Medical-Surgical Nursing Exam 20:

NLE Style (100 Items)

Answers & Rationale

Answers are in Italic.

Situation 1 A client is brought into the emergency department with brain stem contusion

1. Two days after the admission, the client has a large amount of urine and a serum
sodium level of 155 mEq/dl. Which, of the following conditions may be developing?

a. Myxedema coma
b. Diabetic insipidus
c. Type 1 diabetes mellitus
d. Syndrome of inappropriate ant-diuretic Hormone secretion

2. After a thorough assessment and laboratory works shall shows serum ketones and
serum glucose level above 300mg/dl, what condition would be diagnosed to patient?

a. Diabetes insipidus
b. Diabetes ketoacidosis
c. Hypoglycemia
d. Somogyi phenomena

3. Which of the following combinations of adverse effects must be carefully monitored

when administering I.V. insulin to a client diagnosed with diabetic ketoacidosis?

a. Hypokalemia and hypoglycemia

b. Hypocalcemia and Hyperkalemia
c. Hyperkalemia and hyperglycemia
d. Hypernatremia and hypercaleemia

4. Which of the following method of insulin administration would be used in the initial
treatment of hyperglycemia in a client with diabetic ketoacidosis.

a. Subcutaneous
b. Intramuscular
c. I.V bolus only
d. I.V. bolus followed by continuous infusion

5. Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) can be differentiated

from diabetic ketoacidosis by which of the following conditions?

a. Hyperglycemia
b. Serum osmolarity
c. Absence of ketosis
d. Hypokalemia

Situation 2: Mr. Reynaldo Layag executive officer, was brought to the hospital because of
chest pain-Diagnosis of angina was established.

6. Mr. Layag state that his anginal pain increases after activity. The nurse should
realize that the angina pectoris is a sign of:

1
a. Mitral insufficiency
b. Myocardial infraction
c. Myocardial ischemia
d. Coronary thrombosis

7. Nitroglycerine S.L. is prescribed for Mr. Layag’a anginal pain. When teaching how to
use nitroglycerine, the nurse tells him to place 1 tablet under the tongue when pain
occurs and to repeat the dose in 5 minutes if pain persist. The nurse should tell Mr.
Layag to:

a. Place two tablets under the tongue when the intense pain occurs
b. Swallow 1 tablet and place 1 tablet under the tongue when pain is intense
c. Place 1 tablet under the tongue 3 minutes before activity and repeat the dose in 5 minutes
if pain occurs
d. Place 1 tablet under the tongue when pain occurs and use an additional tablet after the
attack to prevent reoccurrence

8. The nurse realizes that the pain associated with coronary occlusion is caused
primarily by:

a. Arterial Spasm
b. Ischemia of the heart muscle
c. Blocking of the coronary veins
d. Irritation of the nerve endings in the cardiac plexus

9. When cardiovascular disease is concern, reduction of the saturated fat in the diet
may be desired and substance made of polyunsaturated fat When teaching about this
diet the nurse should instruct Mr. Layag to avoid :

a. Fish
b. Corn Oil
c. Whole milk
d. soft margarine

10. When teaching Mr. Layag, who has been placed on a high-unsaturated fatty acid
diet, the nurse should stress the importance of increasing the intake of:

a. Enriched whole milk

b. Red meats, such as beef
c. Vegetables and Whole Grains
d. Liver and other glandular organ meals

Situation 3: A group of nursing students were discussing the normal growth and development
concepts when assigned to observe the school children.

11. During the oedipal stage of growth and development, the child:

a. Loves and hates ( ambivalence) both parents

b. Loves the parent of the same sex and the parent of the opposite sex
c. Loves the parent of the opposite sex and hates the parent of the same sex
d. Love the parent of the same sex and hates the parent of the opposite sex.

