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Table of Contents
Part 1 Test Nursing Practice I Nursing Practice II Mock Board Examination Scope/
Coverage Foundation of Nursing, Nursing Research, Professional Adjustment, Leade
rship and Management Maternal and Child Health, Community Health Nursing, Commun
icable Diseases, Integrated Management of Childhood Illness Medical and Surgical
Nursing Medical and Surgical Nursing Psychiatric Nursing
Nursing Practice III Nursing Practice IV Nursing Practice V Part 2 Nursing Pract
ice I-V 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 Rat
ionale
Answers and Rationale
Selected Practice Test from Nursing Crib’s website
Foundation of Nursing Maternal and Child Health Medical Surgical Nursing Psychia
tric Nursing
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PART I
NURSING PRACTICE I
Foundation of Professional Nursing Practice
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TEST I - Foundation of Professional Nursing Practice 1. The nurse In-charge in l
abor and delivery unit administered a dose of terbutaline to a client without ch
ecking the client’s pulse. The standard that would be used to determine if the nur
se was negligent is: a. The physician’s orders. b. The action of a clinical nurse
specialist who is recognized expert in the field. c. The statement in the drug l
iterature about administration of terbutaline. d. The actions of a reasonably pr
udent nurse with similar education and experience. 2. Nurse Trish is caring for
a female client with a history of GI bleeding, sickle cell disease, and a platel
et count of 22,000/μl. The female client is dehydrated and receiving dextrose 5% i
n half-normal saline solution at 150 ml/hr. The client complains of severe bone
pain and is scheduled to receive a dose of morphine sulfate. In administering th
e medication, Nurse Trish should avoid which route? a. b. c. d. I.V I.M Oral S.C
3. Dr. Garcia writes the following order for the client who has been recently ad
mitted “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.
“Digoxin .1250 mg P.O. once daily” “Digoxin 0.1250 mg P.O. once daily” “Digoxin 0.125 mg
P.O. once daily” “Digoxin .125 mg P.O. once daily”
4. A newly admitted female client was diagnosed with deep vein thrombosis. Which
nursing diagnosis should receive the highest priority? a. b. c. d. Ineffective
peripheral tissue perfusion related to venous congestion. Risk for injury relate
d to edema. Excess fluid volume related to peripheral vascular disease. Impaired
gas exchange related to increased blood flow.
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5. Nurse Betty is assigned to the following clients. The client that the nurse w
ould see first after endorsement? a. A 34 year-old post operative appendectomy c
lient of five hours who is complaining of pain. b. A 44 year-old myocardial infa
rction (MI) client who is complaining of nausea. c. A 26 year-old client admitte
d for dehydration whose intravenous (IV) has infiltrated. d. A 63 year-old post
operative’s abdominal hysterectomy client of three days whose incisional dressing
is saturated with serosanguinous fluid. 6. Nurse Gail places a client in a four-
point restraint following orders from the physician. The client care plan should
include: a. b. c. d. Assess temperature frequently. Provide diversional activit
ies. Check circulation every 15-30 minutes. Socialize with other patients once a
shift.
7. A male client who has severe burns is receiving H2 receptor antagonist therap
y. The nurse In-charge knows the purpose of this therapy is to: a. b. c. d. Prev
ent stress ulcer Block prostaglandin synthesis Facilitate protein synthesis. Enh
ance gas exchange
8. The doctor orders hourly urine output measurement for a postoperative male cl
ient. The nurse Trish records the following amounts of output for 2 consecutive
hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should
the nurse take? a. b. c. d. Increase the I.V. fluid infusion rate Irrigate the
indwelling urinary catheter Notify the physician Continue to monitor and record
hourly urine output
9. Tony, a basketball player twist his right ankle while playing on the court an
d seeks care for ankle pain and swelling. After the nurse applies ice to the ank
le for 30 minutes, which statement by Tony suggests that ice application has bee
n effective? a. “My ankle looks less swollen now”. b. “My ankle feels warm”.
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c. “My ankle appears redder now”. d. “I need something stronger for pain relief” 10. The
physician prescribes a loop diuretic for a client. When administering this drug
, the nurse anticipates that the client may develop which electrolyte imbalance?
a. b. c. d. Hypernatremia Hyperkalemia Hypokalemia Hypervolemia
11. She finds out that some managers have benevolent-authoritative style of mana
gement. Which of the following behaviors will she exhibit most likely? a. b. c.
d. Have condescending trust and confidence in their subordinates. Gives economic
and ego awards. Communicates downward to staffs. Allows decision making among s
ubordinates.
12. Nurse Amy is aware that the following is true about functional nursing a. Pr
ovides continuous, coordinated and comprehensive nursing services. b. One-to-one
nurse patient ratio. c. Emphasize the use of group collaboration. d. Concentrat
es on tasks and activities. 13. Which type of medication order might read "Vitam
in K 10 mg I.M. daily × 3 days?" a. b. c. d. Single order Standard written order S
tanding order Stat order
14. A female client with a fecal impaction frequently exhibits which clinical ma
nifestation? a. b. c. d. Increased appetite Loss of urge to defecate Hard, brown
, formed stools Liquid or semi-liquid stools
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15. Nurse Linda prepares to perform an otoscopic examination on a female client.
For proper visualization, the nurse should position the client s ear by: a. b.
c. d. Pulling the lobule down and back Pulling the helix up and forward Pulling
the helix up and back Pulling the lobule down and forward
16. Which instruction should nurse Tom give to a male client who is having exter
nal radiation therapy: a. b. c. d. Protect the irritated skin from sunlight. Eat
3 to 4 hours before treatment. Wash the skin over regularly. Apply lotion or oi
l to the radiated area when it is red or sore.
17. In assisting a female client for immediate surgery, the nurse In-charge is a
ware that she should: a. b. c. d. Encourage the client to void following preoper
ative medication. Explore the client’s fears and anxieties about the surgery. Assi
st the client in removing dentures and nail polish. Encourage the client to drin
k water prior to surgery.
18. A male client is admitted and diagnosed with acute pancreatitis after a holi
day celebration of excessive food and alcohol. Which assessment finding reflects
this diagnosis? a. b. c. d. Blood pressure above normal range. Presence of crac
kles in both lung fields. Hyperactive bowel sounds Sudden onset of continuous ep
igastric and back pain.
19. Which dietary guidelines are important for nurse Oliver to implement in cari
ng for the client with burns? a. b. c. d. Provide high-fiber, high-fat diet Prov
ide high-protein, high-carbohydrate diet. Monitor intake to prevent weight gain.
