. Cocaine
d. Benzodiazepines
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 self-examination. Which
assessment finding would strongly suggest that this client's lump is cancerous?
a.
b.
c.
d.
48. A 35-year-old client with vaginal cancer asks the nurse, "What is the usual
treatment for this type of cancer?" Which treatment should the nurse name?
a.
b.
c.
d.
Surgery
Chemotherapy
Radiation
Immunotherapy
57
51. A 37-year-old client with uterine cancer asks the nurse, "Which is the most
common type of cancer in women?" The nurse replies that it's breast cancer.
Which type of cancer causes the most deaths in women?
a.
b.
c.
d.
Breast cancer
Lung cancer
Brain cancer
Colon and rectal cancer
52. Antonio with lung cancer develops Horner's syndrome when the tumor
invades the ribs and affects the sympathetic nerve ganglia. When assessing for
signs and symptoms of this syndrome, the nurse should note:
a. miosis, partial eyelid ptosis, and anhidrosis on the affected side of the
face.
b. chest pain, dyspnea, cough, weight loss, and fever.
c. arm and shoulder pain and atrophy of arm and hand muscles, both on
the affected side.
d. hoarseness and dysphagia.
53. Vic asks the nurse what PSA is. The nurse should reply that it stands for:
a. prostate-specific antigen, which is used to screen for prostate cancer.
b. protein serum antigen, which is used to determine protein levels.
c. pneumococcal strep antigen, which is a bacteria that causes
pneumonia.
d. Papanicolaou-specific antigen, which is used to screen for cervical
cancer.
54. What is the most important postoperative instruction that nurse Kate must
give a client who has just returned from the operating room after receiving a
subarachnoid block?
a.
b.
c.
d.
55. A male client suspected of having colorectal cancer will require which
diagnostic study to confirm the diagnosis?
a.
b.
c.
d.
Stool Hematest
Carcinoembryonic antigen (CEA)
Sigmoidoscopy
Abdominal computed tomography (CT) scan
58
56. During a breast examination, which finding most strongly suggests that the
Luz has breast cancer?
a. Slight asymmetry of the breasts.
b. A fixed nodular mass with dimpling of the overlying skin
c. Bloody discharge from the nipple
d. Multiple firm, round, freely movable masses that change with the
menstrual cycle
57. A female client with cancer is being evaluated for possible metastasis. Which
of the following is one of the most common metastasis sites for cancer cells?
a.
b.
c.
d.
Liver
Colon
Reproductive tract
White blood cells (WBCs)
58. Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to
confirm or rule out a spinal cord lesion. During the MRI scan, which of the
following would pose a threat to the client?
a.
b.
c.
d.
59
61. Mr. Rodriguez is admitted with severe pain in the knees. Which form of
arthritis is characterized by urate deposits and joint pain, usually in the feet and
legs, and occurs primarily in men over age 30?
a.
b.
c.
d.
Septic arthritis
Traumatic arthritis
Intermittent arthritis
Gouty arthritis
62. A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old client with
stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of
saline solution. How many milliliters per hour should be given?
a. 15 ml/hour
b. 30 ml/hour
c. 45 ml/hour
d. 50 ml/hour
63. A 76-year-old male client had a thromboembolic right stroke; his left arm is
swollen. Which of the following conditions may cause swelling after a stroke?
a.
b.
c.
d.
64. Heberdens nodes are a common sign of osteoarthritis. Which of the following
statement is correct about this deformity?
a.
b.
c.
d.
65. Which of the following statements explains the main difference between
rheumatoid arthritis and osteoarthritis?
a.
b.
c.
d.
66. Mrs. Cruz uses a cane for assistance in walking. Which of the following
statements is true about a cane or other assistive devices?
60
a.
b.
c.
d.
aspirin
furosemide (Lasix)
colchicines
calcium gluconate (Kalcinate)
Adrenal cortex
Pancreas
Adrenal medulla
Parathyroid
70. For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wetto-dry dressing change every shift, and blood glucose monitoring before meals
and bedtime. Why are wet-to-dry dressings used for this client?
a.
b.
c.
d.
71. Nurse Zeny is caring for a client in acute addisonian crisis. Which laboratory
data would the nurse expect to find?
a. Hyperkalemia
61
73. A female client tells nurse Nikki that she has been working hard for the last 3
months to control her type 2 diabetes mellitus with diet and exercise. To
determine the effectiveness of the client's efforts, the nurse should check:
a.
b.
c.
d.
10:00 am
Noon
4:00 pm
10:00 pm
76. On the third day after a partial thyroidectomy, Proserfina exhibits muscle
twitching and hyperirritability of the nervous system. When questioned, the client
reports numbness and tingling of the mouth and fingertips. Suspecting a lifethreatening electrolyte disturbance, the nurse notifies the surgeon immediately.
Which electrolyte disturbance most commonly follows thyroid surgery?
a. Hypocalcemia
b. Hyponatremia
c. Hyperkalemia
62
d. Hypermagnesemia
77. Which laboratory test value is elevated in clients who smoke and can't be
used as a general indicator of cancer?
a.
b.
c.
d.
78. Francis with anemia has been admitted to the medical-surgical unit. Which
assessment findings are characteristic of iron-deficiency anemia?
a.
b.
c.
d.
79. In teaching a female client who is HIV-positive about pregnancy, the nurse
would know more teaching is necessary when the client says:
a. The baby can get the virus from my placenta."
b. "I'm planning on starting on birth control pills."
c. "Not everyone who has the virus gives birth to a baby who has the
virus."
d. "I'll need to have a C-section if I become pregnant and have a baby."
80. When preparing Judy with acquired immunodeficiency syndrome (AIDS) for
discharge to the home, the nurse should be sure to include which instruction?
a.
b.
c.
d.
81. Nurse Marie is caring for a 32-year-old client admitted with pernicious
anemia. Which set of findings should the nurse expect when assessing the
client?
a.
b.
c.
d.
63
weight gain.
fine motor tremors.
respiratory acidosis.
bilateral hearing loss.
Neutrophil
Basophil
Monocyte
Lymphocyte
85. In an individual with Sjgren's syndrome, nursing care should focus on:
a.
b.
c.
d.
moisture replacement.
electrolyte balance.
nutritional supplementation.
arrhythmia management.
64
E-rosette immunofluorescence.
quantification of T-lymphocytes.
enzyme-linked immunosorbent assay (ELISA).
Western blot test with ELISA.
88. A complete blood count is commonly performed before a Joe goes into
surgery. What does this test seek to identify?
a. Potential hepatic dysfunction indicated by decreased blood urea
nitrogen (BUN) and creatinine levels
b. Low levels of urine constituents normally excreted in the urine
c. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
d. Electrolyte imbalance that could affect the blood's ability to coagulate
properly
89. While monitoring a client for the development of disseminated intravascular
coagulation (DIC), the nurse should take note of what assessment parameters?
a.
b.
c.
d.
90. When taking a dietary history from a newly admitted female client, Nurse Len
should remember that which of the following foods is a common allergen?
a.
b.
c.
d.
Bread
Carrots
Orange
Strawberries
91. Nurse John is caring for clients in the outpatient clinic. Which of the following
phone calls should the nurse return first?
a. A client with hepatitis A who states, My arms and legs are itching.
b. A client with cast on the right leg who states, I have a funny feeling in
my right leg.
c. A client with osteomyelitis of the spine who states, I am so nauseous
that I cant eat.
65
95. Nurse Tina prepares a client for peritoneal dialysis. Which of the following
actions should the nurse take first?
a.
b.
c.
d.
66
96. Nurse Jannah teaches an elderly client with right-sided weakness how to use
cane. Which of the following behaviors, if demonstrated by the client to the nurse,
indicates that the teaching was effective?
a. The client holds the cane with his right hand, moves the can forward
followed by the right leg, and then moves the left leg.
b. The client holds the cane with his right hand, moves the cane forward
followed by his left leg, and then moves the right leg.
c. The client holds the cane with his left hand, moves the cane forward
followed by the right leg, and then moves the left leg.
d. The client holds the cane with his left hand, moves the cane forward
followed by his left leg, and then moves the right leg.
97. An elderly client is admitted to the nursing home setting. The client is
occasionally confused and her gait is often unsteady. Which of the following
actions, if taken by the nurse, is most appropriate?
a. Ask the womans 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 nurses 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.
b.
c.
d.
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100. A male client with emphysema becomes restless and confused. What step
should nurse Jasmine take next?
a.
b.
c.
d.
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NURSING PRACTICE IV
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Pain
Weight
Hematuria
Hypertension
4. Ricardo, was diagnosed with type I diabetes. The nurse is aware that
acute hypoglycemia also can develop in the client who is diagnosed with:
a.
b.
c.
d.
Liver disease
Hypertension
Type 2 diabetes
Hyperthyroidism
Ascites
Nystagmus
Leukopenia
Polycythemia
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Administer Kayexalate
Restrict foods high in protein
Increase oral intake of cheese and milk.
Administer large amounts of normal saline via I.V.
9. Mario has burn injury. After Forty48 hours, the physician orders for Mario
2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is
10 gtt/ml. The nurse should set the flow to provide:
a. 18 gtt/min
b. 28 gtt/min
c. 32 gtt/min
d. 36 gtt/min
10. Terence suffered form burn injury. Using the rule of nines, which has the
largest percent of burns?
a. Face and neck
b. Right upper arm and penis
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72
a.
b.
c.
d.
16. Nurse Tristan is caring for a male client in acute renal failure. The nurse
should expect hypertonic glucose, insulin infusions, and sodium
bicarbonate to be used to treat:
a.
b.
c.
d.
hypernatremia.
hypokalemia.
hyperkalemia.
hypercalcemia.
17. Ms. X has just been diagnosed with condylomata acuminata (genital
warts). What information is appropriate to tell this client?
a. This condition puts her at a higher risk for cervical cancer;
therefore, she should have a Papanicolaou (Pap) smear annually.
b. The most common treatment is metronidazole (Flagyl), which
should eradicate the problem within 7 to 10 days.
c. The potential for transmission to her sexual partner will be
eliminated if condoms are used every time they have sexual
intercourse.
d. The human papillomavirus (HPV), which causes condylomata
acuminata, can't be transmitted during oral sex.
18. Maritess was recently diagnosed with a genitourinary problem and is
being examined in the emergency department. When palpating the her
kidneys, the nurse should keep which anatomical fact in mind?
a. The left kidney usually is slightly higher than the right one.
b. The kidneys are situated just above the adrenal glands.
c. The average kidney is approximately 5 cm (2") long and 2 to 3 cm
(" to 1-1/8") wide.
d. The kidneys lie between the 10th and 12th thoracic vertebrae.
19. Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The
nurse is aware that the diagnostic test are consistent with CRF if the result
is:
a. Increased pH with decreased hydrogen ions.
b. Increased serum levels of potassium, magnesium, and calcium.
c. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/
dl.
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To prevent confusion
To prevent seizures
To prevent cerebrospinal fluid (CSF) leakage
To prevent cardiac arrhythmias
23. A male client had a nephrectomy 2 days ago and is now complaining of
abdominal pressure and nausea. The first nursing action should be to:
a.
b.
c.
d.
24. Wilfredo with a recent history of rectal bleeding is being prepared for a
colonoscopy. How should the nurse Patricia position the client for this test
initially?
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a.
b.
c.
d.
26. Anthony suffers burns on the legs, which nursing intervention helps
prevent contractures?
a.
b.
c.
d.
27. Nurse Ron is assessing a client admitted with second- and third-degree
burns on the face, arms, and chest. Which finding indicates a potential
problem?
a.
b.
c.
d.
28. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too
weak to move on his own. To help the client avoid pressure ulcers, Nurse
Celia should:
a.
b.
c.
d.
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31. A male client has jugular distention. On what position should the nurse
place the head of the bed to obtain the most accurate reading of jugular
vein distention?
a.
b.
c.
d.
High Fowlers
Raised 10 degrees
Raised 30 degrees
Supine position
32. The nurse is aware that one of the following classes of medications
maximizes cardiac performance in clients with heart failure by increasing
ventricular contractility?
a.
b.
c.
d.
Beta-adrenergic blockers
Calcium channel blocker
Diuretics
Inotropic agents
33. A male client has a reduced serum high-density lipoprotein (HDL) level
and an elevated low-density lipoprotein (LDL) level. Which of the following
dietary modifications is not appropriate for this client?
a. Fiber intake of 25 to 30 g daily
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46 mm Hg
80 mm Hg
95 mm Hg
90 mm Hg
37. A female client arrives at the emergency department with chest and stomach
pain and a report of black tarry stool for several months. Which of the following
order should the nurse Oliver anticipate?
a. Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase levels
b. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split
product values.
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Pancytopenia
Idiopathic thrombocytopemic purpura (ITP)
Disseminated intravascular coagulation (DIC)
Heparin-associated thrombosis and thrombocytopenia (HATT)
39. Which of the following drugs would be ordered by the physician to improve
the platelet count in a male client with idiopathic thrombocytopenic purpura
(ITP)?
a.
b.
c.
d.
Allogeneic
Autologous
Syngeneic
Xenogeneic
41. Marco falls off his bicycle and injuries his ankle. Which of the following
actions shows the initial response to the injury in the extrinsic pathway?
a.
b.
c.
d.
Release of Calcium
Release of tissue thromboplastin
Conversion of factors XII to factor XIIa
Conversion of factor VIII to factor VIIIa
42. Instructions for a client with systemic lupus erythematosus (SLE) would
include information about which of the following blood dyscrasias?
a. Dresslers syndrome
b. Polycythemia
c. Essential thrombocytopenia
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Pericarditis
Night sweat
Splenomegaly
Persistent hypothermia
44. Francis with leukemia has neutropenia. Which of the following functions must
frequently assessed?
a.
b.
c.
d.
Blood pressure
Bowel sounds
Heart sounds
Breath sounds
45. The nurse knows that neurologic complications of multiple myeloma (MM)
usually involve which of the following body system?
a.
b.
c.
d.
Brain
Muscle spasm
Renal dysfunction
Myocardial irritability
46. Nurse Patricia is aware that the average length of time from human
immunodeficiency virus (HIV) infection to the development of acquired
immunodeficiency syndrome (AIDS)?
a.
b.
c.
d.
47. An 18-year-old male client admitted with heat stroke begins to show signs of
disseminated intravascular coagulation (DIC). Which of the following laboratory
findings is most consistent with DIC?
a.
b.
c.
d.
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48. Mario comes to the clinic complaining of fever, drenching night sweats, and
unexplained weight loss over the past 3 months. Physical examination reveals a
single enlarged supraclavicular lymph node. Which of the following is the most
probable diagnosis?
a.
b.
c.
d.
Influenza
Sickle cell anemia
Leukemia
Hodgkins disease
AB Rh-positive
A Rh-positive
A Rh-negative
O Rh-positive
51. Stacys mother states to the nurse that it is hard to see Stacy with no hair.
The best response for the nurse is:
a. Stacy looks very nice wearing a hat.
b. You should not worry about her hair, just be glad that she is alive.
c. Yes it is upsetting. But try to cover up your feelings when you are with her
or else she may be upset.
d. This is only temporary; Stacy will re-grow new hair in 3-6 months, but
may be different in texture.
52. Stacy has beginning stomatitis. To promote oral hygiene and comfort, the
nurse in-charge should:
a. Provide frequent mouthwash with normal saline.
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54. The term blue bloater refers to a male client which of the following
conditions?
a.
b.
c.
d.
55. The term pink puffer refers to the female client with which of the following
conditions?
a.
b.
c.
d.
15 mm Hg
30 mm Hg
40 mm Hg
80 mm Hg
57. Timothys arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80
mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result
represents which of the following conditions?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
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d. Respirator y alkalosis
58. Norma has started a new drug for hypertension. Thirty minutes after she
takes the drug, she develops chest tightness and becomes short of breath and
tachypneic. She has a decreased level of consciousness. These signs indicate
which of the following conditions?
a.
b.
c.
d.