12. The stage of growth and development basically concerned with the role
identification is the:

a. Oral Stage
b. Genital-Stage
c. Oedipal Stage
d. Latency stage

2
13. Play for the preschool-age child is necessary for the emotional development of:

a. Projection
b. Introjection
c. Competition
d. Independence

14. Resolution of the oedipal complex takes place when the child overcomes the
castration complex and:

a. Rejects the parent of the same sex

b. Introjects behavior of both parents
c. Identities with me parent of the same sex
d. Identifies with the parent of the opposite sex

15. Any surgery should be delayed, if possible, because of me effects on personality

development during the

a. Oral Stage.
b. Anal Stage
c. Oedipal Stage
d. Latency Stage

Situation 4 – Transurethral resection prostatectomy, (TURP) is performed to Mr. Recto, 60

years old, due to prostate enlargement. Post operatively he has continuous irrigation
(Cystoclysis).

16. Which of these statements explain the reason for continuous bladder irrigation?

a. To remove clot from the bladder

b. To maintain the patency of the catheter
c. To maintain the patency of me bladder
d. To dilute urine

17. Nursing assessment is vital to prevent and detect indications of postoperative

complications. The following are the possible complications after prostatectomy
except:

a. Residual urine
b. Urethral structure
c. Erectile dysfunction
d. The drainage has stopped

18. When should the nurse increase, the flow rate of cystoclysis of Mr.Recto?

a. The drainage appear cloudy

b. The drainage is continuous but slow
c. The drainage is bright red
d. The drainage has stopped

19. After the removal of the three way catheter, the nurse should inform Mr. Recto that
he can normally experience:

a. Dribbling incontinence
b. Polyuria
c. Dysuria
d. The drainage has stopped

3
20. Which of the following measures should you encourage Mr. Recto to do, in order to
regain urinary control?

a. Wear scrotal support

b. Take warm bath 2 times daily
c. Ambulate frequently
d. Alternately tense and relax the perineal muscles

Situation 5 – Nurses are generalist, in order to cope up with the works demand you must have
broad knowledge on anything. Nurse Joan was assigned in the medical ward. During the
endorsement she found out that she was assigned to several patients of different case

21. When developing a teaching session on glaucoma for the community, which of the
following statements would the nurse stress

a. Glaucoma is easily corrected with eye glasses

b. White and Asian individuals are the highest risk of glaucoma
c. Yearly screening for people ages 20 to 40 years is recommended
d. Glaucoma can be painless and visions may be lost before the person is aware of the
problem.

22. Which of the conditions is an early symptoms cgmmonly seen in Myasthenia

Gravis?

a. Dysphagia
b. Fatigue improving at the end of the day
c. Ptosis
d. Respiratory Distress

23. Which of the following statements best describes the Parkinson’s Disease?

a. Loss of myelin sheath surrounding peripheral nerves

b. Degeneration of the substantia nigra; depleting dopamine
c. Bleeding into the brain stem, resulting in meter dysfunction
d. An autoimmune disorder that destroys acetlycholine receptors

24. Which of the following pathophysiological processes are involved in multiple

sclerosis (MS)?

a. Destruction of the brain stem and basal ganglia in the brain

b. Degeneration of the nucleus pulposus, causing pressure on the spinal cord
c. Chronic inflammation of rhizomes just outside the central nervous system
d. Development of demyelinization of the myelin sheath, interfering with the nerve
transmission

25. When teaching the client, with Meniere’s disease, which of the following
instructions would a nurse give about vertigo.

a. Report dizziness at once

b. Drive in daylight hours only
c. Get up slowly, turning the entire body
d. Change your position using the logroll technique

Situatitm 6 – Mr. Punsalan is 36 years old, was admitted to the hospital with complaints of a
burning sensation in the epigastric area after eating and inability to sleep at night. He was
placed on bed rest and schedule for diagnostic studies. A diagnosis of Peptic Ulcer was
made.

4
26. Mr. Punsalan with gastric pain is advised to take any one of the following antacids,
except:

a. Aluminum hydroxide
b. Calcium bicarbonate
c. Magnesium carbonate
d. Sodium bicarbonate

27. An occult blood examination was ordered. The specific specimen needed from Mr.
Punsalan is;

a. Stool
b. Blood
c. Sputum
d. Gastric juice

28. Preparation of Mr. Punsalan for occult blood examination is :

a. Fluid intake is limited only 1 liter/day

b. NPO for 12 hours prior to obtaining of specimen
c. Fluid intake is increased
d. Meatless diet for 48 hours prior to obtaining of specimen