Provide ice chips or water intake.
20. Nurse Hazel will administer a unit of whole blood, which priority informatio
n should the nurse have about the client? a. Blood pressure and pulse rate.
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b. Height and weight. c. Calcium and potassium levels d. Hgb and Hct levels. 21.
Nurse Michelle witnesses a female client sustain a fall and suspects that the l
eg may be broken. The nurse takes which priority action? a. b. c. d. Takes a set
of vital signs. Call the radiology department for X-ray. Reassure the client th
at everything will be alright. Immobilize the leg before moving the client.
22. A male client is being transferred to the nursing unit for admission after r
eceiving a radium implant for bladder cancer. The nurse in-charge would take whi
ch priority action in the care of this client? a. b. c. d. Place client on rever
se isolation. Admit the client into a private room. Encourage the client to take
frequent rest periods. Encourage family and friends to visit.
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
24. A male client is receiving total parenteral nutrition suddenly demonstrates
signs and symptoms of an air embolism. What is the priority action by the nurse?
a. b. c. d. Notify the physician. Place the client on the left side in the Tren
delenburg position. Place the client in high-Fowlers position. Stop the total pa
renteral nutrition.
25. Nurse May attends an educational conference on leadership styles. The nurse
is sitting with a nurse employed at a large trauma center who states that the le
adership style at the trauma center is task-oriented and directive. The nurse de
termines that the leadership style used at the trauma center is: a. Autocratic.
b. Laissez-faire.
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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 su
pplied 20 mEq/10 cc. How many cc’s of KCl will be added to the IV solution? a. b.
c. d. .5 cc 5 cc 1.5 cc 2.5 cc
27. A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift.
The IV drip factor is 60. The IV rate that will deliver this amount is: a. b. c
. d. 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 retu
rns from surgery is: a. b. c. d. Assess the IV for type of fluid and rate of flo
w. Assess the client for presence of pain. Assess the Foley catheter for patency
and urine output Assess the dressing for drainage.
29. Which of the following vital sign assessments that may indicate cardiogenic
shock after myocardial infarction? a. b. c. d. BP – 80/60, Pulse – 110 irregular BP –
90/50, Pulse – 50 regular BP – 130/80, Pulse – 100 regular BP – 180/100, Pulse – 90 irregu
lar
30. Which is the most appropriate nursing action in obtaining a blood pressure m
easurement? a. Take the proper equipment, place the client in a comfortable posi
tion, and record the appropriate information in the client’s chart. b. Measure the
client’s arm, if you are not sure of the size of cuff to use. c. Have the client
recline or sit comfortably in a chair with the forearm at the level of the heart
.
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d. Document the measurement, which extremity was used, and the position that the
client was in during the measurement. 31. Asking the questions to determine if
the person understands the health teaching provided by the nurse would be includ
ed during which step of the nursing process? a. b. c. d. Assessment Evaluation I
mplementation Planning and goals
32. Which of the following item is considered the single most important factor i
n assisting the health professional in arriving at a diagnosis or determining th
e person’s needs? a. b. c. d. Diagnostic test results Biographical date History of
present illness Physical examination
33. In preventing the development of an external rotation deformity of the hip i
n a client who must remain in bed for any period of time, the most appropriate n
ursing action would be to use: a. Trochanter roll extending from the crest of th
e ileum to the midthigh. b. Pillows under the lower legs. c. Footboard d. Hip-ab
ductor pillow 34. Which stage of pressure ulcer development does the ulcer exten
d into the subcutaneous tissue? 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 surgica
lly approximated and integumentary continuity is restored by granulations, the w
ound healing is termed a. Second intention healing b. Primary intention healing
c. Third intention healing
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d. First intention healing 36. An 80-year-old male client is admitted to the hos
pital with a diagnosis of pneumonia. Nurse Oliver learns that the client lives a
lone and hasn’t been eating or drinking. When assessing him for dehydration, nurse
Oliver would expect to find: a. b. c. d. Hypothermia Hypertension Distended nec
k veins Tachycardia
37. The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as n
eeded, to control a client’s postoperative pain. The package insert is “Meperidine,
100 mg/ml.” How many milliliters of meperidine should the client receive? a. b. c.
d. 0.75 0.6 0.5 0.25
38. A male client with diabetes mellitus is receiving insulin. Which statement c
orrectly describes an insulin unit? a. b. c. d. It’s a common measurement in the m
etric system. It’s the basis for solids in the avoirdupois system. It’s the smallest
measurement in the apothecary system. It’s a measure of effect, not a standard me
asure of weight or quantity.
39. Nurse Oliver measures a client’s temperature at 102° F. What is the equivalent C
entigrade temperature? 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 physician’s of
fice 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 t
one. c. Failing eyesight, especially close vision.
13
d. Having more frequent aches and pains. 41. The physician inserts a chest tube
into a female client to treat a pneumothorax. The tube is connected to water-sea
l drainage. The nurse in-charge can prevent chest tube air leaks by: a. b. c. d.
Checking and taping all connections. Checking patency of the chest tube. Keepin
g the head of the bed slightly elevated. Keeping the chest drainage system below
the level of the chest.
42. Nurse Trish must verify the client’s identity before administering medication.
She is aware that the safest way to verify identity is to: a. Check the client’s
identification band. b. Ask the client to state his name. c. State the client’s na
me out loud and wait a client to repeat it. d. Check the room number and the cli
ent’s name on the bed. 43. The physician orders dextrose 5 % in water, 1,000 ml to
be infused over 8 hours. The I.V. tubing delivers 15 drops/ml. Nurse John shoul
d run the I.V. infusion at a rate of: a. b. c. d. 30 drops/minute 32 drops/minut
e 20 drops/minute 18 drops/minute
44. If a central venous catheter becomes disconnected accidentally, what should
the nurse in-charge do immediately? a. b. c. d. Clamp the catheter Call another
nurse Call the physician Apply a dry sterile dressing to the site.
45. A female client was recently admitted. She has fever, weight loss, and water
y diarrhea is being admitted to the facility. While assessing the client, Nurse
Hazel inspects the client’s abdomen and notice that it is slightly concave. Additi
onal assessment should proceed in which order: a. b. c. d. Palpation, auscultati
on, and percussion. Percussion, palpation, and auscultation. Palpation, percussi
on, and auscultation. Auscultation, percussion, and palpation.