Asthma attack
Pulmonary embolism
Respiratory failure
Rheumatoid arthritis
Situation: Mr. Gonzales was admitted to the hospital with ascites and
jaundice. To rule out cirrhosis of the liver:
59. Which laboratory test indicates liver cirrhosis?
a.
b.
c.
d.
60.The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales
is at increased risk for excessive bleeding primarily because of:
a.
b.
c.
d.
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c. Ill lower the dosage as ordered so the drug causes only 2 to 4 stools
a day.
d. Frequently, bowel movements are needed to reduce sodium level.
63. Which of the following groups of symptoms indicates a ruptured abdominal
aortic aneurysm?
a. Lower back pain, increased blood pressure, decreased re blood cell
(RBC) count, increased white blood (WBC) count.
b. Severe lower back pain, decreased blood pressure, decreased
RBC count, increased WBC count.
c. Severe lower back pain, decreased blood pressure, decreased
RBC count, decreased RBC count, decreased WBC count.
d. Intermitted lower back pain, decreased blood pressure, decreased
RBC count, increased WBC count.
64. After undergoing a cardiac catheterization, Tracy has a large puddle of blood
under his buttocks. Which of the following steps should the nurse take first?
a.
b.
c.
d.
65. Which of the following treatment is a suitable surgical intervention for a client
with unstable angina?
a.
b.
c.
d.
Cardiac catheterization
Echocardiogram
Nitroglycerin
Percutaneous transluminal coronary angioplasty (PTCA)
66. The nurse is aware that the following terms used to describe reduced cardiac
output and perfusion impairment due to ineffective pumping of the heart is:
a.
b.
c.
d.
Anaphylactic shock
Cardiogenic shock
Distributive shock
Myocardial infarction (MI)
67. A client with hypertension ask the nurse which factors can cause blood
pressure to drop to normal levels?
a. Kidneys excretion to sodium only.
b. Kidneys retention of sodium and water
c. Kidneys excretion of sodium and water
83
69. Nurse Nikki knows that laboratory results supports the diagnosis of systemic
lupus erythematosus (SLE) is:
a.
b.
c.
d.
70. Arnold, a 19-year-old client with a mild concussion is discharged from the
emergency department. Before discharge, he complains of a headache. When
offered acetaminophen, his mother tells the nurse the headache is severe and
she would like her son to have something stronger. Which of the following
responses by the nurse is appropriate?
a. Your son had a mild concussion, acetaminophen is strong enough.
b. Aspirin is avoided because of the danger of Reyes syndrome in
children or young adults.
c. Narcotics are avoided after a head injury because they may hide a
worsening condition.
d. Stronger medications may lead to vomiting, which increases the
intracarnial pressure (ICP).
71. When evaluating an arterial blood gas from a male client with a subdural
hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following
responses best describes the result?
a. Appropriate; lowering carbon dioxide (CO2) reduces intracranial
pressure (ICP)
b. Emergent; the client is poorly oxygenated
c. Normal
d. Significant; the client has alveolar hypoventilation
72. When prioritizing care, which of the following clients should the nurse Olivia
assess first?
84
a.
b.
c.
d.
73. JP has been diagnosed with gout and wants to know why colchicine is used
in the treatment of gout. Which of the following actions of colchicines explains
why its effective for gout?
a.
b.
c.
d.
Replaces estrogen
Decreases infection
Decreases inflammation
Decreases bone demineralization
74. Norma asks for information about osteoarthritis. Which of the following
statements about osteoarthritis is correct?
a.
b.
c.
d.
75. Ruby is receiving thyroid replacement therapy develops the flu and forgets to
take her thyroid replacement medicine. The nurse understands that skipping this
medication will put the client at risk for developing which of the following lifethreatening complications?
a.
b.
c.
d.
Exophthalmos
Thyroid storm
Myxedema coma
Tibial myxedema
77. Cyrill with severe head trauma sustained in a car accident is admitted to the
intensive care unit. Thirty-six hours later, the client's urine output suddenly rises
above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which
laboratory findings support the nurse's suspicion of diabetes insipidus?
85
Diabetes mellitus
Diabetes insipidus
Hypoparathyroidism
Hyperparathyroidism
80. Nurse Lourdes is teaching a client recovering from addisonian crisis about
the need to take fludrocortisone acetate and hydrocortisone at home. Which
statement by the client indicates an understanding of the instructions?
a. "I'll take my hydrocortisone in the late afternoon, before dinner."
b. "I'll take all of my hydrocortisone in the morning, right after I wake
up."
c. "I'll take two-thirds of the dose when I wake up and one-third in the
late afternoon."
d. "I'll take the entire dose at bedtime."
81..Which of the following laboratory test results would suggest to the nurse Len
that a client has a corticotropin-secreting pituitary adenoma?
a. High corticotropin and low cortisol levels
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83. Capillary glucose monitoring is being performed every 4 hours for a client
diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of
regular insulin according to glucose results. At 2 p.m., the client has a capillary
glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse
Mariner should expect the dose's:
a.
b.
c.
d.
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87. For a client with Graves' disease, which nursing intervention promotes
comfort?
a.
b.
c.
d.
89. Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the
development of this disorder?
a.
b.
c.
d.
90. Johnny a firefighter was involved in extinguishing a house fire and is being
treated to smoke inhalation. He develops severe hypoxia 48 hours after the
incident, requiring intubation and mechanical ventilation. He most likely has
developed which of the following conditions?
a. Adult respiratory distress syndrome (ARDS)
b. Atelectasis
c. Bronchitis
88
d. Pneumonia
91. A 67-year-old client develops acute shortness of breath and progressive
hypoxia requiring right femur. The hypoxia was probably caused by which of the
following conditions?
a.
b.
c.
d.
Asthma attack
Atelectasis
Bronchitis
Fat embolism
92. A client with shortness of breath has decreased to absent breath sounds on
the right side, from the apex to the base. Which of the following conditions would
best explain this?
a.
b.
c.
d.
Acute asthma
Chronic bronchitis
Pneumonia
Spontaneous pneumothorax
Bronchitis
Pneumonia
Pneumothorax
Tuberculosis (TB)
94. If a client requires a pneumonectomy, what fills the area of the thoracic
cavity?
a.
b.
c.
d.
95. Hemoptysis may be present in the client with a pulmonary embolism because
of which of the following reasons?
a. Alveolar damage in the infracted area
b. Involvement of major blood vessels in the occluded area
c. Loss of lung parenchyma
89
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
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.
b.
c.
d.
Air leak
Adequate suction
Inadequate suction
Kinked chest tube
98. Nurse Michelle calculates the IV flow rate for a postoperative client. The
client receives 3,000 ml of Ringers 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 clients IV to deliver how many drops per minute?
a.
b.
c.
d.
18
21
35
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.
b.
c.
d.
1.2 ml
2.4 ml
3.5 ml
4.2 ml
100. Nurse Alexandra teaches a client about elastic stockings. Which of the
following statements, if made by the client, indicates to the nurse that the
teaching was successful?
90
a.
b.
c.
d.
I will wear the stockings until the physician tells me to remove them.
I should wear the stockings even when I am sleep.
Every four hours I should remove the stockings for a half hour.
I should put on the stockings before getting out of bed in the morning.
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NURSING PRACTICE V
92
Observations
Restating
Exploring
Focusing
93
a.
b.
c.
d.
Perceptual disorders.
Impending coma.
Recent alcohol intake.
Depression with mutism.
6. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains
that it doesnt help and refuses to take it. What should the nurse say or
do?
a.
b.
c.
d.
Id
Ego
Superego
Oedipal complex
Short-acting anesthesia
Decreased oral and respiratory secretions.
Skeletal muscle paralysis.
Analgesia.
9. Nurse Gina is aware that the dietary implications for a client in manic
phase of bipolar disorder is:
a. Serve the client a bowl of soup, buttered French bread, and apple
slices.
b. Increase calories, decrease fat, and decrease protein.
c. Give the client pieces of cut-up steak, carrots, and an apple.
d. Increase calories, carbohydrates, and protein.
10. What parental behavior toward a child during an admission procedure
should cause Nurse Ron to suspect child abuse?
94
a.
b.
c.
d.
Flat affect
Expressing guilt
Acting overly solicitous toward the child.
Ignoring the child.
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14. Nurse Krina knows that the following drugs have been known to be
effective in treating obsessive-compulsive disorder (OCD):
a.
b.
c.
d.
15. Alfred was newly diagnosed with anxiety disorder. The physician
prescribed buspirone (BuSpar). The nurse is aware that the teaching
instructions for newly prescribed buspirone should include which of the
following?
a. A warning about the drugs delayed therapeutic effect, which is from
14 to 30 days.
b. A warning about the incidence of neuroleptic malignant syndrome
(NMS).
c. A reminder of the need to schedule blood work in 1 week to check
blood levels of the drug.
d. A warning that immediate sedation can occur with a resultant drop
in pulse.
16. Richard with agoraphobia has been symptom-free for 4 months. Classic
signs and symptoms of phobias include:
a.
b.
c.
d.
17. Which medications have been found to help reduce or eliminate panic
attacks?
a.
b.
c.
d.
Antidepressants
Anticholinergics
Antipsychotics
Mood stabilizers
18. A client seeks care because she feels depressed and has gained weight.
To treat her atypical depression, the physician prescribes tranylcypromine
sulfate (Parnate), 10 mg by mouth twice per day. When this drug is used
to treat atypical depression, what is its onset of action?
a. 1 to 2 days
b. 3 to 5 days
c. 6 to 8 days
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d. 10 to 14 days
19. A 65 years old client is in the first stage of Alzheimer's disease. Nurse
Patricia should plan to focus this client's care on:
a. Offering nourishing finger foods to help maintain the client's
nutritional status.
b. Providing emotional support and individual counseling.
c. Monitoring the client to prevent minor illnesses from turning into
major problems.
d. Suggesting new activities for the client and family to do together.
20. The nurse is assessing a client who has just been admitted to the
emergency department. Which signs would suggest an overdose of an
antianxiety agent?
a.
b.
c.
d.
21. The nurse is caring for a client diagnosed with antisocial personality
disorder. The client has a history of fighting, cruelty to animals, and
stealing. Which of the following traits would the nurse be most likely to
uncover during assessment?
a.
b.
c.
d.
22. Nurse Amy is providing care for a male client undergoing opiate
withdrawal. Opiate withdrawal causes severe physical discomfort and can
be life-threatening. To minimize these effects, opiate users are commonly
detoxified with:
a.
b.
c.
d.
Barbiturates
Amphetamines
Methadone
Benzodiazepines
23. Nurse Cristina is caring for a client who experiences false sensory
perceptions with no basis in reality. These perceptions are known as:
a. Delusions
b. Hallucinations
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c. Loose associations
d. Neologisms
24. Nurse Marco is developing a plan of care for a client with anorexia
nervosa. Which action should the nurse include in the plan?
a. Restricts visits with the family and friends until the client begins to
eat.
b. Provide privacy during meals.
c. Set up a strict eating plan for the client.
d. Encourage the client to exercise, which will reduce her anxiety.
25. Tim is admitted with a diagnosis of delusions of grandeur. The nurse is
aware that this diagnosis reflects a belief that one is:
a.
b.
c.
d.
26. Nurse Jen is caring for a male client with manic depression. The plan of
care for a client in a manic state would include:
a. Offering a high-calorie meals and strongly encouraging the client to
finish all food.
b. Insisting that the client remain active through the day so that hell
sleep at night.
c. Allowing the client to exhibit hyperactive, demanding, manipulative
behavior without setting limits.
d. Listening attentively with a neutral attitude and avoiding power
struggles.
27. Ramon is admitted for detoxification after a cocaine overdose. The client
tells the nurse that he frequently uses cocaine but that he can control his
use if he chooses. Which coping mechanism is he using?
a.
b.
c.
d.
Withdrawal
Logical thinking
Repression
Denial
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c. Emotional affect
d. Independence needs
29. Nurse Mickey is caring for a client diagnosed with bulimia. The most
appropriate initial goal for a client diagnosed with bulimia is to:
a.
b.
c.
d.
31. Nicolas is experiencing hallucinations tells the nurse, The voices are
telling me Im no good. The client asks if the nurse hears the voices. The
most appropriate response by the nurse would be:
a. It is the voice of your conscience, which only you can control.
b. No, I do not hear your voices, but I believe you can hear them.
c. The voices are coming from within you and only you can hear
them.
d. Oh, the voices are a symptom of your illness; dont pay any
attention to them.
32. The nurse is aware that the side effect of electroconvulsive therapy that a
client may experience:
a.
b.
c.
d.
Loss of appetite
Postural hypotension
Confusion for a time after treatment
Complete loss of memory for a time
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d. Acceptance stage
34. The outcome that is unrelated to a crisis state is:
a.
b.
c.
d.
Driving at night
Staying in the sun
Ingesting wines and cheeses
Taking medications containing aspirin
36. Jen a nursing student is anxious about the upcoming board examination
but is able to study intently and does not become distracted by a
roommates talking and loud music. The students ability to ignore
distractions and to focus on studying demonstrates:
a.
b.
c.
d.
Mild-level anxiety
Panic-level anxiety
Severe-level anxiety
Moderate-level anxiety
Rigidity
Stubbornness
Diverse interest
Over meticulousness
38. Nurse Krina recognizes that the suicidal risk for depressed client is
greatest:
a.
b.
c.
d.
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39. Nurse Kate would expect that a client with vascular dementis would
experience:
a.
b.
c.
d.
41. The psychiatrist orders lithium carbonate 600 mg p.o t.i.d for a female
client. Nurse Katrina would be aware that the teaching about the side
effects of this drug were understood when the client state, I will call my
doctor immediately if I notice any:
a.
b.
c.
d.
42. Nurse Mylene recognizes that the most important factor necessary for the
establishment of trust in a critical care area is:
a.
b.
c.
d.
Privacy
Respect
Empathy
Presence
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a.
b.
c.
d.
45. Nurse John is a aware that most crisis situations should resolve in about:
a.
b.
c.
d.
1 to 2 weeks
4 to 6 weeks
4 to 6 months
6 to 12 months
46. Nurse Judy knows that statistics show that in adolescent suicide
behavior:
a.
b.
c.
d.
phenelzine (Nardil)
chlordiazepoxide (Librium)
lithium carbonate (Lithane)
imipramine (Tofranil)
49. Which information is most important for the nurse Trinity to include in a
teaching plan for a male schizophrenic client taking clozapine (Clozaril)?
a. Monthly blood tests will be necessary.
b. Report a sore throat or fever to the physician immediately.
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Tardive dyskinesia.
Dystonia.
Neuroleptic malignant syndrome.
Akathisia.
Cyclothymic disorder.
Atypical affective disorder.
Major depression.
Dysthymic disorder.
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54. What herbal medication for depression, widely used in Europe, is now
being prescribed in the United States?
a.
b.
c.
d.
Ginkgo biloba
Echinacea
St. John's wort
Ephedra
55. Cely with manic episodes is taking lithium. Which electrolyte level should
the nurse check before administering this medication?
a.
b.
c.
d.
Calcium
Sodium
Chloride
Potassium
56. Nurse Josefina is caring for a client who has been diagnosed with
delirium. Which statement about delirium is true?
a. It's characterized by an acute onset and lasts about 1 month.
b. It's characterized by a slowly evolving onset and lasts about 1
week.
c. It's characterized by a slowly evolving onset and lasts about 1
month.
d. It's characterized by an acute onset and lasts hours to a number of
days.
57. Edward, a 66 year old client with slight memory impairment and poor
concentration is diagnosed with primary degenerative dementia of the
Alzheimer's type. Early signs of this dementia include subtle personality
changes and withdrawal from social interactions. To assess for
progression to the middle stage of Alzheimer's disease, the nurse should
observe the client for:
a.
b.
c.
d.