29. X -ray examination for Mr. Punsalan to detect tumors or ulcerations of the stomach
and duodenum is:

a. Gastroscopy
b. GIT series
c. Cold G.I. series
d. Ba enema

30. Diet that prevents gastric irritation in case of Mr. Punsalan is:
a. Bland Diet
b. Liquid Diet
c. Full Diet
d. High Protein low fat diet

Situation 7 – Mr. Reyes suffered head injuries in a motor vehicle accident

31. When caring for Mr. Reyes, the nurse should assess for

a. Decreased carotid pulses

b. Bleeding from oral cavity
c. Altered level of consciousness
d. Absence of deep tendon-reflexes

32. Mr. Reyes is extremely confused. The nurse provide new information slowly and in
small amounts because;

a. Confusion or delirium can be a defense against further stress

b. Destruction of brain cells has occurred, interrupting mental activity
c. Teaching based on information progressing from the simple to the complex
d. A minimum of information should be given, since he is unaware of surroundings

33. Mr. Reyea complains of hearing ringing noises. The nurse recognizes that this
assessment suggests injury of the

a. Frontal lobe
b. Occipital lobe

5
c. Six cranial nerve (abducent)
d. Eight Cranial Nerve (Vestibulocochlear)

34. Mr. Reyes has a possible skull fracture. The nurse should:

a. Observe him for signs of Brain injury

b. Check for hemorrhaging from the oral cavity
c. Elevate the foot of the bed if he develops symptoms of shock
d. Observe for symptoms of decreased intracranial pressure and temperature

35. Mr. Reyea has expressive aphasia. As a part of a long range planning. The nurse
should ;

a. Provide positive feedback when he uses the word correctly

b. Wait for him to verbally state needs regardless of how long it may take c. Suggest that he
get help at home because the disability is permanent
d. Help the family to accept the fact that Mr, Reyes cannot participate in verbal
communication

Situation 8 – Patricia Zeno is a client with history myasthenia gravis.

36. Clients with myastherda gravis, Guillain – Barre Syndrome or amyothrophic

sclerosis experience:

a. Progressive deterioration until death

b. Increased risk of respiratory complications
c. Deficiencies of essential neurotransmitter
d. Involuntary twitching of small muscle groups

37. Myasthenia gravis most frequently affect:

a. Males ages 15 to 3 5 years

b. Children ages 5 to 15 years
c. Female ages 10 to 30 years old
d. Both sexes ages 20 to 40 years

38. Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply
on the knowledge that there is:

a. A genetic defect in the production of acetylcholine

b. A reduced amount of neurotransmitter acetylcholine
c. A decreased number of functioning acetyl-choline receptor sites
d. An inhibition of the enzyme Ache leaving the end plates folded.

39. To provide safe care for Mrs. Zeno, it is important for the nurse to check the
bedside for the presence of:

a. A tracheostomy set
b. An intravenous set-up
c. A hypothermia blanket
d. A syringe and edrophonium HCl(Tensilon)

40. Mrs. Zeno continues to become a weaker despite .treatment with neostigmine.
Edrophonium HCL is ordered:

a. For its synergestic effect

b. To rule out cholinergic crisis
c. To confirm the diagnosis of myasthenia
d. Because of the client’s resistance to Neostigmine

6
Situation 9 – Hariet, a 38 year-old school teacher with rheumatoid arthritis, is admitted to the
hospital with severe and swelling of the joints of both hands.

41. A regimen of rest, exercises and physical therapy is ordered for Hariet This
regimen will;

a. Prevent arthritic pain

b. Halt me inflammatory process
c. Help prevent the drippling effects of the disease
d. Provide for the return of joint motion after prolonged loss

42. Hariet ask the nurse why the physician is going to inject hydrocortisone into her
affected joint. The nurse explains that the most important reason for doing this is to:

a. Relieve pain
b. Reduce inflammation
c. Provide Psychotherapy
d. Prevent ankylosis of the joint

43. When planning nursing care for Hariet, the nurse should take into consideration the
fact that:

a. Inflammation of the synovial membrane will rarely occur

b. Bony ankylosis of the joint is irreversible and causes immobility
c. Complete immobility is desired during the acute phase of inflammation
d. If the redness and swelling of a joint occur, they signify irreversible damage