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46. Nurse Betty is assessing tactile fremitus in a client with pneumonia. For th
is examination, nurse Betty should use the: a. b. c. d. Fingertips Finger pads D
orsal surface of the hand Ulnar surface of the hand
47. Which type of evaluation occurs continuously throughout the teaching and lea
rning 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 f
actors for this disease. Nurse John should instruct her to have mammogram how of
ten? a. b. c. d. Twice per year Once per year Every 2 years Once, to establish b
aseline
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 sho
uld expect which condition? a. b. c. d. Respiratory acidosis Respiratory alkalos
is Metabolic acidosis Metabolic alkalosis
50. Nurse Len refers a female client with terminal cancer to a local hospice. Wh
at is the goal of this referral? a. To help the client find appropriate treatmen
t options. b. To provide support for the client and family in coping with termin
al illness. c. To ensure that the client gets counseling regarding health care c
osts. 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 cocc
yx, which of the following actions can the nurse institute independently? a. Mas
saging the area with an astringent every 2 hours. b. Applying an antibiotic crea
m 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-iodin
e wash on the ulceration three times per day. 52. Nurse Oliver must apply an ela
stic bandage to a client’s ankle and calf. He should apply the bandage beginning a
t the client’s: 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 Hype
rcalcemia
54. Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly
admitted client. Immediately afterward, the client may experience: a. b. c. d. T
hrobbing headache or dizziness Nervousness or paresthesia. Drowsiness or blurred
vision. Tinnitus or diplopia.
55. Nurse Michelle hears the alarm sound on the telemetry monitor. The nurse qui
ckly looks at the monitor and notes that a client is in a ventricular tachycardi
a. The nurse rushes to the client’s room. Upon reaching the client’s bedside, the nu
rse would take which action first? a. b. c. d. Prepare for cardioversion Prepare
to defibrillate the client Call a code Check the client’s level of consciousness
16
56. Nurse Hazel is preparing to ambulate a female client. The best and the safes
t position for the nurse in assisting the client is to stand: a. b. c. d. On the
unaffected side of the client. On the affected side of the client. In front of
the client. Behind the client.
57. Nurse Janah is monitoring the ongoing care given to the potential organ dono
r who has been diagnosed with brain death. The nurse determines that the standar
d of care had been maintained if which of the following data is observed? a. b.
c. d. Urine output: 45 ml/hr Capillary refill: 5 seconds Serum pH: 7.32 Blood pr
essure: 90/48 mmHg
58. Nurse Amy has an order to obtain a urinalysis from a male client with an ind
welling urinary catheter. The nurse avoids which of the following, which contami
nate the specimen? a. b. c. d. Wiping the port with an alcohol swab before inser
ting the syringe. Aspirating a sample from the port on the drainage bag. Clampin
g the tubing of the drainage bag. Obtaining the specimen from the urinary draina
ge bag.
59. Nurse Meredith is in the process of giving a client a bed bath. In the middl
e of the procedure, the unit secretary calls the nurse on the intercom to tell t
he nurse that there is an emergency phone call. The appropriate nursing action i
s to: a. Immediately walk out of the client’s room and answer the phone call. b. C
over the client, place the call light within reach, and answer the phone call. c
. Finish the bed bath before answering the phone call. d. Leave the client’s door
open so the client can be monitored and the nurse can answer the phone call. 60.
Nurse Janah is collecting a sputum specimen for culture and sensitivity testing
from a client who has a productive cough. Nurse Janah plans to implement which
intervention to obtain the specimen? a. Ask the client to expectorate a small am
ount of sputum into the emesis basin.
17
b. Ask the client to obtain the specimen after breakfast. c. Use a sterile plast
ic container for obtaining the specimen. d. Provide tissues for expectoration an
d obtaining the specimen. 61. Nurse Ron is observing a male client using a walke
r. The nurse determines that the client is using the walker correctly if the cli
ent: a. Puts all the four points of the walker flat on the floor, puts weight on
the hand pieces, and then walks into it. b. Puts weight on the hand pieces, mov
es the walker forward, and then walks into it. c. Puts weight on the hand pieces
, slides the walker forward, and then walks into it. d. Walks into the walker, p
uts weight on the hand pieces, and then puts all four points of the walker flat
on the floor. 62. Nurse Amy has documented an entry regarding client care in the
client’s medical record. When checking the entry, the nurse realizes that incorre
ct information was documented. How does the nurse correct this error? a. Erases
the error and writes in the correct information. b. Uses correction fluid to cov
er up the incorrect information and writes in the correct information. c. Draws
one line to cross out the incorrect information and then initials the change. d.
Covers up the incorrect information completely using a black pen and writes in
the correct information 63. Nurse Ron is assisting with transferring a client fr
om the operating room table to a stretcher. To provide safety to the client, the
nurse should: a. b. c. d. Moves the client rapidly from the table to the stretc
her. Uncovers the client completely before transferring to the stretcher. Secure
s the client safety belts after transferring to the stretcher. Instructs the cli
ent to move self from the table to the stretcher.
64. Nurse Myrna is providing instructions to a nursing assistant assigned to giv
e a bed bath to a client who is on contact precautions. Nurse Myrna instructs th
e nursing assistant to use which of the following protective items when giving b
ed bath? a. b. c. d. Gown and goggles Gown and gloves Gloves and shoe protectors
Gloves and goggles
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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 st
raight-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 p
osition for the procedure? a. b. c. d. Prone with head turned toward the side su
pported by a pillow. Sims’ position with the head of the bed flat. Right side-lyin
g with the head of the bed elevated 45 degrees. Left side-lying with the head of
the bed elevated 45 degrees.