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c. The client should avoid eating such foods as aged cheeses, yogurt,
and chicken livers while taking the medication.
d. This medication may initially cause tiredness, which should become
less bothersome over time.
59. Kathleen is admitted to the psychiatric clinic for treatment of anorexia
nervosa. To promote the client's physical health, the nurse should plan to:
a. Severely restrict the client's physical activities.
b. Weigh the client daily, after the evening meal.
c. Monitor vital signs, serum electrolyte levels, and acid-base balance.
d. Instruct the client to keep an accurate record of food and fluid
intake.
60. Celia with a history of polysubstance abuse is admitted to the facility. She
complains of nausea and vomiting 24 hours after admission. The nurse
assesses the client and notes piloerection, pupillary dilation, and
lacrimation. The nurse suspects that the client is going through which of
the following withdrawals?
a.
b.
c.
d.
Alcohol withdrawal
Cannibis withdrawal
Cocaine withdrawal
Opioid withdrawal
61. Mr. Garcia, an attorney who throws books and furniture around the office
after losing a case is referred to the psychiatric nurse in the law firm's
employee assistance program. Nurse Beatriz knows that the client's
behavior most likely represents the use of which defense mechanism?
a.
b.
c.
d.
Regression
Projection
Reaction-formation
Intellectualization
62. Nurse Anne is caring for a client who has been treated long term with
antipsychotic medication. During the assessment, Nurse Anne checks the
client for tardive dyskinesia. If tardive dyskinesia is present, Nurse Anne
would most likely observe:
a. Abnormal movements and involuntary movements of the mouth,
tongue, and face.
b. Abnormal breathing through the nostrils accompanied by a thrill.
c. Severe headache, flushing, tremors, and ataxia.
d. Severe hypertension, migraine headache,
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63. Dennis has a lithium level of 2.4 mEq/L. The nurse immediately would
assess the client for which of the following signs or symptoms?
a.
b.
c.
d.
Weakness
Diarrhea
Blurred vision
Fecal incontinence
64. Nurse Jannah is monitoring a male client who has been placed inrestraints
because of violent behavior. Nurse determines that it will be safe to
remove the restraints when:
a. The client verbalizes the reasons for the violent behavior.
b. The client apologizes and tells the nurse that it will never happen
again.
c. No acts of aggression have been observed within 1 hour after the
release of two of the extremity restraints.
d. The administered medication has taken effect.
65. Nurse Irish is aware that Ritalin is the drug of choice for a child with
ADHD. The side effects of the following may be noted by the nurse:
a.
b.
c.
d.
66. Kitty, a 9 year old child has very limited vocabulary and interaction skills.
She has an I.Q. of 45. She is diagnosed to have Mental retardation of this
classification:
a.
b.
c.
d.
Profound
Mild
Moderate
Severe
67. The therapeutic approach in the care of Armand an autistic child include
the following EXCEPT:
a.
b.
c.
d.
68. Jeremy is brought to the emergency room by friends who state that he
took something an hour ago. He is actively hallucinating, agitated, with
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Heroin
Cocaine
LSD
Marijuana
69. Nurse Pauline is aware that Dementia unlike delirium is characterized by:
a.
b.
c.
d.
Slurred speech
Insidious onset
Clouding of consciousness
Sensory perceptual change
70. A 35 year old female has intense fear of riding an elevator. She claims
As if I will die inside. The client is suffering from:
a. Agoraphobia
b. Social phobia
c. Claustrophobia
d. Xenophobia
71. Nurse Myrna develops a counter-transference reaction. This is evidenced
by:
a. Revealing personal information to the client
b. Focusing on the feelings of the client.
c. Confronting the client about discrepancies in verbal or non-verbal
behavior
d. The client feels angry towards the nurse who resembles his mother.
72. Tristan is on Lithium has suffered from diarrhea and vomiting. What
should the nurse in-charge do first:
a. Recognize this as a drug interaction
b. Give the client Cogentin
c. Reassure the client that these are common side effects of lithium
therapy
d. Hold the next dose and obtain an order for a stat serum lithium
level
73. Nurse Sarah ensures a therapeutic environment for all the client. Which of
the following best describes a therapeutic milieu?
a. A therapy that rewards adaptive behavior
b. A cognitive approach to change behavior
c. A living, learning or working environment.
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Splitting
Transference
Countertransference
Resistance
75. Marielle, 17 years old was sexually attacked while on her way home from
school. She is brought to the hospital by her mother. Rape is an example
of which type of crisis:
a.
b.
c.
d.
Situational
Adventitious
Developmental
Internal
76. Nurse Greta is aware that the following is classified as an Axis I disorder
by the Diagnosis and Statistical Manual of Mental Disorders, Text
Revision (DSM-IV-TR) is:
a.
b.
c.
d.
Obesity
Borderline personality disorder
Major depression
Hypertension
77. Katrina, a newly admitted is extremely hostile toward a staff member she
has just met, without apparent reason. According to Freudian theory, the
nurse should suspect that the client is experiencing which of the following
phenomena?
a.
b.
c.
d.
Intellectualization
Transference
Triangulation
Splitting
78. An 83year-old male client is in extended care facility is anxious most of the
time and frequently complains of a number of vague symptoms that
interfere with his ability to eat. These symptoms indicate which of the
following disorders?
a. Conversion disorder
b. Hypochondriasis
c. Severe anxiety
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d. Sublimation
79. Charina, a college student who frequently visited the health center during the
past year with multiple vague complaints of GI symptoms before course
examinations. Although physical causes have been eliminated, the student
continues to express her belief that she has a serious illness. These symptoms
are typically of which of the following disorders?
a.
b.
c.
d.
Conversion disorder
Depersonalization
Hypochondriasis
Somatization disorder
80. Nurse Daisy is aware that the following pharmacologic agents are sedativehypnotic medication is used to induce sleep for a client experiencing a sleep
disorder is:
a.
b.
c.
d.
Triazolam (Halcion)
Paroxetine (Paxil)\
Fluoxetine (Prozac)
Risperidone (Risperdal)
81. Aldo, with a somatoform pain disorder may obtain secondary gain. Which of
the following statement refers to a secondary gain?
a.
b.
c.
d.
82. Dervid is diagnosed with panic disorder with agoraphobia is talking with the
nurse in-charge about the progress made in treatment. Which of the following
statements indicates a positive client response?
a.
b.
c.
d.
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Anxiety disorder
Behavioral difficulties
Cognitive impairment
Labile moods
87. The nurse is aware that the following ways in vascular dementia different
from Alzheimers disease is:
a.
b.
c.
d.
88. Loretta, a newly admitted client was diagnosed with delirium and has history
of hypertension and anxiety. She had been taking digoxin, furosemide (Lasix),
and diazepam (Valium) for anxiety. This clients impairment may be related to
which of the following conditions?
a. Infection
b. Metabolic acidosis
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c. Drug intoxication
d. Hepatic encephalopathy
89. Nurse Ron enters a clients room, the client says, Theyre crawling on my
sheets! Get them off my bed! Which of the following assessment is the most
accurate?
a.
b.
c.
d.
90. Which of the following descriptions of a clients experience and behavior can
be assessed as an illusion?
a. The client tries to hit the nurse when vital signs must be taken
b. The client says, I keep hearing a voice telling me to run away
c. The client becomes anxious whenever the nurse leaves the
bedside
d. The client looks at the shadow on a wall and tells the nurse she
sees frightening faces on the wall.
91. During conversation of Nurse John with a client, he observes that the client
shift from one topic to the next on a regular basis. Which of the following terms
describes this disorder?
a.
b.
c.
d.
Flight of ideas
Concrete thinking
Ideas of reference
Loose association
92. Francis tells the nurse that her coworkers are sabotaging the computer.
When the nurse asks questions, the client becomes argumentative. This
behavior shows personality traits associated with which of the following
personality disorder?
a.
b.
c.
d.
Antisocial
Histrionic
Paranoid
Schizotypal
93. Which of the following interventions is important for a Cely experiencing with
paranoid personality disorder taking olanzapine (Zyprexa)?
a. Explain effects of serotonin syndrome
b. Teach the client to watch for extrapyramidal adverse reaction
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Lack of honesty
Belief in superstition
Show of temper tantrums
Constant need for attention
95. Tommy, with dependent personality disorder is working to increase his selfesteem. Which of the following statements by the Tommy shows teaching was
successful?
a.
b.
c.
d.
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.
b.
c.
d.
Modeling
Echopraxia
Ego-syntonicity
Ritualism
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98. Jun approaches the nurse and tells that he hears a voice telling him that hes
evil and deserves to die. Which of the following terms describes the clients
perception?
a.
b.
c.
d.
Delusion
Disorganized speech
Hallucination
Idea of reference
Projection
Rationalization
Regression
Repression
100. Rocky has started taking haloperidol (Haldol). Which of the following
instructions is most appropriate for Ricky before taking haloperidol?
a.
b.
c.
d.
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PART II
ANSWERS
&
RATIONALE
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TEST I
Answers and Rationale Foundation of Professional Nursing Practice
1. Answer: (D) The actions of a reasonably prudent nurse with similar
education and experience.
Rationale: The standard of care is determined by the average degree of
skill, care, and diligence by nurses in similar circumstances.
2. Answer: (B) I.M
Rationale: With a platelet count of 22,000/l, the clients tends to bleed
easily. Therefore, the nurse should avoid using the I.M. route because the
area is a highly vascular and can bleed readily when penetrated by a
needle. The bleeding can be difficult to stop.
3. Answer: (C) Digoxin 0.125 mg P.O. once daily
Rationale: The nurse should always place a zero before a decimal point
so that no one misreads the figure, which could result in a dosage error.
The nurse should never insert a zero at the end of a dosage that includes
a decimal point because this could be misread, possibly leading to a
tenfold increase in the dosage.
4. Answer: (A) Ineffective peripheral tissue perfusion related to venous
congestion.
Rationale: Ineffective peripheral tissue perfusion related to venous
congestion takes the highest priority because venous inflammation and
clot formation impede blood flow in a client with deep vein thrombosis.
5. Answer: (B) A 44 year-old myocardial infarction (MI) client who is
complaining of nausea.
Rationale: Nausea is a symptom of impending myocardial infarction (MI)
and should be assessed immediately so that treatment can be instituted
and further damage to the heart is avoided.
6. Answer: (C) Check circulation every 15-30 minutes.
Rationale: Restraints encircle the limbs, which place the client at risk for
circulation being restricted to the distal areas of the extremities. Checking
the clients circulation every 15-30 minutes will allow the nurse to adjust
the restraints before injury from decreased blood flow occurs.
7. Answer: (A) Prevent stress ulcer
Rationale: Curlings ulcer occurs as a generalized stress response in burn
patients. This results in a decreased production of mucus and increased
secretion of gastric acid. The best treatment for this prophylactic use of
antacids and H2 receptor blockers.
8. Answer: (D) Continue to monitor and record hourly urine output
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61. Answer: (A) Puts all the four points of the walker flat on the floor, puts
weight on the hand pieces, and then walks into it.
Rationale: When the client uses a walker, the nurse stands adjacent to
the affected side. The client is instructed to put all four points of the walker
2 feet forward flat on the floor before putting weight on hand pieces. This
will ensure client safety and prevent stress cracks in the walker. The client
is then instructed to move the walker forward and walk into it.
62. Answer: (C) Draws one line to cross out the incorrect information and
then initials the change.
Rationale: To correct an error documented in a medical record, the nurse
draws one line through the incorrect information and then initials the error.
An error is never erased and correction fluid is never used in the medical
record.
63. Answer: (C) Secures the client safety belts after transferring to the
stretcher.
Rationale: During the transfer of the client after the surgical procedure is
complete, the nurse should avoid exposure of the client because of the
risk for potential heat loss. Hurried movements and rapid changes in the
position should be avoided because these predispose the client to
hypotension. At the time of the transfer from the surgery table to the
stretcher, the client is still affected by the effects of the anesthesia;
therefore, the client should not move self. Safety belts can prevent the
client from falling off the stretcher.
64. Answer: (B) Gown and gloves
Rationale: Contact precautions require the use of gloves and a gown if
direct client contact is anticipated. Goggles are not necessary unless the
nurse anticipates the splashes of blood, body fluids, secretions, or
excretions may occur. Shoe protectors are not necessary.
65. Answer: (C) Quad cane
Rationale: Crutches and a walker can be difficult to maneuver for a client
with weakness on one side. A cane is better suited for client with
weakness of the arm and leg on one side. However, the quad cane would
provide the most stability because of the structure of the cane and
because a quad cane has four legs.
66. Answer: (D) Left side-lying with the head of the bed elevated 45 degrees.
Rationale: To facilitate removal of fluid from the chest wall, the client is
positioned sitting at the edge of the bed leaning over the bedside table
with the feet supported on a stool. If the client is unable to sit up, the client
is positioned lying in bed on the unaffected side with the head of the bed
elevated 30 to 45 degrees.
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76. Answer: (C) May apply for re-issuance of his/her license based on certain
conditions stipulated in RA 9173
Rationale: RA 9173 sec. 24 states that for equity and justice, a revoked
license maybe re-issued provided that the following conditions are met: a)
the cause for revocation of license has already been corrected or
removed; and, b) at least four years has elapsed since the license has
been revoked.
77. Answer: (B) Review related literature
Rationale: After formulating and delimiting the research problem, the
researcher conducts a review of related literature to determine the extent
of what has been done on the study by previous researchers.
78. Answer: (B) Hawthorne effect
Rationale: Hawthorne effect is based on the study of Elton Mayo and
company about the effect of an intervention done to improve the working
conditions of the workers on their productivity. It resulted to an increased
productivity but not due to the intervention but due to the psychological
effects of being observed. They performed differently because they were
under observation.
79. Answer: (B) Determines the different nationality of patients frequently
admitted and decides to get representations samples from each.
Rationale: Judgment sampling involves including samples according to
the knowledge of the investigator about the participants in the study.
80. Answer: (B) Madeleine Leininger
Rationale: Madeleine Leininger developed the theory on transcultural
theory based on her observations on the behavior of selected people
within a culture.
81. Answer: (A) Random
Rationale: Random sampling gives equal chance for all the elements in
the population to be picked as part of the sample.
82. Answer: (A) Degree of agreement and disagreement
Rationale: Likert scale is a 5-point summated scale used to determine the
degree of agreement or disagreement of the respondents to a statement
in a study
83. Answer: (B) Sr. Callista Roy
Rationale: Sr. Callista Roy developed the Adaptation Model which
involves the physiologic mode, self-concept mode, role function mode and
dependence mode.
84. Answer: (A) Span of control
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TEST II
Answers and Rationale Community Health Nursing and Care of the
Mother and Child
1. Answer: (A) Inevitable
Rationale: An inevitable abortion is termination of pregnancy that cannot
be prevented. Moderate to severe bleeding with mild cramping and
cervical dilation would be noted in this type of abortion.
2. Answer: (B) History of syphilis
Rationale: Maternal infections such as syphilis, toxoplasmosis, and
rubella are causes of spontaneous abortion.
3. Answer: (C) Monitoring apical pulse
Rationale: Nursing care for the client with a possible ectopic pregnancy is
focused on preventing or identifying hypovolemic shock and controlling
pain. An elevated pulse rate is an indicator of shock.
4. Answer: (B) Increased caloric intake
Rationale: Glucose crosses the placenta, but insulin does not. High fetal
demands for glucose, combined with the insulin resistance caused by
hormonal changes in the last half of pregnancy can result in elevation of
maternal blood glucose levels. This increases the mothers demand for
insulin and is referred to as the diabetogenic effect of pregnancy.