44. The diet the nurse would expect the physician to order for Hariet would be:

a. Salt free and low fiber

b. High calorie with low cholesterol
c. High protein with minimal calcium
d. Regular diet with vitamins and minerals

45. The medication the nurse would expect to prescribed to relieve Hariet’s pain;

a. Xanax 0.5 mg, TID

b. Aspirin, 0.6 g_q4
c. Codeine , 30 mg, q4
d. Meperidine 30 mg q4 pm

Situation 10 – Lizbeth 20 year-old college student is brought to the hospital by her mother
who states that for the past week her behavior has become very strange. She has become
more and more withdrawn – Diagnosis: Schizophrenia Catatosis. ‘ •

46. During the physical assessment Lizbeth’s arms remains outstretched after her
pulse and blood pressure were taken and the nurse has to reposition it for her. Lizbeth
is showing;

a. Distractability
b. Muscle rigidity
c. Waxy flexibility
d. Echopraxia

47. Lizbeth keeps her eyes closed and does not answer the questions asked by the
nurse or physician. The nurse know that;

a. The patient can cannot hear nor understand what is being asked
b. The patient is aware of what is happening around her even though she does not respond

7
c. The patient is in regressed state and should be treated like a frightened child
d. The patient is aware of what is going on around her and could respond if she wants to.

48. While Lizbeth remains in an unreasonable state, does not eat or drink, the nurse
first priority id to assess her:

a. Fluid intake and output

b. Skin turgor
c. Bowel elimination
d. Vital signs such as T.P.R. and blood pressure

49. One evening, Lizbeth suddenly begins running up and down the hall. She strips her
clothing and strikes out widely at anyone she sees. All of the following interventions
would be appropriate except:

a. Restrain me patient and call for help

b. Call for the assistance of at least three staff members
c. Clear the area of other patients
d. Obtain me order and prepare chlorpromazine (thorazine)

50. When Lizbeth become agitated, the therapeutic approach of the nurse is one that
is:

a. Authoritarian and directive

b. Related casual and friendly
c. Permissive and comforting
d. Calm and firm but not threatening

Situation 11- Michelle, 36 weeks gestation visits the hospital because the suspects that her
bag of water was ruptured. -

51. While the nurse is assessing Michelle, she states that her bag of water ruptured few
minutes ago. Which of the following should the nurse do first?

a. Check the status of the fetal heart rate

b. Turn the client to her right side
c. Test the leaking fluid with nitrazine paper
d. Perform a sterile vaginal examination

52. To confirm Michelle’s statement, the nurse uses nitrazine paper; if the membrane
has ruptured the paper which of the following color?

a. Yellow
b. Green
c. Blue
d. Blue

53. After being confirmed that membranes has been ruptured and there was no
evidence of labor, which of me following would the nurse expect the physician to
order?

a. Frequent assessment of cervical dilation

b. Intravenous oxytocin adminitration
c. Vaginal culture for Neisseria Gonorrhoeae
d. Sonogram for amniotic fluid volume index

54. Few hours after, the nurse noted that her cervix is 2 cm dilated and 50% effaced.
Which of the following would the priority assessment for this client?

8
a. Red blood cell count
b. Degree of Discomfort
c. Urinary Output
d. Temperature

55. Michelle is to be discharged home on bed rest with follow -tip by the community
health nurse. After instruction about care while at home, which of the following client’s
statements indicates effective teaching?

a. “It is permissible to douche if the fluid irritates my vaginal area.”

b. ” I can take either a tub Bath or a shower when I feel it”
c. “I shouldn’t limit my fluid intake to less than 1 quart daily.”
d. ” I should contact the doctor if my temperature is 100.4 F or higher.”

Situation 12 – Jerome, a 37 years old man, was admitted to the hospital with periodic episode
of manic behavior alternating with me depression. Diagnosis: Bipolar I disorder.

56. Which of the following statements is true and manic reaction? It is;

a. An expression of destructive impulse

b. A means of coping with frustrations and disappointments
c. A Means of Ignoring reality
d. An attempt toward off feeling of underlying depression.