67. Nurse John develops methods for data gathering. Which of the following crite
ria of a good instrument refers to the ability of the instrument to yield the sa
me results upon its repeated administration? a. b. c. d. Validity Specificity Se
nsitivity Reliability
68. Harry knows that he has to protect the rights of human research subjects. Wh
ich of the following actions of Harry ensures anonymity? a. b. c. d. Keep the id
entities of the subject secret Obtain informed consent Provide equal treatment t
o all the subjects of the study. Release findings only to the participants of th
e study
69. Patient’s refusal to divulge information is a limitation because it is beyond
the control of Tifanny”. What type of research is appropriate for this study? a. 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 variabl
es is possible and the elements of control or randomization are not attendant. W
hich type of research is referred to this? a. b. c. d. Field study Quasi-experim
ent Solomon-Four group design Post-test only design
72. Cherry notes down ideas that were derived from the description of an investi
gation written by the person who conducted it. Which type of reference source re
fers 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 he
r duty is bound not to do doing any action that will cause the patient harm. Thi
s is the meaning of the bioethical principle: a. b. c. d. Non-maleficence Benefi
cence Justice Solidarity
74. When a nurse in-charge causes an injury to a female patient and the injury c
aused 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 Re
s 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 n
ursing law and code of ethics c. The Board can visit a school applying for a per
mit 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 a
llowed to practice the profession for the rest of her life b. Will never have he
r/his license re-issued since it has been revoked c. May apply for re-issuance o
f his/her license based on certain conditions stipulated in RA 9173 d. Will rema
in unable to practice professional nursing 77. Ronald plans to conduct a researc
h 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. Formulating the research hypothesis Review related literature Formulating and
delimiting the research problem Design the theoretical and conceptual framework
78. The leader of the study knows that certain patients who are in a specialized
research setting tend to respond psychologically to the conditions of the study
. This referred to as : a. b. c. d. Cause and effect Hawthorne effect Halo effec
t Horns effect
79. Mary finally decides to use judgment sampling on her research. Which of the
following actions of is correct? a. Plans to include whoever is there during his
study. b. Determines the different nationality of patients frequently admitted
and decides to get representations samples from each. c. Assigns numbers for eac
h of the patients, place these in a fishbowl and draw 10 from it.
21
d. Decides to get 20 samples from the admitted patients 80. The nursing theorist
who developed transcultural nursing theory is: a. b. c. d. Florence Nightingale
Madeleine Leininger Albert Moore Sr. Callista Roy
81. Marion is aware that the sampling method that gives equal chance to all unit
s in the population to get picked is: a. b. c. d. Random Accidental Quota Judgme
nt
82. John plans to use a Likert Scale to his study to determine the: a. b. c. d.
Degree of agreement and disagreement Compliance to expected standards Level of s
atisfaction Degree of acceptance
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 commu
nication 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. Benefic
ence Autonomy Veracity Non-maleficence
22
86. Nurse Reese is teaching a female client with peripheral vascular disease abo
ut foot care; Nurse Reese should include which instruction? a. b. c. d. Avoid we
aring cotton socks. Avoid using a nail clipper to cut toenails. Avoid wearing ca
nvas shoes. Avoid using cornstarch on feet.
87. A client is admitted with multiple pressure ulcers. When developing the clie
nt s diet plan, the nurse should include: a. b. c. d. Fresh orange slices Steame
d broccoli Ice cream Ground beef patties
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
89. Nurse Marian is preparing to administer a blood transfusion. Which action sh
ould the nurse take first? a. Arrange for typing and cross matching of the clien
t’s blood. b. Compare the client’s identification wristband with the tag on the unit
of blood. c. Start an I.V. infusion of normal saline solution. d. Measure the c
lient’s vital signs. 90. A 65 years old male client requests his medication at 9 p
.m. instead of 10 p.m. so that he can go to sleep earlier. Which type of nursing
intervention is required? a. b. c. d. Independent Dependent Interdependent Intr
adependent
91. A female client is to be discharged from an acute care facility after treatm
ent for right leg thrombophlebitis. The Nurse Betty notes that the client s leg
is pain-free, without redness or edema. The nurse s actions reflect which step o
f the nursing process?
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a. b. c. d.
Assessment Diagnosis Implementation Evaluation
92. Nursing care for a female client includes removing elastic stockings once pe
r day. The Nurse Betty is aware that the rationale for this intervention? a. b.
c. d. To increase blood flow to the heart To observe the lower extremities To al
low the leg muscles to stretch and relax To permit veins in the legs to fill wit
h blood.
93. Which nursing intervention takes highest priority when caring for a newly ad
mitted client who s receiving a blood transfusion? a. b. c. d. Instructing the c
lient to report any itching, swelling, or dyspnea. Informing the client that the
transfusion usually take 1 ½ to 2 hours. Documenting blood administration in the
client care record. Assessing the client’s vital signs when the transfusion ends.
94. A male client complains of abdominal discomfort and nausea while receiving t
ube feedings. Which intervention is most appropriate for this problem? a. b. c.
d. Give the feedings at room temperature. Decrease the rate of feedings and the
concentration of the formula. Place the client in semi-Fowler s position while f
eeding. Change the feeding container every 12 hours.
95. Nurse Patricia is reconstituting a powdered medication in a vial. After addi
ng the solution to the powder, she nurse should: a. b. c. d. Do nothing. Invert
the vial and let it stand for 3 to 5 minutes. Shake the vial vigorously. Roll th
e vial gently between the palms.
96. Which intervention should the nurse Trish use when administering oxygen by f
ace mask to a female client? a. Secure the elastic band tightly around the clien
t 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.
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d. Loosen the connectors between the oxygen equipment and humidifier. 97. The ma
ximum transfusion time for a unit of packed red blood cells (RBCs) is: a. b. c.
d. 6 hours 4 hours 3 hours 2 hours
98. Nurse Monique is monitoring the effectiveness of a client s drug therapy. Wh
en should the nurse Monique obtain a blood sample to measure the trough drug lev
el? a. b. c. d. 1 hour before administering the next dose. Immediately before ad
ministering the next dose. Immediately after administering the next dose. 30 min
utes after administering the next dose.
99. Nurse May is aware that the main advantage of using a floor stock system is:
a. b. c. d. The nurse can implement medication orders quickly. The nurse receiv
es input from the pharmacist. The system minimizes transcription errors. The sys
tem reinforces accurate calculations.
100. Nurse Oliver is assessing a client s abdomen. Which finding should the nurs
e report as abnormal? a. b. c. d. Dullness over the liver. Bowel sounds occurrin
g every 10 seconds. Shifting dullness over the abdomen. Vascular sounds heard ov
er the renal arteries.
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NURSING PRACTICE II
Community Health Nursing and Care of the Mother and Child
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TEST II - Community Health Nursing and Care of the Mother and Child 1. May arriv
es 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 positiv
e 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 d
ilated cervix. The nurse determines that May is experiencing which type of abort
ion? a. b. c. d. Inevitable Incomplete Threatened Septic
2. Nurse Reese is reviewing the record of a pregnant client for her first prenat
al visit. Which of the following data, if noted on the client’s record, would aler
t the nurse that the client is at risk for a spontaneous abortion? a. b. c. d. A
ge 36 years History of syphilis History of genital herpes History of diabetes me
llitus
3. Nurse Hazel is preparing to care for a client who is newly admitted to the ho
spital with a possible diagnosis of ectopic pregnancy. Nurse Hazel develops a pl
an of care for the client and determines that which of the following nursing act
ions is the priority? a. b. c. d. Monitoring weight Assessing for edema Monitori
ng apical pulse Monitoring temperature
4. Nurse Oliver is teaching a diabetic pregnant client about nutrition and insul
in needs during pregnancy. The nurse determines that the client understands diet
ary and insulin needs if the client states that the second half of pregnancy req
uire: a. b. c. d. Decreased caloric intake Increased caloric intake Decreased In
sulin Increase Insulin
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5. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidi
form mole. She is aware that one of the following is unassociated with this cond
ition? a. b. c. d. Excessive fetal activity. Larger than normal uterus for gesta
tional age. Vaginal bleeding Elevated levels of human chorionic gonadotropin.