5. Answer: (A) Excessive fetal activity.
Rationale: The most common signs and symptoms of hydatidiform mole
includes elevated levels of human chorionic gonadotropin, vaginal
bleeding, larger than normal uterus for gestational age, failure to detect
fetal heart activity even with sensitive instruments, excessive nausea and
vomiting, and early development of pregnancy-induced hypertension.
Fetal activity would not be noted.
6. Answer: (B) Absent patellar reflexes
Rationale: Absence of patellar reflexes is an indicator of
hypermagnesemia, which requires administration of calcium gluconate.
7. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines.
Rationale: Fetus at station plus two indicates that the presenting part is 2
cm below the plane of the ischial spines.
8. Answer: (A) Contractions every 1 minutes lasting 70-80 seconds.
Rationale: Contractions every 1 minutes lasting 70-80 seconds, is
indicative of hyperstimulation of the uterus, which could result in injury to
the mother and the fetus if Pitocin is not discontinued.
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community, many of whom are well individuals who have greater need for
preventive rather than curative services.
17. Answer: (B) Efficiency
Rationale: Efficiency is determining whether the goals were attained at
the least possible cost.
18. Answer: (D) Rural Health Unit
Rationale: R.A. 7160 devolved basic health services to local government
units (LGUs ). The public health nurse is an employee of the LGU.
19. Answer: (A) Mayor
Rationale: The local executive serves as the chairman of the Municipal
Health Board.
20. Answer: (A) 1
Rationale: Each rural health midwife is given a population assignment of
about 5,000.
21. Answer: (B) Health education and community organizing are necessary in
providing community health services.
Rationale: The community health nurse develops the health capability of
people through health education and community organizing activities.
22. Answer: (B) Measles
Rationale: Presidential Proclamation No. 4 is on the Ligtas Tigdas
Program.
23. Answer: (D) Core group formation
Rationale: In core group formation, the nurse is able to transfer the
technology of community organizing to the potential or informal community
leaders through a training program.
24. Answer: (D) To maximize the communitys resources in dealing with
health problems.
Rationale: Community organizing is a developmental service, with the
goal of developing the peoples self-reliance in dealing with community
health problems. A, B and C are objectives of contributory objectives to
this goal.
25. Answer: (D) Terminal
Rationale: Tertiary prevention involves rehabilitation, prevention of
permanent disability and disability limitation appropriate for convalescents,
the disabled, complicated cases and the terminally ill (those in the terminal
stage of a disease).
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is voiding. If the client is not voiding, the nurse should withhold the
potassium and notify the physician.
44. Answer: (c) Laundry detergent
Rationale: Eczema or dermatitis is an allergic skin reaction caused by an
offending allergen. The topical allergen that is the most common causative
factor is laundry detergent.
45. Answer: (A) 6 inches
Rationale: This distance allows for easy flow of the formula by gravity, but
the flow will be slow enough not to overload the stomach too rapidly.
46. Answer: (A) The older one gets, the more susceptible he becomes to the
complications of chicken pox.
Rationale: Chicken pox is usually more severe in adults than in children.
Complications, such as pneumonia, are higher in incidence in adults.
47. Answer: (D) Consult a physician who may give them rubella
immunoglobulin.
Rationale: Rubella vaccine is made up of attenuated German measles
viruses. This is contraindicated in pregnancy. Immune globulin, a specific
prophylactic against German measles, may be given to pregnant women.
48. Answer: (A) Contact tracing
Rationale: Contact tracing is the most practical and reliable method of
finding possible sources of person-to-person transmitted infections, such
as sexually transmitted diseases.
49. Answer: (D) Leptospirosis
Rationale: Leptospirosis is transmitted through contact with the skin or
mucous membrane with water or moist soil contaminated with urine of
infected animals, like rats.
50. Answer: (B) Cholera
Rationale: Passage of profuse watery stools is the major symptom of
cholera. Both amebic and bacillary dysentery are characterized by the
presence of blood and/or mucus in the stools. Giardiasis is characterized
by fat malabsorption and, therefore, steatorrhea.
51. Answer: (A) Hemophilus influenzae
Rationale: Hemophilus meningitis is unusual over the age of 5 years. In
developing countries, the peak incidence is in children less than 6 months
of age. Morbillivirus is the etiology of measles. Streptococcus pneumoniae
and Neisseria meningitidis may cause meningitis, but age distribution is
not specific in young children.
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TEST III
Answers and Rationale Care of Clients with Physiologic and
Psychosocial Alterations
1. Answer: (C) Loose, bloody
Rationale: Normal bowel function and soft-formed stool usually do not
occur until around the seventh day following surgery. The stool
consistency is related to how much water is being absorbed.
2. Answer: (A) On the clients right side
Rationale: The client has left visual field blindness. The client will see only
from the right side.
3. Answer: (C) Check respirations, stabilize spine, and check circulation
Rationale: Checking the airway would be priority, and a neck injury should
be suspected.
4. Answer: (D) Decreasing venous return through vasodilation.
Rationale: The significant effect of nitroglycerin is vasodilation and
decreased venous return, so the heart does not have to work hard.
5. Answer: (A) Call for help and note the time.
Rationale: Having established, by stimulating the client, that the client is
unconscious rather than sleep, the nurse should immediately call for help.
This may be done by dialing the operator from the clients phone and
giving the hospital code for cardiac arrest and the clients room number to
the operator, of if the phone is not available, by pulling the emergency call
button. Noting the time is important baseline information for cardiac arrest
procedure.
6. Answer: (C) Make sure that the client takes food and medications at
prescribed intervals.
Rationale: Food and drug therapy will prevent the accumulation of
hydrochloric acid, or will neutralize and buffer the acid that does
accumulate.
7. Answer: (B) Continue treatment as ordered.
Rationale: The effects of heparin are monitored by the PTT is normally 30
to 45 seconds; the therapeutic level is 1.5 to 2 times the normal level.
8. Answer: (B) In the operating room.
Rationale: The stoma drainage bag is applied in the operating room.
Drainage from the ileostomy contains secretions that are rich in digestive
enzymes and highly irritating to the skin. Protection of the skin from the
effects of these enzymes is begun at once. Skin exposed to these
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and avoiding stress are all important factors in decreasing the risk of
atherosclerosis.
23. Answer: (A) Laminectomy
Rationale: The client who has had spinal surgery, such as laminectomy,
must be log rolled to keep the spinal column straight when turning.
Thoracotomy and cystectomy may turn themselves or may be assisted
into a comfortable position. Under normal circumstances,
hemorrhoidectomy is an outpatient procedure, and the client may resume
normal activities immediately after surgery.
24. Answer: (D) Avoiding straining during bowel movement or bending at the
waist.
Rationale: The client should avoid straining, lifting heavy objects, and
coughing harshly because these activities increase intraocular pressure.
Typically, the client is instructed to avoid lifting objects weighing more than
15 lb (7kg) not 5lb. instruct the client when lying in bed to lie on either
the side or back. The client should avoid bright light by wearing
sunglasses.
25. Answer: (D) Before age 20.
Rationale: Testicular cancer commonly occurs in men between ages 20
and 30. A male client should be taught how to perform testicular selfexamination before age 20, preferably when he enters his teens.
26. Answer: (B) Place a saline-soaked sterile dressing on the wound.
Rationale: The nurse should first place saline-soaked sterile dressings on
the open wound to prevent tissue drying and possible infection. Then the
nurse should call the physician and take the clients vital signs. The
dehiscence needs to be surgically closed, so the nurse should never try to
close it.
27. Answer: (A) A progressively deeper breaths followed by shallower
breaths with apneic periods.
Rationale: Cheyne-Strokes respirations are breaths that become
progressively deeper fallowed by shallower respirations with apneas
periods. Biots respirations are rapid, deep breathing with abrupt pauses
between each breath, and equal depth between each breath. Kussmauls
respirationa are rapid, deep breathing without pauses. Tachypnea is
shallow breathing with increased respiratory rate.
28. Answer: (B) Fine crackles
Rationale: Fine crackles are caused by fluid in the alveoli and commonly
occur in clients with heart failure. Tracheal breath sounds are auscultated
over the trachea. Coarse crackles are caused by secretion accumulation
in the airways. Friction rubs occur with pleural inflammation.
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29. Answer: (B) The airways are so swollen that no air cannot get through
Rationale: During an acute attack, wheezing may stop and breath sounds
become inaudible because the airways are so swollen that air cant get
through. If the attack is over and swelling has decreased, there would be
no more wheezing and less emergent concern. Crackles do not replace
wheezes during an acute asthma attack.
30. Answer: (D) Place the client on his side, remove dangerous objects, and
protect his head.
Rationale: During the active seizure phase, initiate precautions by placing
the client on his side, removing dangerous objects, and protecting his
head from injury. A bite block should never be inserted during the active
seizure phase. Insertion can break the teeth and lead to aspiration.
31. Answer: (B) Kinked or obstructed chest tube
Rationales: Kinking and blockage of the chest tube is a common cause of
a tension pneumothorax. Infection and excessive drainage wont cause a
tension pneumothorax. Excessive water wont affect the chest tube
drainage.
32. Answer: (D) Stay with him but not intervene at this time.
Rationale: If the client is coughing, he should be able to dislodge the
object or cause a complete obstruction. If complete obstruction occurs, the
nurse should perform the abdominal thrust maneuver with the client
standing. If the client is unconscious, she should lay him down. A nurse
should never leave a choking client alone.
33. Answer: (B) Current health promotion activities
Rationale: Recognizing an individuals positive health measures is very
useful. General health in the previous 10 years is important, however, the
current activities of an 84 year old client are most significant in planning
care. Family history of disease for a client in later years is of minor
significance. Marital status information may be important for discharge
planning but is not as significant for addressing the immediate medical
problem.
34. Answer: (C) Place the client in a side lying position, with the head of the
bed lowered.
Rationale: The client should be positioned in a side-lying position with the
head of the bed lowered to prevent aspiration. A small amount of
toothpaste should be used and the mouth swabbed or suctioned to
remove pooled secretions. Lemon glycerin can be drying if used for
extended periods. Brushing the teeth with the client lying supine may lead
to aspiration. Hydrogen peroxide is caustic to tissues and should not be
used.
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minimize wound discomfort. Dry sterile dressings protect the wound from
mechanical trauma and promote healing.
71. Answer: (A) Hyperkalemia
Rationale: In adrenal insufficiency, the client has hyperkalemia due to
reduced aldosterone secretion. BUN increases as the glomerular filtration
rate is reduced. Hyponatremia is caused by reduced aldosterone
secretion. Reduced cortisol secretion leads to impaired glyconeogenesis
and a reduction of glycogen in the liver and muscle, causing
hypoglycemia.
72. Answer: (C) Restricting fluids
Rationale: To reduce water retention in a client with the SIADH, the
nurse should restrict fluids. Administering fluids by any route would further
increase the client's already heightened fluid load.
73. Answer: (D) glycosylated hemoglobin level.
Rationale: Because some of the glucose in the bloodstream attaches to
some of the hemoglobin and stays attached during the 120-day life span
of red blood cells, glycosylated hemoglobin levels provide information
about blood glucose levels during the previous 3 months. Fasting blood
glucose and urine glucose levels only give information about glucose
levels at the point in time when they were obtained. Serum fructosamine
levels provide information about blood glucose control over the past 2 to 3
weeks.
74. Answer: (C) 4:00 pm
Rationale: NPH is an intermediate-acting insulin that peaks 8 to 12 hours
after administration. Because the nurse administered NPH insulin at 7
a.m., the client is at greatest risk for hypoglycemia from 3 p.m. to 7 p.m.
75. Answer: (A) Glucocorticoids and androgens
Rationale: The adrenal glands have two divisions, the cortex and
medulla. The cortex produces three types of hormones: glucocorticoids,
mineralocorticoids, and androgens. The medulla produces catecholamines
epinephrine and norepinephrine.
76. Answer: (A) Hypocalcemia
Rationale: Hypocalcemia may follow thyroid surgery if the parathyroid
glands were removed accidentally. Signs and symptoms of hypocalcemia
may be delayed for up to 7 days after surgery. Thyroid surgery doesn't
directly cause serum sodium, potassium, or magnesium abnormalities.
Hyponatremia may occur if the client inadvertently received too much fluid;
however, this can happen to any surgical client receiving I.V. fluid therapy,
not just one recovering from thyroid surgery. Hyperkalemia and
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93. Answer: (C) The client spontaneously flexes his wrist when the blood
pressure is obtained.
Rationale: Carpal spasms indicate hypocalcemia.
94. Answer: (D) Use comfort measures and pillows to position the client.
Rationale: Using comfort measures and pillows to position the client is a
non-pharmacological methods of pain relief.
95. Answer: (B) Warm the dialysate solution.
Rationale: Cold dialysate increases discomfort. The solution should be
warmed to body temperature in warmer or heating pad; dont use
microwave oven.
96. Answer: (C) The client holds the cane with his left hand, moves the cane
forward followed by the right leg, and then moves the left leg.
Rationale: The cane acts as a support and aids in weight bearing for the
weaker right leg.
97. Answer: (A) Ask the womans family to provide personal items such as
photos or mementos.
Rationale: Photos and mementos provide visual stimulation to reduce
sensory deprivation.
98. Answer: (B) The client lifts the walker, moves it forward 10 inches, and
then takes several small steps forward.
Rationale: A walker needs to be picked up, placed down on all legs.
99. Answer: (C) Isolation from their families and familiar surroundings.
Rationale: Gradual loss of sight, hearing, and taste interferes with normal
functioning.
100. Answer: (A) Encourage the client to perform pursed lip breathing.
Rationale: Purse lip breathing prevents the collapse of lung unit and helps
client control rate and depth of breathing.
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TEST IV
Answers and Rationale Care of Clients with Physiologic and
Psychosocial Alterations
1. Answer: (C) Hypertension
Rationale: Hypertension, along with fever, and tenderness over the
grafted kidney, reflects acute rejection.
2. Answer: (A) Pain
Rationale: Sharp, severe pain (renal colic) radiating toward the genitalia
and thigh is caused by uretheral distention and smooth muscle spasm;
relief form pain is the priority.
3. Answer: (D) Decrease the size and vascularity of the thyroid gland.
Rationale: Lugols solution provides iodine, which aids in decreasing the
vascularity of the thyroid gland, which limits the risk of hemorrhage when
surgery is performed.
4. Answer: (A) Liver Disease
Rationale: The client with liver disease has a decreased ability to
metabolize carbohydrates because of a decreased ability to form glycogen
(glycogenesis) and to form glucose from glycogen.
5. Answer: (C) Leukopenia
Rationale: Leukopenia, a reduction in WBCs, is a systemic effect of
chemotherapy as a result of myelosuppression.
6. Answer: (C) Avoid foods that in the past caused flatus.
Rationale: Foods that bothered a person preoperatively will continue to do
so after a colostomy.
7. Answer: (B) Keep the irrigating container less than 18 inches above the
stoma.
Rationale: This height permits the solution to flow slowly with little force
so that excessive peristalsis is not immediately precipitated.
8. Answer: (A) Administer Kayexalate
Rationale: Kayexalate,a potassium exchange resin, permits sodium to be
exchanged for potassium in the intestine, reducing the serum potassium
level.
9. Answer:(B) 28 gtt/min
Rationale: This is the correct flow rate; multiply the amount to be infused
(2000 ml) by the drop factor (10) and divide the result by the amount of
time in minutes (12 hours x 60 minutes)
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17. Answer: (A) This condition puts her at a higher risk for cervical cancer;
therefore, she should have a Papanicolaou (Pap) smear annually.
Rationale: Women with condylomata acuminata are at risk for cancer of
the cervix and vulva. Yearly Pap smears are very important for early
detection. Because condylomata acuminata is a virus, there is no
permanent cure. Because condylomata acuminata can occur on the vulva,
a condom won't protect sexual partners. HPV can be transmitted to other
parts of the body, such as the mouth, oropharynx, and larynx.