57. Nursing care plan for a hyperactive patient like Jerome, should give priority to:

a. Discourage him from manipulating the staff

b. Prevent him from assaulting other patients
c. Protect him against suicidal attempts
d. Provide adequate food and fluid intake

58. During a nurse patient interaction, Jerome jumps rapidly from one topic to another.
This is known as:

a. Flight of Ideas
b. Idea of Reference
c. Clang association
d. Neologism

59. A priority nursing diagnosis would be

a. Ineffective individual coping

b. Altered family process
c. Potential for violence, self directed
d. Sensory perceptual disturbance

60. Initially one of the following activities would be appropriate for Jerome;

a. Playing basketball
b. Playing chess
c. Gardening
d. Writing

Situation 13 – .Mr,. Baldo , 36 years old patient complaints of fatigue, weight loss, and low-
grade fever. He also has pa in his fingers, elbows, and ankles.

61. Which of the following conditions is suspected?

9
a. Anemia
b. Leukemia
c. Rheumatic arthritis
d. Systematic Lupus Erythematosus (SLE)

62. Systematic lupus erymematosus (SLE) primarily attacks which of the following
tissues?

a. Connective
b. B. Heart
c. Lung
d. Nerve

63. Which of the following elements shows that the client does not understand the
cause of exacerbation of system lupus erythematosus (SLE)?

a. ” I need to stay away from sunlight”

b. “I don’t have to worry if I get a strep. throat
c. I need to work on managing stress in life.”
d. “I don’t have to worry about changing my diet.”

64. Which of the following symptoms is a classic sign of systemic lupus

erythematosus (SLE)?

a. Vomiting
b. Weight loss
c. Difficulty urinating
d. Superficial lesions over the cheek and nose

65. Mr Balao asks the nurse as to the source of this disease. The nurse is aware that
this is a disease of:

a. Joints
b. Bones
c. connective tissue
d. purine metabolism

Situation 14 – Mr Gil age 86 years, has been diagnosed with Alzheimer’s disease.

66. Which characteristics could the nurse expect when observing Mr. Gil?

a. Transient ischemic attacks

b. Remissions & exacerbations
c. Rapid deterioration of mental functioning because of arteriosclerosis
d. Slowly progressive deficits in intellect, which may be noted for a long time

67. Mr. Gil frequently switches from being pleasant and happy to being hostile and sad
without apparent external cause. How can the nurse best care for Mr. Gil?

a. Try to point out reality to him

b. Avoid Mr. Gilwhen he is angry and sad
c. Encourage him to talk about his feelings
d. Attempt to give nursing care when he is in a pleasant mood

68. What type of environment should be provided by the health care team for Mr. Gil?

a. Familiar
b. Variable

10
c. Challenging
d. Non-stimulating

69. Mr. Gil will need assistance in maintaining contact with society for as long as
possible. Which therapy might help him achieve this goal?

a. Psychodrama
b. Recreation therapy
c. Occupational therapy
d. Remotivation therapy

70. What is the nurse’s primary objective for Mr. Gil when he is experiencing dementia
and delirium?

a. Diminished psychologic faculties

b. Interaction with the environment
c. Participation with the environment
d. Face to face contact with the other clients

Situation I5: Baby Philip, a full term male child, is delivered by his mother who is RH negative.

71. At the time of delivery, baby Philip’s blood is typed to determine the ABO group
and the presence of the RH factor. The nurse is aware that:

a. The RH factor is not genetically determined

b. Not all infants of RH-positive fathers are RH positive
c. The RH factor of the fetus is determined by the father
d. During gestation, the RH factor of the fetus may change

72. Baby Philip is RH positive and his mother is RH negative. Baby Philip is to receive
an exchange transfusion. The nurse know that he will receive RH-negative blood
because:

a. It is me same as die mother’s blood

b. It is neutral and will not react with his blood
c. It eliminates the possibility of a transfusion reaction occurring
d. His RBC’s will not be destroyed by the maternal anti-RH antibodies

73. Hyperbilirubinemia is anticipated to baby Philip because of RH incompatibility.

Hyperbilirubinemia occurs with incompatibility between mother and fetus because

a. The mother’s blood does not contain the RH factor, so she produces anti-RH antibodies
that cross the placental barrier and cause hemolysis of red blood cells in infants
b. The mother’s blood contains the RH factor and the infant’s does not, and antibodies are
formed in the fetus that destroy red blood cells.
c. The mother has the history of previous yellow jaundice caused by a blood transfusion,
which was passed the fetus through the placenta.
d. The infant develops a congenital defect shortly after birth that causes the destruction of red
blood cells.