6. A pregnant client is receiving magnesium sulfate for severe pregnancy induced
hypertension (PIH). The clinical findings that would warrant use of the antidot
e , calcium gluconate is: a. b. c. d. Urinary output 90 cc in 2 hours. Absent pa
tellar reflexes. Rapid respiratory rate above 40/min. Rapid rise in blood pressu
re.
7. During vaginal examination of Janah who is in labor, the presenting part is a
t station plus two. Nurse, correctly interprets it as: a. b. c. d. Presenting pa
rt is 2 cm above the plane of the ischial spines. Biparietal diameter is at the
level of the ischial spines. Presenting part in 2 cm below the plane of the isch
ial spines. Biparietal diameter is 2 cm above the ischial spines.
8. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A c
ondition that warrant the nurse in-charge to discontinue I.V. infusion of Pitoci
n is: a. b. c. d. Contractions every 1 ½ minutes lasting 70-80 seconds. Maternal t
emperature 101.2 Early decelerations in the fetal heart rate. Fetal heart rate b
aseline 140-160 bpm.
9. Calcium gluconate is being administered to a client with pregnancy induced hy
pertension (PIH). A nursing action that must be initiated as the plan of care th
roughout injection of the drug is: a. b. c. d. Ventilator assistance CVP reading
s EKG tracings Continuous CPR
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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 he
rpes type 2 infections; vaginal culture at 39 weeks pregnancy was positive. b. F
irst and second caesareans were for cephalopelvic disproportion. c. First caesar
ean through a classic incision as a result of severe fetal distress. d. First lo
w transverse caesarean was for breech position. Fetus in this pregnancy is in a
vertex presentation. 11. Nurse Ryan is aware that the best initial approach when
trying to take a crying toddler’s temperature is: a. b. c. d. Talk to the mother
first and then to the toddler. Bring extra help so it can be done quickly. Encou
rage the mother to hold the child. Ignore the crying and screaming.
12. Baby Tina a 3 month old infant just had a cleft lip and palate repair. What
should the nurse do to prevent trauma to operative site? a. b. c. d. Avoid touch
ing the suture line, even when cleaning. Place the baby in prone position. Give
the baby a pacifier. Place the infant’s arms in soft elbow restraints.
13. Which action should nurse Marian include in the care plan for a 2 month old
with heart failure? a. b. c. d. Feed the infant when he cries. Allow the infant
to rest before feeding. Bathe the infant and administer medications before feedi
ng. Weigh and bathe the infant before feeding.
14. Nurse Hazel is teaching a mother who plans to discontinue breast feeding aft
er 5 months. The nurse should advise her to include which foods in her infant’s di
et? a. b. c. d. Skim milk and baby food. Whole milk and baby food. Iron-rich for
mula only. Iron-rich formula and baby food.
15. Mommy Linda is playing with her infant, who is sitting securely alone on the
floor of the clinic. The mother hides a toy behind her back and the
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infant looks for it. The nurse is aware that estimated age of the infant would b
e: 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 nursin
g? 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 catchmen
ts area. c. The public health nurse functions as part of a team providing a publ
ic health nursing services. d. Public health nursing focuses on preventive, not
curative, services. 17. When the nurse determines whether resources were maximiz
ed in implementing Ligtas Tigdas, she is evaluating a. b. c. d. Effectiveness Ef
ficiency 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 Offic
e Regional Health Office Rural Health Unit
19. Tony is aware the Chairman of the Municipal Health Board is: a. b. c. d. May
or 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 ma
ny more midwife items will the RHU need?
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a. b. c. d.
1 2 3 The RHU does not need any more midwife item.
21. According to Freeman and Heinrich, community health nursing is a development
al service. Which of the following best illustrates this statement? a. The commu
nity health nurse continuously develops himself personally and professionally. b
. Health education and community organizing are necessary in providing community
health services. c. Community health nursing is intended primarily for health p
romotion and prevention and treatment of disease. d. The goal of community healt
h nursing is to provide nursing services to people in their own places of reside
nce. 22. Nurse Tina is aware that the disease declared through Presidential Proc
lamation No. 4 as a target for eradication in the Philippines is? a. b. c. d. Po
liomyelitis Measles Rabies Neonatal tetanus
23. May knows that the step in community organizing that involves training of po
tential leaders in the community is: a. b. c. d. Integration Community organizat
ion 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 regar
ding community health problems b. To mobilize the people to resolve community he
alth problems c. To maximize the community’s resources in dealing with health prob
lems. d. To maximize the community’s resources in dealing with health problems.
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25. Tertiary prevention is needed in which stage of the natural history of disea
se? a. b. c. d. 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 c
oagulation (DIC)? a. b. c. d. Intrauterine fetal death. Placenta accreta. Dysfun
ctional labor. Premature rupture of the membranes.
27. A fullterm client is in labor. Nurse Betty is aware that the fetal heart rat
e would be: a. b. c. d. 80 to 100 beats/minute 100 to 120 beats/minute 120 to 16
0 beats/minute 160 to 180 beats/minute
28. The skin in the diaper area of a 7 month old infant is excoriated and red. N
urse Hazel should instruct the mother to: a. b. c. d. Change the diaper more oft
en. Apply talc powder with diaper changes. Wash the area vigorously with each di
aper change. Decrease the infant’s fluid intake to decrease saturating diapers.