18. Answer: (A) The left kidney usually is slightly higher than the right one.
Rationale: The left kidney usually is slightly higher than the right one. An
adrenal gland lies atop each kidney. The average kidney measures
approximately 11 cm (4-3/8") long, 5 to 5.8 cm (2" to 2") wide, and 2.5
cm (1") thick. The kidneys are located retroperitoneally, in the posterior
aspect of the abdomen, on either side of the vertebral column. They lie
between the 12th thoracic and 3rd lumbar vertebrae.
19. Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine
6.5 mg/dl.
Rationale: The normal BUN level ranges 8 to 23 mg/dl; the normal serum
creatinine level ranges from 0.7 to 1.5 mg/dl. The test results in option C
are abnormally elevated, reflecting CRF and the kidneys' decreased ability
to remove nonprotein nitrogen waste from the blood. CRF causes
decreased pH and increased hydrogen ions not vice versa. CRF also
increases serum levels of potassium, magnesium, and phosphorous, and
decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls
within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also
falls with the normal range of 60% to 75%.
20. Answer: (D) Alteration in the size, shape, and organization of
differentiated cells
Rationale: Dysplasia refers to an alteration in the size, shape, and
organization of differentiated cells. The presence of completely
undifferentiated tumor cells that don't resemble cells of the tissues of their
origin is called anaplasia. An increase in the number of normal cells in a
normal arrangement in a tissue or an organ is called hyperplasia.
Replacement of one type of fully differentiated cell by another in tissues
where the second type normally isn't found is called metaplasia.
21. Answer: (D) Kaposi's sarcoma
Rationale: Kaposi's sarcoma is the most common cancer associated with
AIDS. Squamous cell carcinoma, multiple myeloma, and leukemia may
occur in anyone and aren't associated specifically with AIDS.
22. Answer: (C) To prevent cerebrospinal fluid (CSF) leakage
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and notify the health care provider. The other manifestations are expected
side effects of chemotherapy.
51. Answer: (D) This is only temporary; Stacy will re-grow new hair in 3-6
months, but may be different in texture.
Rationale: This is the appropriate response. The nurse should help the
mother how to cope with her own feelings regarding the childs disease so
as not to affect the child negatively. When the hair grows back, it is still of
the same color and texture.
52. Answer: (B) Apply viscous Lidocaine to oral ulcers as needed.
Rationale: Stomatitis can cause pain and this can be relieved by applying
topical anesthetics such as lidocaine before mouth care. When the patient
is already comfortable, the nurse can proceed with providing the patient
with oral rinses of saline solution mixed with equal part of water or
hydrogen peroxide mixed water in 1:3 concentrations to promote oral
hygiene. Every 2-4 hours.
53. Answer: (C) Immediately discontinue the infusion
Rationale: Edema or swelling at the IV site is a sign that the needle has
been dislodged and the IV solution is leaking into the tissues causing the
edema. The patient feels pain as the nerves are irritated by pressure and
the IV solution. The first action of the nurse would be to discontinue the
infusion right away to prevent further edema and other complication.
54. Answer: (C) Chronic obstructive bronchitis
Rationale: Clients with chronic obstructive bronchitis appear bloated; they
have large barrel chest and peripheral edema, cyanotic nail beds, and at
times, circumoral cyanosis. Clients with ARDS are acutely short of breath
and frequently need intubation for mechanical ventilation and large
amount of oxygen. Clients with asthma dont exhibit characteristics of
chronic disease, and clients with emphysema appear pink and cachectic.
55. Answer: (D) Emphysema
Rationale: Because of the large amount of energy it takes to breathe,
clients with emphysema are usually cachectic. Theyre pink and usually
breathe through pursed lips, hence the term puffer. Clients with ARDS
are usually acutely short of breath. Clients with asthma dont have any
particular characteristics, and clients with chronic obstructive bronchitis
are bloated and cyanotic in appearance.
56. Answer: D 80 mm Hg
Rationale: A client about to go into respiratory arrest will have inefficient
ventilation and will be retaining carbon dioxide. The value expected would
be around 80 mm Hg. All other values are lower than expected.
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80. Answer: (C) "I'll take two-thirds of the dose when I wake up and one-third
in the late afternoon."
Rationale: Hydrocortisone, a glucocorticoid, should be administered
according to a schedule that closely reflects the body's own secretion of
this hormone; therefore, two-thirds of the dose of hydrocortisone should
be taken in the morning and one-third in the late afternoon. This dosage
schedule reduces adverse effects.
81. Answer: (C) High corticotropin and high cortisol levels
Rationale: A corticotropin-secreting pituitary tumor would cause high
corticotropin and high cortisol levels. A high corticotropin level with a low
cortisol level and a low corticotropin level with a low cortisol level would be
associated with hypocortisolism. Low corticotropin and high cortisol levels
would be seen if there was a primary defect in the adrenal glands.
82. Answer: (D) Performing capillary glucose testing every 4 hours
Rationale: The nurse should perform capillary glucose testing every 4
hours because excess cortisol may cause insulin resistance, placing the
client at risk for hyperglycemia. Urine ketone testing isn't indicated
because the client does secrete insulin and, therefore, isn't at risk for
ketosis. Urine specific gravity isn't indicated because although fluid
balance can be compromised, it usually isn't dangerously imbalanced.
Temperature regulation may be affected by excess cortisol and isn't an
accurate indicator of infection.
83. Answer: (C) onset to be at 2:30 p.m. and its peak to be at 4 p.m.
Rationale: Regular insulin, which is a short-acting insulin, has an onset of
15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the
insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m.
and the peak from 4 p.m. to 6 p.m.
84. Answer: (A) No increase in the thyroid-stimulating hormone (TSH) level
after 30 minutes during the TSH stimulation test
Rationale: In the TSH test, failure of the TSH level to rise after 30
minutes confirms hyperthyroidism. A decreased TSH level indicates a
pituitary deficiency of this hormone. Below-normal levels of T3 and T4, as
detected by radioimmunoassay, signal hypothyroidism. A below-normal T4
level also occurs in malnutrition and liver disease and may result from
administration of phenytoin and certain other drugs.
85. Answer: (B) "Rotate injection sites within the same anatomic region, not
among different regions."
Rationale: The nurse should instruct the client to rotate injection sites
within the same anatomic region. Rotating sites among different regions
may cause excessive day-to-day variations in the blood glucose level;
also, insulin absorption differs from one region to the next. Insulin should
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be injected only into healthy tissue lacking large blood vessels, nerves, or
scar tissue or other deviations. Injecting insulin into areas of hypertrophy
may delay absorption. The client shouldn't inject insulin into areas of
lipodystrophy (such as hypertrophy or atrophy); to prevent lipodystrophy,
the client should rotate injection sites systematically. Exercise speeds
drug absorption, so the client shouldn't inject insulin into sites above
muscles that will be exercised heavily.
86. Answer: (D) Below-normal serum potassium level
Rationale: A client with HHNS has an overall body deficit of potassium
resulting from diuresis, which occurs secondary to the hyperosmolar,
hyperglycemic state caused by the relative insulin deficiency. An elevated
serum acetone level and serum ketone bodies are characteristic of
diabetic ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur
in HHNS.
87. Answer: (D) Maintaining room temperature in the low-normal range
Rationale: Graves' disease causes signs and symptoms of
hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst
and appetite, and weight loss. To reduce heat intolerance and
diaphoresis, the nurse should keep the client's room temperature in the
low-normal range. To replace fluids lost via diaphoresis, the nurse should
encourage, not restrict, intake of oral fluids. Placing extra blankets on the
bed of a client with heat intolerance would cause discomfort. To provide
needed energy and calories, the nurse should encourage the client to eat
high-carbohydrate foods.
88. Answer: (A) Fracture of the distal radius
Rationale: Colles' fracture is a fracture of the distal radius, such as from
a fall on an outstretched hand. It's most common in women. Colles'
fracture doesn't refer to a fracture of the olecranon, humerus, or carpal
scaphoid.
89. Answer: (B) Calcium and phosphorous
Rationale: In osteoporosis, bones lose calcium and phosphate salts,
becoming porous, brittle, and abnormally vulnerable to fracture. Sodium
and potassium aren't involved in the development of osteoporosis.
90. Answer: (A) Adult respiratory distress syndrome (ARDS)
Rationale: Severe hypoxia after smoke inhalation is typically related to
ARDS. The other conditions listed arent typically associated with smoke
inhalation and severe hypoxia.
91. Answer: (D) Fat embolism
Rationale: Long bone fractures are correlated with fat emboli, which
cause shortness of breath and hypoxia. Its unlikely the client has
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TEST V
Answers and Rationale Care of Clients with Physiologic and
Psychosocial Alterations
1. Answer: (D) Focusing
Rationale: The nurse is using focusing by suggesting that the client
discuss a specific issue. The nurse didnt restate the question, make
observation, or ask further question (exploring).
2. Answer: (D) Remove all other clients from the dayroom.
Rationale: The nurses first priority is to consider the safety of the clients
in the therapeutic setting. The other actions are appropriate responses
after ensuring the safety of other clients.
3. Answer: (A) The client is disruptive.
Rationale: Group activity provides too much stimulation, which the client
will not be able to handle (harmful to self) and as a result will be disruptive
to others.
4. Answer: (C) Agree to talk with the mother and the father together.
Rationale: By agreeing to talk with both parents, the nurse can provide
emotional support and further assess and validate the familys needs.
5. Answer: (A) Perceptual disorders.
Rationale: Frightening visual hallucinations are especially common in
clients experiencing alcohol withdrawal.
6. Answer: (D) Suggest that it takes awhile before seeing the results.
Rationale: The client needs a specific response; that it takes 2 to 3 weeks
(a delayed effect) until the therapeutic blood level is reached.
7. Answer: (C) Superego
Rationale: This behavior shows a weak sense of moral consciousness.
According to Freudian theory, personality disorders stem from a weak
superego.
8. Answer: (C) Skeletal muscle paralysis.
Rationale: Anectine is a depolarizing muscle relaxant causing paralysis. It
is used to reduce the intensity of muscle contractions during the
convulsive stage, thereby reducing the risk of bone fractures or
dislocation.
9. Answer: (D) Increase calories, carbohydrates, and protein.
Rationale: This client increased protein for tissue building and increased
calories to replace what is burned up (usually via carbohydrates).
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26. Answer: (D) Listening attentively with a neutral attitude and avoiding
power struggles.
Rationale: The nurse should listen to the clients requests, express
willingness to seriously consider the request, and respond later. The nurse
should encourage the client to take short daytime naps because he
expends so much energy. The nurse shouldnt try to restrain the client
when he feels the need to move around as long as his activity isnt
harmful. High calorie finger foods should be offered to supplement the
clients diet, if he cant remain seated long enough to eat a complete meal.
The nurse shouldnt be forced to stay seated at the table to finid=sh a
meal. The nurse should set limits in a calm, clear, and self-confident tone
of voice.
27. Answer: (D) Denial
Rationale: Denial is unconscious defense mechanism in which emotional
conflict and anxiety is avoided by refusing to acknowledge feelings,
desires, impulses, or external facts that are consciously intolerable.
Withdrawal is a common response to stress, characterized by apathy.
Logical thinking is the ability to think rationally and make responsible
decisions, which would lead the client admitting the problem and seeking
help. Repression is suppressing past events from the consciousness
because of guilty association.
28. Answer: (B) Paranoid thoughts
Rationale: Clients with schizotypal personality disorder experience
excessive social anxiety that can lead to paranoid thoughts. Aggressive
behavior is uncommon, although these clients may experience agitation
with anxiety. Their behavior is emotionally cold with a flattened affect,
regardless of the situation. These clients demonstrate a reduced capacity
for close or dependent relationships.
29. Answer: (C) Identify anxiety-causing situations
Rationale: Bulimic behavior is generally a maladaptive coping response to
stress and underlying issues. The client must identify anxiety-causing
situations that stimulate the bulimic behavior and then learn new ways of
coping with the anxiety.
30. Answer: (A) Tension and irritability
Rationale: An amphetamine is a nervous system stimulant that is subject
to abuse because of its ability to produce wakefulness and euphoria. An
overdose increases tension and irritability. Options B and C are incorrect
because amphetamines stimulate norepinephrine, which increase the
heart rate and blood flow. Diarrhea is a common adverse effect so option
D in is incorrect.
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31. Answer: (B) No, I do not hear your voices, but I believe you can hear
them.
Rationale: The nurse, demonstrating knowledge and understanding,
accepts the clients perceptions even though they are hallucinatory.
32. Answer: (C) Confusion for a time after treatment
Rationale: The electrical energy passing through the cerebral cortex
during ECT results in a temporary state of confusion after treatment.
33. Answer: (D) Acceptance stage
Rationale: Communication and intervention during this stage are mainly
nonverbal, as when the client gestures to hold the nurses hand.
34. Answer: (D) A higher level of anxiety continuing for more than 3 months.
Rationale: This is not an expected outcome of a crisis because by
definition a crisis would be resolved in 6 weeks.
35. Answer: (B) Staying in the sun
Rationale: Haldol causes photosensitivity. Severe sunburn can occur on
exposure to the sun.
36. Answer: (D) Moderate-level anxiety
Rationale: A moderately anxious person can ignore peripheral events and
focuses on central concerns.
37. Answer: (C) Diverse interest
Rationale: Before onset of depression, these clients usually have very
narrow, limited interest.
38. Answer: (A) As their depression begins to improve
Rationale: At this point the client may have enough energy to plan and
execute an attempt.
39. Answer: (D) Disturbance in recalling recent events related to cerebral
hypoxia.
Rationale: Cell damage seems to interfere with registering input stimuli,
which affects the ability to register and recall recent events; vascular
dementia is related to multiple vascular lesions of the cerebral cortex and
subcortical structure.
40. Answer: (D) Encouraging the client to have blood levels checked as
ordered.
Rationale: Blood levels must be checked monthly or bimonthly when the
client is on maintenance therapy because there is only a small range
between therapeutic and toxic levels.
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49. Answer: (B) Report a sore throat or fever to the physician immediately.
Rationale: A sore throat and fever are indications of an infection caused
by agranulocytosis, a potentially life-threatening complication of clozapine.
Because of the risk of agranulocytosis, white blood cell (WBC) counts are
necessary weekly, not monthly. If the WBC count drops below 3,000/l,
the medication must be stopped. Hypotension may occur in clients taking
this medication. Warn the client to stand up slowly to avoid dizziness from
orthostatic hypotension. The medication should be continued, even when
symptoms have been controlled. If the medication must be stopped, it
should be slowly tapered over 1 to 2 weeks and only under the
supervision of a physician.
50. Answer: (C) Neuroleptic malignant syndrome.
Rationale: The client's signs and symptoms suggest neuroleptic
malignant syndrome, a life-threatening reaction to neuroleptic medication
that requires immediate treatment. Tardive dyskinesia causes involuntary
movements of the tongue, mouth, facial muscles, and arm and leg
muscles. Dystonia is characterized by cramps and rigidity of the tongue,
face, neck, and back muscles. Akathisia causes restlessness, anxiety, and
jitteriness.
51. Answer: (B) Advising the client to sit up for 1 minute before getting out of
bed.
Rationale: To minimize the effects of amitriptyline-induced orthostatic
hypotension, the nurse should advise the client to sit up for 1 minute
before getting out of bed. Orthostatic hypotension commonly occurs with
tricyclic antidepressant therapy. In these cases, the dosage may be
reduced or the physician may prescribe nortriptyline, another tricyclic
antidepressant. Orthostatic hypotension disappears only when the drug is
discontinued.