74. If RhoGAm is given to Baby Philip’s mother after delivering Baby Philip, the
condition that must be present rbr the globulin to be effective is that:

a. Philip’s mother is Rh positive

b. Baby Philip is Rh negative
c. Philip’s mother has no titer in her blood
d. Philip’s mother has some titer in her blood

11
75. When the nurse brings Philip to his mother, she comments about the milia on the
baby’s face. The nurse should:

a. Tell her that all babies have them and they clear up in 2 to 3 days
b. Explain that these are birthmarks that will disappear within a few months
c. Instruct her about proper handwashing since the milia can be infectious
d. Instruct her to avoid squeezing them or attempting to wash them off

Situation 16: Ronald 23 years old was voluntarily admitted to the in-patient unit with a
diagnosis of paranoid schizophrenia.

76. As the nurse approaches Ronald he says, “If come any closer. I’ll die.” This is an
example of:

a. Hallucination
b. Delusion
c. Illusion
d. Idea of reference

77. The best response for the nurse to make to this behavior is:

a. “How can I hurt you?”

b. “I’m the nurse.”
c. “Tell me more about this.”
d. “That’s a silly thing to say.”

78. When communicating with the paranoid client, the main principle is to:

a. Use logic and be persistent

b. Provide an anxiety-free environment
c. Express doubt and do not argue
d. Encourage ventilation of anger

79. Ronald is pacing the hall and is agitated. The nurse hears him saying, “Those
doctors are faying to commit me to the state hospital. The nurse’s continued
assessment should include:

a. Clarifying information with the doctor

b. Observing Ronald for rising anxiety
c. Reviewing history of involuntary commitment
d. Checking dosage of prescribed medication

80. An appropriate activity for the nurse is to recommend for a client who is extremely
agitated is:

a. Competitive sports
b. Bingo
c. Trivial Pursuit
d. Daily walks

Situation 17: Mrs. Lim has had confirmation of her pregnancy. She presents the emergency
room with abdominal pain not yet. diagnosed.

81. The nurse would suspect an ectopic pregnancy if Mrs Lim complained of:

a. An adherent painful ovarian mass

b. Lower abdommal cramping for a long period of time
c. Leukonhea and dysuria a few days after the first missed period
d. Sharp lower right or left abdominal pain radiating to the shoulder

12
82. The most common type of ectopic pregnancy is tubal. Within a few weeks after
conception the tube may rupture suddenly, causing:

a. Painless vaginal bleeding

b. Intermittent abdominal contractions
c. Continues dull, upper-quadrant abdominal pain
d. Sudden knife-like, lower-quadrant abdominal pain

83. Mrs. Lim has been complaining of vaginal bleeding and one sided lower quadrant
pain. The nurse suspects mat she has:

a. Abruptio placenta
b. An incomplete abortion
c. An ectopic pregnancy
d. A rupture of graafian follicle

84. A few hours after being admitted with a diagnosis of inevitable abortion, a client
begins to experience bearing down sensations and suddenly expels the products of
conception in bed. To give safe nursing care, the nurse should first

a. Check the fundus for firmness

b. Give her the sedation
c. Immediately notify the physician
d. take her immediately to the delivery home

85. After a spontaneous abortion the nurse should observe the client for:

a. Hemorrhage and infection

b. Dehydration and hemorrhage
c. Subiiivolution and dehydration
d. Signs of pregnancy-induced hypertension

Situation 18: Arnold, age 67, has had successfully treated depressive disease for more than
10 years. Lately he has been developing a plan of action. Arnold is admitted to hospital for
reassessment.