29. Nurse Carla knows that the common cardiac anomalies in children with Down Sy
ndrome (tri-somy 21) is: a. b. c. d. Atrial septal defect Pulmonic stenosis Vent
ricular septal defect Endocardial cushion defect
30. Malou was diagnosed with severe preeclampsia is now receiving I.V. magnesium
sulfate. The adverse effects associated with magnesium sulfate is: a. Anemia
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b. Decreased urine output c. Hyperreflexia d. Increased respiratory rate 31. A 2
3 year old client is having her menstrual period every 2 weeks that last for 1 w
eek. This type of menstrual pattern is bets defined by: a. b. c. d. Menorrhagia
Metrorrhagia Dyspareunia Amenorrhea
32. Jannah is admitted to the labor and delivery unit. The critical laboratory r
esult for this client would be: a. b. c. d. Oxygen saturation Iron binding capac
ity Blood typing Serum Calcium
33. Nurse Gina is aware that the most common condition found during the second-t
rimester of pregnancy is: a. b. c. d. Metabolic alkalosis Respiratory acidosis M
astitis Physiologic anemia
34. Nurse Lynette is working in the triage area of an emergency department. She
sees that several pediatric clients arrive simultaneously. The client who needs
to be treated first is: a. A crying 5 year old child with a laceration on his sc
alp. b. A 4 year old child with a barking coughs and flushed appearance. c. A 3
year old child with Down syndrome who is pale and asleep in his mother’s arms. d.
A 2 year old infant with stridorous breath sounds, sitting up in his mother’s arms
and drooling. 35. Maureen in her third trimester arrives at the emergency room
with painless vaginal bleeding. Which of the following conditions is suspected?
a. b. c. d. Placenta previa Abruptio placentae Premature labor Sexually transmit
ted disease
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36. A young child named Richard is suspected of having pinworms. The community n
urse collects a stool specimen to confirm the diagnosis. The nurse should schedu
le the collection of this specimen for: a. b. c. d. Just before bedtime After th
e child has been bathe Any time during the day Early in the morning
37. In doing a child’s admission assessment, Nurse Betty should be alert to note w
hich signs or symptoms of chronic lead poisoning? a. b. c. d. Irritability and s
eizures Dehydration and diarrhea Bradycardia and hypotension Petechiae and hemat
uria
38. To evaluate a woman’s understanding about the use of diaphragm for family plan
ning, Nurse Trish asks her to explain how she will use the appliance. Which resp
onse indicates a need for further health teaching? a. “I should check the diaphrag
m carefully for holes every time I use it” b. “I may need a different size of diaphr
agm if I gain or lose weight more than 20 pounds” c. “The diaphragm must be left in
place for atleast 6 hours after intercourse” d. “I really need to use the diaphragm
and jelly most during the middle of my menstrual cycle”. 39. Hypoxia is a common c
omplication of laryngotracheobronchitis. Nurse Oliver should frequently assess a
child with laryngotracheobronchitis for: a. b. c. d. Drooling Muffled voice Res
tlessness 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 h
all. b. Walk one step ahead, with the child’s hand on the nurse’s elbow. c. Walk sli
ghtly behind, gently guiding the child forward. d. Walk next to the child, holdi
ng the child’s hand.
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41. When assessing a newborn diagnosed with ductus arteriosus, Nurse Olivia shou
ld expect that the child most likely would have an: a. b. c. d. Loud, machinery-
like murmur. Bluish color to the lips. Decreased BP reading in the upper extremi
ties Increased BP reading in the upper extremities.
42. The reason nurse May keeps the neonate in a neutral thermal environment is t
hat when a newborn becomes too cool, the neonate requires: a. b. c. d. Less oxyg
en, and the newborn’s metabolic rate increases. More oxygen, and the newborn’s metab
olic rate decreases. More oxygen, and the newborn’s metabolic rate increases. Less
oxygen, and the newborn’s metabolic rate decreases.
43. Before adding potassium to an infant’s I.V. line, Nurse Ron must be sure to as
sess whether this infant has: a. b. c. d. Stable blood pressure Patant fontanell
es Moro’s reflex Voided
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 det
ergent Powder with cornstarch
45. During tube feeding, how far above an infant’s stomach should the nurse hold t
he syringe with formula? a. b. c. d. 6 inches 12 inches 18 inches 24 inches
46. In a mothers’ class, Nurse Lhynnete discussed childhood diseases such as chick
en pox. Which of the following statements about chicken pox is correct?
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a. The older one gets, the more susceptible he becomes to the complications of c
hicken pox. b. A single attack of chicken pox will prevent future episodes, incl
uding conditions such as shingles. c. To prevent an outbreak in the community, q
uarantine may be imposed by health authorities. d. Chicken pox vaccine is best g
iven when there is an impending outbreak in the community. 47. Barangay Pinoy ha
d an outbreak of German measles. To prevent congenital rubella, what is the BEST
advice that you can give to women in the first trimester of pregnancy in the ba
rangay Pinoy? a. b. c. d. Advice them on the signs of German measles. Avoid crow
ded places, such as markets and movie houses. Consult at the health center where
rubella vaccine may be given. Consult a physician who may give them rubella imm
unoglobulin.
48. Myrna a public health nurse knows that to determine possible sources of sexu
ally 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 d
iscoloration 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 conditi
on 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 c
omplaint of severe diarrhea and the passage of “rice water” stools. The client is mo
st probably suffering from which condition? a. Giardiasis b. Cholera c. Amebiasi
s
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d. Dysentery 51. The most prevalent form of meningitis among children aged 2 mon
ths to 3 years is caused by which microorganism? a. b. c. d. Hemophilus influenz
ae Morbillivirus Steptococcus pneumoniae Neisseria meningitidis
52. The student nurse is aware that the pathognomonic sign of measles is Koplik’s
spot and you may see Koplik’s spot by inspecting the: a. b. c. d. Nasal mucosa Buc
cal 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
54. In Integrated Management of Childhood Illness, the nurse is aware that the s
evere conditions generally require urgent referral to a hospital. Which of the f
ollowing severe conditions DOES NOT always require urgent referral to a hospital
? a. b. c. d. Mastoiditis Severe dehydration Severe pneumonia Severe febrile dis
ease
55. Myrna a public health nurse will conduct outreach immunization in a barangay
Masay with a population of about 1500. The estimated number of infants in the b
arangay would be: a. b. c. d. 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 po
lio vaccine Measles vaccine MMR
57. It is the most effective way of controlling schistosomiasis in an endemic ar
ea? a. b. c. d. Use of molluscicides Building of foot bridges Proper use of sani
tary toilets Use of protective footwear, such as rubber boots
58. Several clients is newly admitted and diagnosed with leprosy. Which of the f
ollowing clients should be classified as a case of multibacillary leprosy? a. b.
c. d. 3 skin lesions, negative slit skin smear 3 skin lesions, positive slit sk
in smear 5 skin lesions, negative slit skin smear 5 skin lesions, positive slit
skin smear
59. Nurses are aware that diagnosis of leprosy is highly dependent on recognitio
n of symptoms. Which of the following is an early sign of leprosy? a. b. c. d. M
acular lesions Inability to close eyelids Thickened painful nerves Sinking of th
e nosebridge
60. Marie brought her 10 month old infant for consultation because of fever, sta
rted 4 days prior to consultation. In determining malaria risk, what will you do
? a. b. c. d. Perform a tourniquet test. Ask where the family resides. Get a spe
cimen for blood smear. Ask if the fever is present everyday.