52. Answer: (D) Dysthymic disorder.
Rationale: Dysthymic disorder is marked by feelings of depression lasting
at least 2 years, accompanied by at least two of the following symptoms:
sleep disturbance, appetite disturbance, low energy or fatigue, low selfesteem, poor concentration, difficulty making decisions, and
hopelessness. These symptoms may be relatively continuous or
separated by intervening periods of normal mood that last a few days to a
few weeks. Cyclothymic disorder is a chronic mood disturbance of at least
2 years' duration marked by numerous periods of depression and
hypomania. Atypical affective disorder is characterized by manic signs and
symptoms. Major depression is a recurring, persistent sadness or loss of
interest or pleasure in almost all activities, with signs and symptoms
recurring for at least 2 weeks.
53. Answer: (C) 30 g mixed in 250 ml of water
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PART III
PRACTICE TEST I
FOUNDATION OF NURSING
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FOUNDATION OF NURSING
1. Which element in the circular chain of infection can be eliminated by
preserving skin integrity?
a. Host
b. Reservoir
c. Mode of transmission
d. Portal of entry
2. Which of the following will probably result in a break in sterile technique for
respiratory isolation?
a. Opening the patients window to the outside environment
b. Turning on the patients room ventilator
c. Opening the door of the patients room leading into the hospital
corridor
d. Failing to wear gloves when administering a bed bath
3. Which of the following patients is at greater risk for contracting an
infection?
a. A patient with leukopenia
b. A patient receiving broad-spectrum antibiotics
c. A postoperative patient who has undergone orthopedic surgery
d. A newly diagnosed diabetic patient
4. Effective hand washing requires the use of:
a. Soap or detergent to promote emulsification
b. Hot water to destroy bacteria
c. A disinfectant to increase surface tension
d. All of the above
5. After routine patient contact, hand washing should last at least:
a. 30 seconds
b. 1 minute
c. 2 minute
d. 3 minutes
6. Which of the following procedures always requires surgical asepsis?
a. Vaginal instillation of conjugated estrogen
b. Urinary catheterization
c. Nasogastric tube insertion
d. Colostomy irrigation
7. Sterile technique is used whenever:
a. Strict isolation is required
b. Terminal disinfection is performed
c. Invasive procedures are performed
d. Protective isolation is necessary
8. Which of the following constitutes a break in sterile technique while
preparing a sterile field for a dressing change?
a. Using sterile forceps, rather than sterile gloves, to handle a sterile
item
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d. Dehydration
31. All of the following are common signs and symptoms of phlebitis except:
a. Pain or discomfort at the IV insertion site
b. Edema and warmth at the IV insertion site
c. A red streak exiting the IV insertion site
d. Frank bleeding at the insertion site
32. The best way of determining whether a patient has learned to instill ear
medication properly is for the nurse to:
a. Ask the patient if he/she has used ear drops before
b. Have the patient repeat the nurses instructions using her own
words
c. Demonstrate the procedure to the patient and encourage to ask
questions
d. Ask the patient to demonstrate the procedure
33. Which of the following types of medications can be administered via
gastrostomy tube?
a. Any oral medications
b. Capsules whole contents are dissolve in water
c. Enteric-coated tablets that are thoroughly dissolved in water
d. Most tablets designed for oral use, except for extended-duration
compounds
34. A patient who develops hives after receiving an antibiotic is exhibiting
drug:
a. Tolerance
b. Idiosyncrasy
c. Synergism
d. Allergy
35. A patient has returned to his room after femoral arteriography. All of the
following are appropriate nursing interventions except:
a. Assess femoral, popliteal, and pedal pulses every 15 minutes for 2
hours
b. Check the pressure dressing for sanguineous drainage
c. Assess a vital signs every 15 minutes for 2 hours
d. Order a hemoglobin and hematocrit count 1 hour after the
arteriography
36. The nurse explains to a patient that a cough:
a. Is a protective response to clear the respiratory tract of irritants
b. Is primarily a voluntary action
c. Is induced by the administration of an antitussive drug
d. Can be inhibited by splinting the abdomen
37. An infected patient has chills and begins shivering. The best nursing
intervention is to:
a. Apply iced alcohol sponges
b. Provide increased cool liquids
c. Provide additional bedclothes
d. Provide increased ventilation
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11. A. The back of the gown is considered clean, the front is contaminated.
So, after removing gloves and washing hands, the nurse should untie the
back of the gown; slowly move backward away from the gown, holding the
inside of the gown and keeping the edges off the floor; turn and fold the
gown inside out; discard it in a contaminated linen container; then wash
her hands again.
12. B. According to the Centers for Disease Control (CDC), blood-to-blood
contact occurs most commonly when a health care worker attempts to cap
a used needle. Therefore, used needles should never be recapped;
instead they should be inserted in a specially designed puncture resistant,
labeled container. Wearing gloves is not always necessary when
administering an I.M. injection. Enteric precautions prevent the transfer of
pathogens via feces.
13. A. Nurses and other health care professionals previously believed that
massaging a reddened area with lotion would promote venous return and
reduce edema to the area. However, research has shown that massage
only increases the likelihood of cellular ischemia and necrosis to the area.
14. B. Before a blood transfusion is performed, the blood of the donor and
recipient must be checked for compatibility. This is done by blood typing (a
test that determines a persons blood type) and cross-matching (a
procedure that determines the compatibility of the donors and recipients
blood after the blood types has been matched). If the blood specimens are
incompatible, hemolysis and antigen-antibody reactions will occur.
15. A. Platelets are disk-shaped cells that are essential for blood coagulation.
A platelet count determines the number of thrombocytes in blood available
for promoting hemostasis and assisting with blood coagulation after injury.
It also is used to evaluate the patients potential for bleeding; however, this
is not its primary purpose. The normal count ranges from 150,000 to
350,000/mm3. A count of 100,000/mm3 or less indicates a potential for
bleeding; count of less than 20,000/mm3 is associated with spontaneous
bleeding.
16. D. Leukocytosis is any transient increase in the number of white blood
cells (leukocytes) in the blood. Normal WBC counts range from 5,000 to
100,000/mm3. Thus, a count of 25,000/mm3 indicates leukocytosis.
17. A. Fatigue, muscle cramping, and muscle weaknesses are symptoms of
hypokalemia (an inadequate potassium level), which is a potential side
effect of diuretic therapy. The physician usually orders supplemental
potassium to prevent hypokalemia in patients receiving diuretics. Anorexia
is another symptom of hypokalemia. Dysphagia means difficulty
swallowing.
18. A. Pregnancy or suspected pregnancy is the only contraindication for a
chest X-ray. However, if a chest X-ray is necessary, the patient can wear
a lead apron to protect the pelvic region from radiation. Jewelry, metallic
objects, and buttons would interfere with the X-ray and thus should not be
worn above the waist. A signed consent is not required because a chest
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temperature and stop the chills. Attempts to cool the body result in further
shivering, increased metabloism, and thus increased heat production.
38. D. A clinical nurse specialist must have completed a masters degree in a
clinical specialty and be a registered professional nurse. The National
League of Nursing accredits educational programs in nursing and provides
a testing service to evaluate student nursing competence but it does not
certify nurses. The American Nurses Association identifies requirements
for certification and offers examinations for certification in many areas of
nursing., such as medical surgical nursing. These certification
(credentialing) demonstrates that the nurse has the knowledge and the
ability to provide high quality nursing care in the area of her certification. A
graduate of an associate degree program is not a clinical nurse specialist:
however, she is prepared to provide bed side nursing with a high degree
of knowledge and skill. She must successfully complete the licensing
examination to become a registered professional nurse.
39. D. Microorganisms usually do not grow in an acidic environment.
40. D. Bile colors the stool brown. Any inflammation or obstruction that impairs
bile flow will affect the stool pigment, yielding light, clay-colored stool.
Upper GI bleeding results in black or tarry stool. Constipation is
characterized by small, hard masses. Many medications and foods will
discolor stool for example, drugs containing iron turn stool black.; beets
turn stool red.
41. D. In the evaluation step of the nursing process, the nurse must decide
whether the patient has achieved the expected outcome that was
identified in the planning phase.
42. A. The main sources of vitamin A are yellow and green vegetables (such
as carrots, sweet potatoes, squash, spinach, collard greens, broccoli, and
cabbage) and yellow fruits (such as apricots, and cantaloupe). Animal
sources include liver, kidneys, cream, butter, and egg yolks.
43. D. Maintaing the drainage tubing and collection bag level with the patients
bladder could result in reflux of urine into the kidney. Irrigating the bladder
with Neosporin and clamping the catheter for 1 hour every 4 hours must
be prescribed by a physician.
44. D. The ELISA test of venous blood is used to assess blood and potential
blood donors to human immunodeficiency virus (HIV). A positive ELISA
test combined with various signs and symptoms helps to diagnose
acquired immunodeficiency syndrome (AIDS)
45. D. Tachypnea (an abnormally rapid rate of breathing) would indicate that
the patient was still hypoxic (deficient in oxygen).The partial pressures of
arterial oxygen and carbon dioxide listed are within the normal range.
Eupnea refers to normal respiration.
46. D. Studies have shown that showering with an antiseptic soap before
surgery is the most effective method of removing microorganisms from the
skin. Shaving the site of the intended surgery might cause breaks in the
skin, thereby increasing the risk of infection; however, if indicated,
shaving, should be done immediately before surgery, not the day before.
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PRACTICE TEST II
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b. October 21
c. November 7
d. December 27
8. When taking an obstetrical history on a pregnant client who states, I had
a son born at 38 weeks gestation, a daughter born at 30 weeks gestation
and I lost a baby at about 8 weeks, the nurse should record her
obstetrical history as which of the following?
a. G2 T2 P0 A0 L2
b. G3 T1 P1 A0 L2
c. G3 T2 P0 A0 L2
d. G4 T1 P1 A1 L2
9. When preparing to listen to the fetal heart rate at 12 weeks gestation, the
nurse would use which of the following?
a. Stethoscope placed midline at the umbilicus
b. Doppler placed midline at the suprapubic region
c. Fetoscope placed midway between the umbilicus and the xiphoid
process
d. External electronic fetal monitor placed at the umbilicus
10. When developing a plan of care for a client newly diagnosed with
gestational diabetes, which of the following instructions would be the
priority?
a. Dietary intake
b. Medication
c. Exercise
d. Glucose monitoring
11. A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of
the following would be the priority when assessing the client?
a. Glucosuria
b. Depression
c. Hand/face edema
d. Dietary intake
12. A client 12 weeks pregnant come to the emergency department with
abdominal cramping and moderate vaginal bleeding. Speculum
examination reveals 2 to 3 cms cervical dilation. The nurse would
document these findings as which of the following?
a. Threatened abortion
b. Imminent abortion
c. Complete abortion
d. Missed abortion
13. Which of the following would be the priority nursing diagnosis for a client
with an ectopic pregnancy?
a. Risk for infection
b. Pain
c. Knowledge Deficit
d. Anticipatory Grieving
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14. Before assessing the postpartum clients uterus for firmness and position
in relation to the umbilicus and midline, which of the following should the
nurse do first?
a. Assess the vital signs
b. Administer analgesia
c. Ambulate her in the hall
d. Assist her to urinate
15. Which of the following should the nurse do when a primipara who is
lactating tells the nurse that she has sore nipples?
a. Tell her to breast feed more frequently
b. Administer a narcotic before breast feeding
c. Encourage her to wear a nursing brassiere
d. Use soap and water to clean the nipples
16. The nurse assesses the vital signs of a client, 4 hours postpartum that are
as follows: BP 90/60; temperature 100.4F; pulse 100 weak, thready; R 20
per minute. Which of the following should the nurse do first?
a. Report the temperature to the physician
b. Recheck the blood pressure with another cuff
c. Assess the uterus for firmness and position
d. Determine the amount of lochia
17. The nurse assesses the postpartum vaginal discharge (lochia) on four
clients. Which of the following assessments would warrant notification of
the physician?
a. A dark red discharge on a 2-day postpartum client
b. A pink to brownish discharge on a client who is 5 days postpartum
c. Almost colorless to creamy discharge on a client 2 weeks after
delivery
d. A bright red discharge 5 days after delivery
18. A postpartum client has a temperature of 101.4F, with a uterus that is
tender when palpated, remains unusually large, and not descending as
normally expected. Which of the following should the nurse assess next?
a. Lochia
b. Breasts
c. Incision
d. Urine
19. Which of the following is the priority focus of nursing practice with the
current early postpartum discharge?
a. Promoting comfort and restoration of health
b. Exploring the emotional status of the family
c. Facilitating safe and effective self-and newborn care
d. Teaching about the importance of family planning
20. Which of the following actions would be least effective in maintaining a
neutral thermal environment for the newborn?
a. Placing infant under radiant warmer after bathing
b. Covering the scale with a warmed blanket prior to weighing
c. Placing crib close to nursery window for family viewing
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27. The postterm neonate with meconium-stained amniotic fluid needs care
designed to especially monitor for which of the following?
a. Respiratory problems
b. Gastrointestinal problems
c. Integumentary problems
d. Elimination problems
28. When measuring a clients fundal height, which of the following techniques
denotes the correct method of measurement used by the nurse?
a. From the xiphoid process to the umbilicus
b. From the symphysis pubis to the xiphoid process
c. From the symphysis pubis to the fundus
d. From the fundus to the umbilicus
29. A client with severe preeclampsia is admitted with of BP 160/110,
proteinuria, and severe pitting edema. Which of the following would be
most important to include in the clients plan of care?
a. Daily weights
b. Seizure precautions
c. Right lateral positioning
d. Stress reduction
30. A postpartum primipara asks the nurse, When can we have sexual
intercourse again? Which of the following would be the nurses best
response?
a. Anytime you both want to.
b. As soon as choose a contraceptive method.
c. When the discharge has stopped and the incision is healed.
d. After your 6 weeks examination.
31. When preparing to administer the vitamin K injection to a neonate, the
nurse would select which of the following sites as appropriate for the
injection?
a. Deltoid muscle
b. Anterior femoris muscle
c. Vastus lateralis muscle
d. Gluteus maximus muscle
32. When performing a pelvic examination, the nurse observes a red swollen
area on the right side of the vaginal orifice. The nurse would document
this as enlargement of which of the following?
a. Clitoris
b. Parotid gland
c. Skenes gland
d. Bartholins gland
33. To differentiate as a female, the hormonal stimulation of the embryo that
must occur involves which of the following?
a. Increase in maternal estrogen secretion
b. Decrease in maternal androgen secretion
c. Secretion of androgen by the fetal gonad
d. Secretion of estrogen by the fetal gonad
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40. Which of the following would be the nurses most appropriate response to
a client who asks why she must have a cesarean delivery if she has a
complete placenta previa?
a. You will have to ask your physician when he returns.
b. You need a cesarean to prevent hemorrhage.
c. The placenta is covering most of your cervix.
d. The placenta is covering the opening of the uterus and blocking
your baby.
41. The nurse understands that the fetal head is in which of the following
positions with a face presentation?
a. Completely flexed
b. Completely extended
c. Partially extended
d. Partially flexed
42. With a fetus in the left-anterior breech presentation, the nurse would
expect the fetal heart rate would be most audible in which of the following
areas?
a. Above the maternal umbilicus and to the right of midline
b. In the lower-left maternal abdominal quadrant
c. In the lower-right maternal abdominal quadrant
d. Above the maternal umbilicus and to the left of midline
43. The amniotic fluid of a client has a greenish tint. The nurse interprets this
to be the result of which of the following?
a. Lanugo
b. Hydramnio
c. Meconium
d. Vernix
44. A patient is in labor and has just been told she has a breech presentation.
The nurse should be particularly alert for which of the following?
a. Quickening
b. Ophthalmia neonatorum
c. Pica
d. Prolapsed umbilical cord
45. When describing dizygotic twins to a couple, on which of the following
would the nurse base the explanation?
a. Two ova fertilized by separate sperm
b. Sharing of a common placenta
c. Each ova with the same genotype
d. Sharing of a common chorion
46. Which of the following refers to the single cell that reproduces itself after
conception?
a. Chromosome
b. Blastocyst
c. Zygote
d. Trophoblast
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47. In the late 1950s, consumers and health care professionals began
challenging the routine use of analgesics and anesthetics during childbirth.