86. Which assessment would best aid the nurse in evaluating Arnold’s potential for
suicide?

a. Ask him about plans for the future

b. Ask other clients about suicide while in a group
c. Ask the family if he had ever attempted suicide
d. Ask him if suicide was ever or is now being considered

87. Which factor is most important in evaluating Arnold’s risk for suicide?

a. Presence of multiple personal problems

b. Length of time the depression has existed
c. Impending of the loss of a loved one
c. development plans for discharge from hospital or program

88. Arnold confides to the nurse that he has been thinking of suicide. Which of the
following motivations should the nurse recognize in Arnold?

a. Wishes to frighten the nurse

b. Wants attention from the staff
c. Feels safe and can share his feelings with the nurse
d. Shows fearful of his own impulses and is seeking protection from them

13
89. Arnold is placed on suicide precautions. Which would be the most therapeutic way
to provide his safety measures?

a. Not allow him to leave his room

b. Remove all sharp and cutting objects
c. Give him the opportunity to ventilate feelings
d. Assign staff member to be with him at all times

90. The psychiatrist prescribes Electro convulsive therapy for Arnold. The nurse when
discussing ECT with Arnold, should tell him which of the following information?

a. Sleep will be induced and treatment will not cause pain

b. There will be a memory loss aa a result of the treatment
c. It is better not to talk about it, but he can asks any question

Situation 19: Josh is a 2-year old child who was bom with a unilateral cleft lip and palate. He
is being readmitted for a palate repair.

91. When a toddler is hospitalized, age appropriate toys would include:

a. Wind-up toys, music boxes, and electric trains

b. Toys requiring pushing, pulling and to big to be swallowed
c. Marble tracks and small blocks encouraging fine-motor coordination
d. Colorful mobiles, wind-up toys, and marble tracks

92. Which of the following would be the most important factor in preparing Josh for his
hospitalization?

a. Gratification of Josh wishes

b. Josh’s previous hospitalization
c. Never leaving Josh with strangers
d. Assurance of affection and security

93. Prior to a repair of a unilateral cleft lip and palate, feeding will probably be:

a. Limited to IV fluids
b. Wish a soft, large altered nipple
c. Accomplished per gastrostomy tube
d. Facilitated by the use of spoon or medicine dropper

94. Which of the following nursing actions would have been included for Josh
following his cleft lip repair?

a. Using a spoon to administer oral feedings

b. Cleansing the suture line to prevent infection
c. Allowing Josh to suck on a pacifier to prevent crying
d. Positioning Josh on the abdomen to avoid aspiration

95. Why will Josh be unable to use toothbrush postoperatively?

a. The suture line might be injured

b. Josh would probably have no teeth
c. The toothbrush might be frightening to Josh
d. Josh would not be accustomed to a brush at home

Situation 20: Vincent, age 26, who is caught in me raging conflict between his mother and his
wife, complains of pains in his right leg that has progressed to the point of paralysis. After
orthopedic consultation has shown no pathology, he is referred for a psychiatric consultation
and is found to have a conversion disorder.

14
96. The nurse understands which of the following concepts about Vincent’s conversion
disorder?

a. It is an unconscious method for him to cope with the present situation

b. It is usually necessary for him to cope with the present situation
c. It is reversible and will subside if he is helped to focus on other things
d. It will probably be solved when he learns to deal with ongoing family conflicts

97. Vincent’s conflict may be caused by which of the following stimuli?

a. Hostile feelings towards his home

b. Ambivalent feelings toward his wife
c. Needs to be a dependent child and an independent adult
d. Inadequate feelings in regard to assuming the role of husband

98. Which behavior is Vincent most likely to manifest?

a. Demonstrate a spread of paralysis to other body parts

b. Require continuous psychiatric treatment to maintain individual functioning
c. Recover the use of the affected leg but under stress, again develop similar symptoms
d. Follow a rather unpredictable emotional course I the future, depending on exposure to
stress

99. How would the nurse expect Vincent to behave?

a. Appear gently depressed

b. Exhibit free floating anxiety
c. Appear calm and composed
d. Demonstrate anxiety when discussing symptoms

100. Which intervention would be most therapeutic for the nurse to make?

a. Encourage him to try to walk

b. Tell him there is nothing wrong
c. Avoid focusing on his physical symptoms
d. Help him follow through with the physical therapy plan

15