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 t
hat 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 t
han 30 days
62. Jimmy a 2-year old child revealed “baggy pants”. As a nurse, using the IMCI guid
elines, 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 feed
ing program. c. Make a teaching plan for the mother, focusing on menu planning f
or 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 diarrhe
a of her 3-year old child. She asked you what to do if her child vomits. As a nu
rse you will tell her to: a. b. c. d. Bring the child to the nearest hospital fo
r further assessment. Bring the child to the health center for intravenous fluid
therapy. Bring the child to the health center for assessment by the physician.
Let the child rest for 10 minutes then continue giving Oresol more slowly.
64. Nikki a 5-month old infant was brought by his mother to the health center be
cause 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 thi
s 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 be
cause of cough. His respiratory rate is 42/minute. Using the Integrated Manageme
nt of Child Illness (IMCI) guidelines of assessment, his breathing is considered
as: a. b. c. d. Fast Slow Normal Insignificant
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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 y
ears 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 baby’s nutrient needs only up to: a. b. c. d. 5 months 6 months 1 y
ear 2 years
69. Nurse Ron is aware that the gestational age of a conceptus that is considere
d viable (able to live outside the womb) is: a. b. c. d. 8 weeks 12 weeks 24 wee
ks 32 weeks
70. When teaching parents of a neonate the proper position for the neonate’s sleep
, the nurse Patricia stresses the importance of placing the neonate on his back
to reduce the risk of which of the following? a. b. c. d. Aspiration Sudden infa
nt death syndrome (SIDS) Suffocation Gastroesophageal reflux (GER)
71. Which finding might be seen in baby James a neonate suspected of having an i
nfection? a. Flushed cheeks b. Increased temperature
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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 com
plication? a. b. c. d. Anemia probably due to chronic fetal hyposia Hyperthermia
due to decreased glycogen stores Hyperglycemia due to decreased glycogen stores
Polycythemia probably due to chronic fetal hypoxia
73. Marjorie has just given birth at 42 weeks’ gestation. When the nurse assessing
the neonate, which physical finding is expected? a. b. c. d. A sleepy, lethargi
c baby Lanugo covering the body Desquamation of the epidermis Vernix caseosa cov
ering the body
74. After reviewing the Myrna’s maternal history of magnesium sulfate during labor
, which condition would nurse Richard anticipate as a potential problem in the n
eonate? a. b. c. d. Hypoglycemia Jitteriness Respiratory depression Tachycardia
75. Which symptom would indicate the Baby Alexandra was adapting appropriately t
o 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 bre
aths/minute
76. When teaching umbilical cord care for Jennifer a new mother, the nurse Jenny
would include which information? a. b. c. d. Apply peroxide to the cord with ea
ch diaper change Cover the cord with petroleum jelly after bathing Keep the cord
dry and open to air Wash the cord with soap and water each day during a tub bat
h.
77. Nurse John is performing an assessment on a neonate. Which of the following
findings is considered common in the healthy neonate?
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 tone
s for which the following reasons? a. b. c. d. To determine fetal well-being. To
assess for prolapsed cord To assess fetal position To prepare for an imminent d
elivery.
79. Which of the following would be least likely to indicate anticipated bonding
behaviors by new parents? a. b. c. d. The parents’ willingness to touch and hold
the new born. The parent’s expression of interest about the size of the new born.
The parents’ indication that they want to see the newborn. The parents’ interactions
with each other.
80. Following a precipitous delivery, examination of the client s vagina reveals
a fourth-degree laceration. Which of the following would be contraindicated whe
n caring for this client? a. Applying cold to limit edema during the first 12 to
24 hours. b. Instructing the client to use two or more peripads to cushion the
area. c. Instructing the client on the use of sitz baths if ordered. d. Instruct
ing the client about the importance of perineal (kegel) exercises. 81. A pregnan
t woman accompanied by her husband, seeks admission to the labor and delivery ar
ea. She states that she s in labor and says she attended the facility clinic for
prenatal care. Which question should the nurse Oliver ask her first? a. b. c. d
. “Do you have any chronic illnesses?” “Do you have any allergies?” “What is your expected
due date?” “Who will be with you during labor?”
82. A neonate begins to gag and turns a dusky color. What should the nurse do fi
rst?
42
a. b. c. d.
Calm the neonate. Notify the physician. Provide oxygen via face mask as ordered
Aspirate the neonate’s nose and mouth with a bulb syringe.
83. When a client states that her "water broke," which of the following actions
would be inappropriate for the nurse to do? a. b. c. d. Observing the pooling of
straw-colored fluid. Checking vaginal discharge with nitrazine paper. Conductin
g a bedside ultrasound for an amniotic fluid index. Observing for flakes of vern
ix in the vaginal discharge.
84. A baby girl is born 8 weeks premature. At birth, she has no spontaneous resp
irations but is successfully resuscitated. Within several hours she develops res
piratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. She s di
agnosed with respiratory distress syndrome, intubated, and placed on a ventilato
r. Which nursing action should be included in the baby s plan of care to prevent
retinopathy of prematurity? a. b. c. d. Cover his eyes while receiving oxygen.
Keep her body temperature low. Monitor partial pressure of oxygen (Pao2) levels.
Humidify the oxygen.