Which of the following was an outgrowth of this concept?
a. Labor, delivery, recovery, postpartum (LDRP)
b. Nurse-midwifery
c. Clinical nurse specialist
d. Prepared childbirth
48. A client has a midpelvic contracture from a previous pelvic injury due to a
motor vehicle accident as a teenager. The nurse is aware that this could
prevent a fetus from passing through or around which structure during
childbirth?
a. Symphysis pubis
b. Sacral promontory
c. Ischial spines
d. Pubic arch
49. When teaching a group of adolescents about variations in the length of the
menstrual cycle, the nurse understands that the underlying mechanism is
due to variations in which of the following phases?
a. Menstrual phase
b. Proliferative phase
c. Secretory phase
d. Ischemic phase
50. When teaching a group of adolescents about male hormone production,
which of the following would the nurse include as being produced by the
Leydig cells?
a. Follicle-stimulating hormone
b. Testosterone
c. Leuteinizing hormone
d. Gonadotropin releasing hormone
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5. C. During the third trimester, the enlarging uterus places pressure on the
intestines. This coupled with the effect of hormones on smooth muscle
relaxation causes decreased intestinal motility (peristalsis). Increasing
fiber in the diet will help fecal matter pass more quickly through the
intestinal tract, thus decreasing the amount of water that is absorbed. As a
result, stool is softer and easier to pass. Enemas could precipitate preterm
labor and/or electrolyte loss and should be avoided. Laxatives may cause
preterm labor by stimulating peristalsis and may interfere with the
absorption of nutrients. Use for more than 1 week can also lead to laxative
dependency. Liquid in the diet helps provide a semisolid, soft consistency
to the stool. Eight to ten glasses of fluid per day are essential to maintain
hydration and promote stool evacuation.
6. D. To ensure adequate fetal growth and development during the 40 weeks
of a pregnancy, a total weight gain 25 to 30 pounds is recommended: 1.5
pounds in the first 10 weeks; 9 pounds by 30 weeks; and 27.5 pounds by
40 weeks. The pregnant woman should gain less weight in the first and
second trimester than in the third. During the first trimester, the client
should only gain 1.5 pounds in the first 10 weeks, not 1 pound per week. A
weight gain of pound per week would be 20 pounds for the total
pregnancy, less than the recommended amount.
7. B. To calculate the EDD by Nageles rule, add 7 days to the first day of the
last menstrual period and count back 3 months, changing the year
appropriately. To obtain a date of September 27, 7 days have been added
to the last day of the LMP (rather than the first day of the LMP), plus 4
months (instead of 3 months) were counted back. To obtain the date of
November 7, 7 days have been subtracted (instead of added) from the
first day of LMP plus November indicates counting back 2 months (instead
of 3 months) from January. To obtain the date of December 27, 7 days
were added to the last day of the LMP (rather than the first day of the
LMP) and December indicates counting back only 1 month (instead of 3
months) from January.
8. D. The client has been pregnant four times, including current pregnancy
(G). Birth at 38 weeks gestation is considered full term (T), while birth
form 20 weeks to 38 weeks is considered preterm (P). A spontaneous
abortion occurred at 8 weeks (A). She has two living children (L).
9. B. At 12 weeks gestation, the uterus rises out of the pelvis and is palpable
above the symphysis pubis. The Doppler intensifies the sound of the fetal
pulse rate so it is audible. The uterus has merely risen out of the pelvis
into the abdominal cavity and is not at the level of the umbilicus. The fetal
heart rate at this age is not audible with a stethoscope. The uterus at 12
weeks is just above the symphysis pubis in the abdominal cavity, not
midway between the umbilicus and the xiphoid process. At 12 weeks the
FHR would be difficult to auscultate with a fetoscope. Although the
external electronic fetal monitor would project the FHR, the uterus has not
risen to the umbilicus at 12 weeks.
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15. A. Feeding more frequently, about every 2 hours, will decrease the infants
frantic, vigorous sucking from hunger and will decrease breast
engorgement, soften the breast, and promote ease of correct latching-on
for feeding. Narcotics administered prior to breast feeding are passed
through the breast milk to the infant, causing excessive sleepiness. Nipple
soreness is not severe enough to warrant narcotic analgesia. All
postpartum clients, especially lactating mothers, should wear a supportive
brassiere with wide cotton straps. This does not, however, prevent or
reduce nipple soreness. Soaps are drying to the skin of the nipples and
should not be used on the breasts of lactating mothers. Dry nipple skin
predisposes to cracks and fissures, which can become sore and painful.
16. D. A weak, thready pulse elevated to 100 BPM may indicate impending
hemorrhagic shock. An increased pulse is a compensatory mechanism of
the body in response to decreased fluid volume. Thus, the nurse should
check the amount of lochia present. Temperatures up to 100.48F in the
first 24 hours after birth are related to the dehydrating effects of labor and
are considered normal. Although rechecking the blood pressure may be a
correct choice of action, it is not the first action that should be
implemented in light of the other data. The data indicate a potential
impending hemorrhage. Assessing the uterus for firmness and position in
relation to the umbilicus and midline is important, but the nurse should
check the extent of vaginal bleeding first. Then it would be appropriate to
check the uterus, which may be a possible cause of the hemorrhage.
17. D. Any bright red vaginal discharge would be considered abnormal, but
especially 5 days after delivery, when the lochia is typically pink to
brownish. Lochia rubra, a dark red discharge, is present for 2 to 3 days
after delivery. Bright red vaginal bleeding at this time suggests late
postpartum hemorrhage, which occurs after the first 24 hours following
delivery and is generally caused by retained placental fragments or
bleeding disorders. Lochia rubra is the normal dark red discharge
occurring in the first 2 to 3 days after delivery, containing epithelial cells,
erythrocyes, leukocytes and decidua. Lochia serosa is a pink to brownish
serosanguineous discharge occurring from 3 to 10 days after delivery that
contains decidua, erythrocytes, leukocytes, cervical mucus, and
microorganisms. Lochia alba is an almost colorless to yellowish discharge
occurring from 10 days to 3 weeks after delivery and containing
leukocytes, decidua, epithelial cells, fat, cervical mucus, cholesterol
crystals, and bacteria.
18. A. The data suggests an infection of the endometrial lining of the uterus.
The lochia may be decreased or copious, dark brown in appearance, and
foul smelling, providing further evidence of a possible infection. All the
clients data indicate a uterine problem, not a breast problem. Typically,
transient fever, usually 101F, may be present with breast engorgement.
Symptoms of mastitis include influenza-like manifestations. Localized
infection of an episiotomy or C-section incision rarely causes systemic
symptoms, and uterine involution would not be affected. The client data do
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anterior femoris muscle is the next safest muscle to use in a newborn but
is not the safest. Because of the proximity of the sciatic nerve, the gluteus
maximus muscle should not be until the child has been walking 2 years.
32. D. Bartholins glands are the glands on either side of the vaginal orifice.
The clitoris is female erectile tissue found in the perineal area above the
urethra. The parotid glands are open into the mouth. Skenes glands open
into the posterior wall of the female urinary meatus.
33. D. The fetal gonad must secrete estrogen for the embryo to differentiate
as a female. An increase in maternal estrogen secretion does not effect
differentiation of the embryo, and maternal estrogen secretion occurs in
every pregnancy. Maternal androgen secretion remains the same as
before pregnancy and does not effect differentiation. Secretion of
androgen by the fetal gonad would produce a male fetus.
34. A. Using bicarbonate would increase the amount of sodium ingested,
which can cause complications. Eating low-sodium crackers would be
appropriate. Since liquids can increase nausea avoiding them in the
morning hours when nausea is usually the strongest is appropriate. Eating
six small meals a day would keep the stomach full, which often decrease
nausea.
35. B. Ballottement indicates passive movement of the unengaged fetus.
Ballottement is not a contraction. Fetal kicking felt by the client represents
quickening. Enlargement and softening of the uterus is known as
Piskaceks sign.
36. B. Chadwicks sign refers to the purple-blue tinge of the cervix. Braxton
Hicks contractions are painless contractions beginning around the 4th
month. Goodells sign indicates softening of the cervix. Flexibility of the
uterus against the cervix is known as McDonalds sign.
37. C. Breathing techniques can raise the pain threshold and reduce the
perception of pain. They also promote relaxation. Breathing techniques do
not eliminate pain, but they can reduce it. Positioning, not breathing,
increases uteroplacental perfusion.
38. A. The clients labor is hypotonic. The nurse should call the physical and
obtain an order for an infusion of oxytocin, which will assist the uterus to
contact more forcefully in an attempt to dilate the cervix. Administering
light sedative would be done for hypertonic uterine contractions. Preparing
for cesarean section is unnecessary at this time. Oxytocin would increase
the uterine contractions and hopefully progress labor before a cesarean
would be necessary. It is too early to anticipate client pushing with
contractions.
39. D. The signs indicate placenta previa and vaginal exam to determine
cervical dilation would not be done because it could cause hemorrhage.
Assessing maternal vital signs can help determine maternal physiologic
status. Fetal heart rate is important to assess fetal well-being and should
be done. Monitoring the contractions will help evaluate the progress of
labor.
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40. D. A complete placenta previa occurs when the placenta covers the
opening of the uterus, thus blocking the passageway for the baby. This
response explains what a complete previa is and the reason the baby
cannot come out except by cesarean delivery. Telling the client to ask the
physician is a poor response and would increase the patients anxiety.
Although a cesarean would help to prevent hemorrhage, the statement
does not explain why the hemorrhage could occur. With a complete
previa, the placenta is covering all the cervix, not just most of it.
41. B. With a face presentation, the head is completely extended. With a
vertex presentation, the head is completely or partially flexed. With a brow
(forehead) presentation, the head would be partially extended.
42. D. With this presentation, the fetal upper torso and back face the left upper
maternal abdominal wall. The fetal heart rate would be most audible
above the maternal umbilicus and to the left of the middle. The other
positions would be incorrect.
43. C. The greenish tint is due to the presence of meconium. Lanugo is the
soft, downy hair on the shoulders and back of the fetus. Hydramnios
represents excessive amniotic fluid. Vernix is the white, cheesy substance
covering the fetus.
44. D. In a breech position, because of the space between the presenting part
and the cervix, prolapse of the umbilical cord is common. Quickening is
the womans first perception of fetal movement. Ophthalmia neonatorum
usually results from maternal gonorrhea and is conjunctivitis. Pica refers to
the oral intake of nonfood substances.
45. A. Dizygotic (fraternal) twins involve two ova fertilized by separate sperm.
Monozygotic (identical) twins involve a common placenta, same genotype,
and common chorion.
46. C. The zygote is the single cell that reproduces itself after conception. The
chromosome is the material that makes up the cell and is gained from
each parent. Blastocyst and trophoblast are later terms for the embryo
after zygote.
47. D. Prepared childbirth was the direct result of the 1950s challenging of the
routine use of analgesic and anesthetics during childbirth. The LDRP was
a much later concept and was not a direct result of the challenging of
routine use of analgesics and anesthetics during childbirth. Roles for
nurse midwives and clinical nurse specialists did not develop from this
challenge.
48. C. The ischial spines are located in the mid-pelvic region and could be
narrowed due to the previous pelvic injury. The symphysis pubis, sacral
promontory, and pubic arch are not part of the mid-pelvis.
49. B. Variations in the length of the menstrual cycle are due to variations in
the proliferative phase. The menstrual, secretory and ischemic phases do
not contribute to this variation.
50. B. Testosterone is produced by the Leyding cells in the seminiferous
tubules. Follicle-stimulating hormone and leuteinzing hormone are
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a. Bowel function
b. Peripheral sensation
c. Bleeding tendencies
d. Intake and out put
16. Lydia is scheduled for elective splenectomy. Before the clients goes to
surgery, the nurse in charge final assessment would be:
a. signed consent
b. vital signs
c. name band
d. empty bladder
17. What is the peak age range in acquiring acute lymphocytic leukemia (ALL)?
a. 4 to 12 years.
b. 20 to 30 years
c. 40 to 50 years
d. 60 60 70 years
18. Marie with acute lymphocytic leukemia suffers from nausea and headache.
These clinical manifestations may indicate all of the following except
a. effects of radiation
b. chemotherapy side effects
c. meningeal irritation
d. gastric distension
19. A client has been diagnosed with Disseminated Intravascular Coagulation
(DIC). Which of the following is contraindicated with the client?
a. Administering Heparin
b. Administering Coumadin
c. Treating the underlying cause
d. Replacing depleted blood products
20. Which of the following findings is the best indication that fluid replacement for
the client with hypovolemic shock is adequate?
a. Urine output greater than 30ml/hr
b. Respiratory rate of 21 breaths/minute
c. Diastolic blood pressure greater than 90 mmhg
d. Systolic blood pressure greater than 110 mmhg
21. Which of the following signs and symptoms would Nurse Maureen include in
teaching plan as an early manifestation of laryngeal cancer?
a. Stomatitis
b. Airway obstruction
c. Hoarseness
d. Dysphagia
22. Karina a client with myasthenia gravis is to receive immunosuppressive
therapy. The nurse understands that this therapy is effective because it:
a. Promotes the removal of antibodies that impair the transmission of
impulses
b. Stimulates the production of acetylcholine at the neuromuscular
junction.
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c. Hypertension
d. Restlessness
37. A client is experiencing spinal shock. Nurse Myrna should expect the function
of the bladder to be which of the following?
a. Normal
b. Atonic
c. Spastic
d. Uncontrolled
38. Which of the following stage the carcinogen is irreversible?
a. Progression stage
b. Initiation stage
c. Regression stage
d. Promotion stage
39. Among the following components thorough pain assessment, which is the
most significant?
a. Effect
b. Cause
c. Causing factors
d. Intensity
40. A 65 year old female is experiencing flare up of pruritus. Which of the clients
action could aggravate the cause of flare ups?
a. Sleeping in cool and humidified environment
b. Daily baths with fragrant soap
c. Using clothes made from 100% cotton
d. Increasing fluid intake
41. Atropine sulfate (Atropine) is contraindicated in all but one of the following
client?
a. A client with high blood
b. A client with bowel obstruction
c. A client with glaucoma
d. A client with U.T.I
42. Among the following clients, which among them is high risk for potential
hazards from the surgical experience?
a. 67-year-old client
b. 49-year-old client
c. 33-year-old client
d. 15-year-old client
43. Nurse Jon assesses vital signs on a client undergone epidural anesthesia.
Which of the following would the nurse assess next?
a. Headache
b. Bladder distension
c. Dizziness
d. Ability to move legs
44. Nurse Katrina should anticipate that all of the following drugs may be used in
the attempt to control the symptoms of Meniere's disease except:
a. Antiemetics
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b. Diuretics
c. Antihistamines
d. Glucocorticoids
45. Which of the following complications associated with tracheostomy tube?
a. Increased cardiac output
b. Acute respiratory distress syndrome (ARDS)
c. Increased blood pressure
d. Damage to laryngeal nerves
46. Nurse Faith should recognize that fluid shift in an client with burn injury results
from increase in the:
a. Total volume of circulating whole blood
b. Total volume of intravascular plasma
c. Permeability of capillary walls
d. Permeability of kidney tubules
47. An 83-year-old woman has several ecchymotic areas on her right arm. The
bruises are probably caused by:
a. increased capillary fragility and permeability
b. increased blood supply to the skin
c. self inflicted injury
d. elder abuse
48. Nurse Anna is aware that early adaptation of client with renal carcinoma is:
a. Nausea and vomiting
b. flank pain
c. weight gain
d. intermittent hematuria
49. A male client with tuberculosis asks Nurse Brian how long the chemotherapy
must be continued. Nurse Brians accurate reply would be:
a. 1 to 3 weeks
b. 6 to 12 months
c. 3 to 5 months
d. 3 years and more
50. A client has undergone laryngectomy. The immediate nursing priority would
be:
a. Keep trachea free of secretions
b. Monitor for signs of infection
c. Provide emotional support
d. Promote means of communication
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18. D. Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It
does invade the central nervous system, and clients experience headaches
and vomiting from meningeal irritation.
19. B. Disseminated Intravascular Coagulation (DIC) has not been found to
respond to oral anticoagulants such as Coumadin.
20. A. Urine output provides the most sensitive indication of the clients response
to therapy for hypovolemic shock. Urine output should be consistently greater
than 30 to 35 mL/hr.
21. C. Early warning signs of laryngeal cancer can vary depending on tumor
location. Hoarseness lasting 2 weeks should be evaluated because it is one
of the most common warning signs.
22. C. Steroids decrease the bodys immune response thus decreasing the
production of antibodies that attack the acetylcholine receptors at the
neuromuscular junction
23. C. The osmotic diuretic mannitol is contraindicated in the presence of
inadequate renal function or heart failure because it increases the
intravascular volume that must be filtered and excreted by the kidney.
24. A. These devices are more accurate because they are easily to used and
have improved adherence in insulin regimens by young people because the
medication can be administered discreetly.
25. C. Damage to blood vessels may decrease the circulatory perfusion of the
toes, this would indicate the lack of blood supply to the extremity.
26. D. Elevation will help control the edema that usually occurs.
27. B. Uric acid has a low solubility, it tends to precipitate and form deposits at
various sites where blood flow is least active, including cartilaginous tissue
such as the ears.
28. B. The palms should bear the clients weight to avoid damage to the nerves in
the axilla.
29. A. Active exercises, alternating extension, flexion, abduction, and adduction,
mobilize exudates in the joints relieves stiffness and pain.
30. C. Alteration in sensation and circulation indicates damage to the spinal cord,
if these occurs notify physician immediately.
31. A. In the diuretic phase fluid retained during the oliguric phase is excreted
and may reach 3 to 5 liters daily, hypovolemia may occur and fluids should be
replaced.
32. C. The constituents of CSF are similar to those of blood plasma. An
examination for glucose content is done to determine whether a body fluid is
a mucus or a CSF. A CSF normally contains glucose.
33. B. Trauma is one of the primary cause of brain damage and seizure activity in
adults. Other common causes of seizure activity in adults include neoplasms,
withdrawal from drugs and alcohol, and vascular disease.
34. A. It is crucial to monitor the pupil size and papillary response to indicate
changes around the cranial nerves.
35. C. The nurse most positive approach is to encourage the client with multiple
sclerosis to stay active, use stress reduction techniques and avoid fatigue
because it is important to support the immune system while remaining active.
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PSYCHIATRIC NURSING
Marco approached Nurse Trish asking for advice on how to deal with his
alcohol addiction. Nurse Trish should tell the client that the only effective
treatment for alcoholism is:
a. Psychotherapy
b. Alcoholics anonymous (A.A.)
c. Total abstinence
d. Aversion Therapy
Nurse Hazel is caring for a male client who experience false sensory
perceptions with no basis in reality. This perception is known as:
a. Hallucinations
b. Delusions
c. Loose associations
d. Neologisms
Nurse Monet is caring for a female client who has suicidal tendency.
When accompanying the client to the restroom, Nurse Monet should
a. Give her privacy
b. Allow her to urinate
c. Open the window and allow her to get some fresh air
d. Observe her
Nurse Maureen is developing a plan of care for a female client with
anorexia nervosa. Which action should the nurse include in the plan?
a. Provide privacy during meals
b. Set-up a strict eating plan for the client
c. Encourage client to exercise to reduce anxiety
d. Restrict visits with the family
A client is experiencing anxiety attack. The most appropriate nursing
intervention should include?
a. Turning on the television
b. Leaving the client alone
c. Staying with the client and speaking in short sentences
d. Ask the client to play with other clients
A female client is admitted with a diagnosis of delusions of GRANDEUR.
This diagnosis reflects a belief that one is:
a. Being Killed
b. Highly famous and important
c. Responsible for evil world
d. Connected to client unrelated to oneself
A 20 year old client was diagnosed with dependent personality disorder.
Which behavior is not likely to be evidence of ineffective individual coping?
a. Recurrent self-destructive behavior
b. Avoiding relationship
c. Showing interest in solitary activities
d. Inability to make choices and decision without advise
A male client is diagnosed with schizotypal personality disorder. Which
signs would this client exhibit during social situation?
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a. Paranoid thoughts
b. Emotional affect
c. Independence need
d. Aggressive behavior
9. Nurse Claire is caring for a client diagnosed with bulimia. The most
appropriate initial goal for a client diagnosed with bulimia is?
a. Encourage to avoid foods
b. Identify anxiety causing situations
c. Eat only three meals a day
d. Avoid shopping plenty of groceries
10. Nurse Tony was caring for a 41 year old female client. Which behavior by
the client indicates adult cognitive development?
a. Generates new levels of awareness
b. Assumes responsibility for her actions
c. Has maximum ability to solve problems and learn new skills
d. Her perception are based on reality
11. A neuromuscular blocking agent is administered to a client before ECT
therapy. The Nurse should carefully observe the client for?
a. Respiratory difficulties
b. Nausea and vomiting
c. Dizziness
d. Seizures
12. A 75 year old client is admitted to the hospital with the diagnosis of
dementia of the Alzheimers type and depression. The symptom that is
unrelated to depression would be?
a. Apathetic response to the environment
b. I dont know answer to questions
c. Shallow of labile effect
d. Neglect of personal hygiene
13. Nurse Trish is working in a mental health facility; the nurse priority nursing
intervention for a newly admitted client with bulimia nervosa would be to?
a. Teach client to measure I & O
b. Involve client in planning daily meal
c. Observe client during meals
d. Monitor client continuously
14. Nurse Patricia is aware that the major health complication associated with
intractable anorexia nervosa would be?
a. Cardiac dysrhythmias resulting to cardiac arrest
b. Glucose intolerance resulting in protracted hypoglycemia
c. Endocrine imbalance causing cold amenorrhea
d. Decreased metabolism causing cold intolerance
15. Nurse Anna can minimize agitation in a disturbed client by?
a. Increasing stimulation
b. limiting unnecessary interaction
c. increasing appropriate sensory perception
d. ensuring constant client and staff contact
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c. Soda
d. Regular Coffee
23. Which of the following would Nurse Hazel expect to assess for a client
who is exhibiting late signs of heroin withdrawal?
a. Yawning & diaphoresis
b. Restlessness & Irritability
c. Constipation & steatorrhea
d. Vomiting and Diarrhea
24. To establish open and trusting relationship with a female client who has
been hospitalized with severe anxiety, the nurse in charge should?
a. Encourage the staff to have frequent interaction with the client
b. Share an activity with the client
c. Give client feedback about behavior
d. Respect clients need for personal space
25. Nurse Monette recognizes that the focus of environmental (MILIEU)
therapy is to:
a. Manipulate the environment to bring about positive changes in
behavior
b. Allow the clients freedom to determine whether or not they will be
involved in activities
c. Role play life events to meet individual needs
d. Use natural remedies rather than drugs to control behavior
26. Nurse Trish would expect a child with a diagnosis of reactive attachment
disorder to:
a. Have more positive relation with the father than the mother
b. Cling to mother & cry on separation
c. Be able to develop only superficial relation with the others
d. Have been physically abuse
27. When teaching parents about childhood depression Nurse Trina should
say?
a. It may appear acting out behavior
b. Does not respond to conventional treatment
c. Is short in duration & resolves easily
d. Looks almost identical to adult depression
28. Nurse Perry is aware that language development in autistic child
resembles:
a. Scanning speech
b. Speech lag
c. Shuttering
d. Echolalia
29. A 60 year old female client who lives alone tells the nurse at the
community health center I really dont need anyone to talk to. The TV is
my best friend. The nurse recognizes that the client is using the defense
mechanism known as?
a. Displacement
b. Projection
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c. Sublimation
d. Denial
30. When working with a male client suffering phobia about black cats, Nurse
Trish should anticipate that a problem for this client would be?
a. Anxiety when discussing phobia
b. Anger toward the feared object
c. Denying that the phobia exist
d. Distortion of reality when completing daily routines
31. Linda is pacing the floor and appears extremely anxious. The duty nurse
approaches in an attempt to alleviate Lindas anxiety. The most
therapeutic question by the nurse would be?
a. Would you like to watch TV?
b. Would you like me to talk with you?
c. Are you feeling upset now?
d. Ignore the client
32. Nurse Penny is aware that the symptoms that distinguish post traumatic
stress disorder from other anxiety disorder would be:
a. Avoidance of situation & certain activities that resemble the stress
b. Depression and a blunted affect when discussing the traumatic
situation
c. Lack of interest in family & others
d. Re-experiencing the trauma in dreams or flashback
33. Nurse Benjie is communicating with a male client with substance-induced
persisting dementia; the client cannot remember facts and fills in the gaps
with imaginary information. Nurse Benjie is aware that this is typical of?
a. Flight of ideas
b. Associative looseness
c. Confabulation
d. Concretism
34. Nurse Joey is aware that the signs & symptoms that would be most
specific for diagnosis anorexia are?
a. Excessive weight loss, amenorrhea & abdominal distension
b. Slow pulse, 10% weight loss & alopecia
c. Compulsive behavior, excessive fears & nausea
d. Excessive activity, memory lapses & an increased pulse
35. A characteristic that would suggest to Nurse Anne that an adolescent may
have bulimia would be:
a. Frequent regurgitation & re-swallowing of food
b. Previous history of gastritis
c. Badly stained teeth
d. Positive body image
36. Nurse Monette is aware that extremely depressed clients seem to do best
in settings where they have:
a. Multiple stimuli
b. Routine Activities
c. Minimal decision making
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d. Varied Activities
37. To further assess a clients suicidal potential. Nurse Katrina should be
especially alert to the client expression of:
a. Frustration & fear of death
b. Anger & resentment
c. Anxiety & loneliness
d. Helplessness & hopelessness
38. A nursing care plan for a male client with bipolar I disorder should include:
a. Providing a structured environment
b. Designing activities that will require the client to maintain contact
with reality
c. Engaging the client in conversing about current affairs
d. Touching the client provide assurance
39. When planning care for a female client using ritualistic behavior, Nurse
Gina must recognize that the ritual:
a. Helps the client focus on the inability to deal with reality
b. Helps the client control the anxiety
c. Is under the clients conscious control
d. Is used by the client primarily for secondary gains
40. A 32 year old male graduate student, who has become increasingly
withdrawn and neglectful of his work and personal hygiene, is brought to
the psychiatric hospital by his parents. After detailed assessment, a
diagnosis of schizophrenia is made. It is unlikely that the client will
demonstrate:
a. Low self esteem
b. Concrete thinking
c. Effective self boundaries
d. Weak ego
41. A 23 year old client has been admitted with a diagnosis of schizophrenia
says to the nurse Yes, its march, March is little woman. Thats literal you
know. These statement illustrate:
a. Neologisms
b. Echolalia
c. Flight of ideas
d. Loosening of association
42. A long term goal for a paranoid male client who has unjustifiably accused
his wife of having many extramarital affairs would be to help the client
develop:
a. Insight into his behavior
b. Better self control
c. Feeling of self worth
d. Faith in his wife
43. A male client who is experiencing disordered thinking about food being
poisoned is admitted to the mental health unit. The nurse uses which
communication technique to encourage the client to eat dinner?
a. Focusing on self-disclosure of own food preference
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a. Neuroleptic medication
b. Short term seclusion
c. Psychosurgery
d. Electroconvulsive therapy
50. Mario is admitted to the emergency room with drug-included anxiety
related to over ingestion of prescribed antipsychotic medication. The most
important piece of information the nurse in charge should obtain initially is
the:
a. Length of time on the med.
b. Name of the ingested medication & the amount ingested
c. Reason for the suicide attempt
d. Name of the nearest relative & their phone number
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20. B. The nurse would specifically use supportive confrontation with the client to
point out discrepancies between what the client states and what actually
exists to increase responsibility for self.
21. C. The nurse would most likely administer benzodiazepine, such as lorazepan
(ativan) to the client who is experiencing symptom: The clients experiences
symptoms of withdrawal because of the rebound phenomenon when the
sedation of the CNS from alcohol begins to decrease.
22. D. Regular coffee contains caffeine which acts as psychomotor stimulants
and leads to feelings of anxiety and agitation. Serving coffee top the client
may add to tremors or wakefulness.
23. D. Vomiting and diarrhea are usually the late signs of heroin withdrawal,
along with muscle spasm, fever, nausea, repetitive, abdominal cramps and
backache.
24. D. Moving to a clients personal space increases the feeling of threat, which
increases anxiety.
25. A. Environmental (MILIEU) therapy aims at having everything in the clients
surrounding area toward helping the client.
26. C. Children who have experienced attachment difficulties with primary
caregiver are not able to trust others and therefore relate superficially
27. A. Children have difficulty verbally expressing their feelings, acting out
behavior, such as temper tantrums, may indicate underlying depression.
28. D. The autistic child repeat sounds or words spoken by others.
29. D. The client statement is an example of the use of denial, a defense that
blocks problem by unconscious refusing to admit they exist
30. A. Discussion of the feared object triggers an emotional response to the
object.
31. B. The nurse presence may provide the client with support & feeling of
control.
32. D. Experiencing the actual trauma in dreams or flashback is the major
symptom that distinguishes post traumatic stress disorder from other anxiety
disorder.
33. C. Confabulation or the filling in of memory gaps with imaginary facts is a
defense mechanism used by people experiencing memory deficits.
34. A. These are the major signs of anorexia nervosa. Weight loss is excessive
(15% of expected weight)
35. C. Dental enamel erosion occurs from repeated self-induced vomiting.
36. B. Depression usually is both emotional & physical. A simple daily routine is
the best, least stressful and least anxiety producing.
37. D. The expression of these feeling may indicate that this client is unable to
continue the struggle of life.
38. A. Structure tends to decrease agitation and anxiety and to increase the
clients feeling of security.
39. B. The rituals used by a client with obsessive compulsive disorder help
control the anxiety level by maintaining a set pattern of action.
40. C. A person with this disorder would not have adequate self-boundaries
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41. D. Loose associations are thoughts that are presented without the logical
connections usually necessary for the listening to interpret the message.
42. C. Helping the client to develop feeling of self worth would reduce the clients
need to use pathologic defenses.
43. B. Open ended questions and silence are strategies used to encourage
clients to discuss their problem in descriptive manner.
44. C. Clients who are withdrawn may be immobile and mute, and require
consistent, repeated interventions. Communication with withdrawn clients
requires much patience from the nurse. The nurse facilitates communication
with the client by sitting in silence, asking open-ended question and pausing
to provide opportunities for the client to respond.
45. D. When hallucination is present, the nurse should reinforce reality with the
client.
46. A. Personal characteristics of abuser include low self-esteem, immaturity,
dependence, insecurity and jealousy.
47. D. A short acting skeletal muscle relaxant such as succinylcholine (Anectine)
is administered during this procedure to prevent injuries during seizure.
48. C. Recognizing situations that produce anxiety allows the client to prepare to
cope with anxiety or avoid specific stimulus.
49. D. Electroconvulsive therapy is an effective treatment for depression that has
not responded to medication
50. B. In an emergency, lives saving facts are obtained first. The name and the
amount of medication ingested are of outmost important in treating this
potentially life threatening situation.
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References
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