85. Which of the following is normal newborn calorie intake? a. b. c. d. 110 to
130 calories per kg. 30 to 40 calories per lb of body weight. At least 2 ml per
feeding 90 to 100 calories per kg
86. Nurse John is knowledgeable that usually individual twins will grow appropri
ately 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 followin
g classifications applies to monozygotic twins for whom the cleavage of the fert
ilized ovum occurs more than 13 days after fertilization? a. conjoined twins b.
diamniotic dichorionic twins
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c. diamniotic monochorionic twin d. monoamniotic monochorionic twins 88. Tyra ex
perienced painless vaginal bleeding has just been diagnosed as having a placenta
previa. Which of the following procedures is usually performed to diagnose plac
enta previa? a. b. c. d. Amniocentesis Digital or speculum examination External
fetal monitoring Ultrasound
89. Nurse Arnold knows that the following changes in respiratory functioning dur
ing pregnancy is considered normal: a. b. c. d. Increased tidal volume Increased
expiratory volume Decreased inspiratory capacity Decreased oxygen consumption
90. Emily has gestational diabetes and it is usually managed by which of the fol
lowing therapy? a. b. c. d. Diet Long-acting insulin Oral hypoglycemic Oral hypo
glycemic drug and insulin
91. Magnesium sulfate is given to Jemma with preeclampsia to prevent which of th
e following condition? a. b. c. d. Hemorrhage Hypertension Hypomagnesemia Seizur
e
92. Cammile with sickle cell anemia has an increased risk for having a sickle ce
ll crisis during pregnancy. Aggressive management of a sickle cell crisis includ
es 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. Calcium gluconate (Kalcinate) Hydralazine (Apresoline) Naloxone (Narcan) Rh
o (D) immune globulin (RhoGAM)
94. Marlyn is screened for tuberculosis during her first prenatal visit. An intr
adermal 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 fl
at 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, 2
4 year-old is 27 weeks’ pregnant arrives at her physician’s office with complaints o
f fever, nausea, vomiting, malaise, unilateral flank pain, and costovertebral an
gle tenderness. Which of the following diagnoses is most likely? a. b. c. d. Asy
mptomatic bacteriuria Bacterial vaginosis Pyelonephritis Urinary tract infection
(UTI)
96. Rh isoimmunization in a pregnant client develops during which of the followi
ng conditions? a. Rh-positive maternal blood crosses into fetal blood, stimulati
ng fetal antibodies. b. Rh-positive fetal blood crosses into maternal blood, sti
mulating maternal antibodies. c. Rh-negative fetal blood crosses into maternal b
lood, stimulating maternal antibodies. d. Rh-negative maternal blood crosses int
o fetal blood, stimulating fetal antibodies. 97. To promote comfort during labor
, the nurse John advises a client to assume certain positions and avoid others.
Which position may cause maternal hypotension and fetal hypoxia? a. Lateral posi
tion b. Squatting position c. Supine position
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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. Lethargy 2 days after birth. Irritability and poor sucking. A flattened n
ose, small eyes, and thin lips. Congenital defects such as limb anomalies.
99. The uterus returns to the pelvic cavity in which of the following time frame
s? a. b. c. d. 7th to 9th day postpartum. 2 weeks postpartum. End of 6th week po
stpartum. When the lochia changes to alba.
100. Maureen, a primigravida client, age 20, has just completed a difficult, for
ceps-assisted delivery of twins. Her labor was unusually long and required oxyto
cin (Pitocin) augmentation. The nurse who s caring for her should stay alert for
: a. b. c. d. Uterine inversion Uterine atony Uterine involution Uterine discomf
ort
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NURSING PRACTICE III
Care of Clients with Physiologic and Psychosocial Alterations
47
TEST III - Care of Clients with Physiologic and Psychosocial Alterations 1. Nurs
e Michelle should know that the drainage is normal 4 days after a sigmoid colost
omy when the stool is: a. b. c. d. Green liquid Solid formed Loose, bloody Semif
ormed
2. Where would nurse Kristine place the call light for a male client with a righ
t-sided brain attack and left homonymous hemianopsia? a. b. c. d. On the client’s
right side On the client’s left side Directly in front of the client Where the cli
ent like
3. A male client is admitted to the emergency department following an accident.
What are the first nursing actions of the nurse? a. b. c. d. Check respiration,
circulation, neurological response. Align the spine, check pupils, and check for
hemorrhage. Check respirations, stabilize spine, and check circulation. Assess
level of consciousness and circulation.
4. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it r
educes preload and relieves angina by: a. b. c. d. Increasing contractility and
slowing heart rate. Increasing AV conduction and heart rate. Decreasing contract
ility and oxygen consumption. Decreasing venous return through vasodilation.
5. Nurse Patricia finds a female client who is post-myocardial infarction (MI) s
lumped on the side rails of the bed and unresponsive to shaking or shouting. Whi
ch is the nurse next action? a. b. c. d. Call for help and note the time. Clear
the airway Give two sharp thumps to the precordium, and check the pulse. Adminis
ter two quick blows.
6. Nurse Monett is caring for a client recovering from gastro-intestinal bleedin
g. The nurse should:
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a. Plan care so the client can receive 8 hours of uninterrupted sleep each night
. b. Monitor vital signs every 2 hours. c. Make sure that the client takes food
and medications at prescribed intervals. d. Provide milk every 2 to 3 hours. 7.
A male client was on warfarin (Coumadin) before admission, and has been receivin
g heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds.
What should Nurse Carla do? a. b. c. d. Stop the I.V. infusion of heparin and no
tify the physician. Continue treatment as ordered. Expect the warfarin to increa
se the PTT. Increase the dosage, because the level is lower than normal.
8. A client undergone ileostomy, when should the drainage appliance be applied t
o the stoma? a. b. c. d. 24 hours later, when edema has subsided. In the operati
ng room. After the ileostomy begin to function. When the client is able to begin
self-care procedures.
9. A client undergone spinal anesthetic, it will be important that the nurse imm
ediately position the client in: a. b. c. d. On the side, to prevent obstruction
of airway by tongue. Flat on back. On the back, with knees flexed 15 degrees. F
lat on the stomach, with the head turned to the side.
10. While monitoring a male client several hours after a motor vehicle accident,
which assessment data suggest increasing intracranial pressure? a. Blood pressu
re 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 anor
exia. 11. Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the foll
owing symptoms may appear first? a. Altered mental status and dehydration
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b. Fever and chills c. Hemoptysis and Dyspnea d. Pleuritic chest pain and cough
12. A male client has active tuberculosis (TB). Which of the following symptoms
will be exhibit? a. b. c. d. Chest and lower back pain Chills, fever, night swea
ts, and hemoptysis Fever of more than 104°F (40°C) and nausea Headache and photophob
ia
13. Mark, a 7-year-old client is brought to the emergency department. He’s tachypn
eic and afebrile and has a respiratory rate of 36 breaths/minute and has a nonpr
oductive cough. He recently had a cold. Form this history; the client may have w
hich of the following conditions? a. b. c. d. Acute asthma Bronchial pneumonia C
hronic obstructive pulmonary disease (COPD) Emphysema
14. Marichu was given morphine sulfate for pain. She is sleeping and her respira
tory rate is 4 breaths/minute. If action isn’t taken quickly, she might have which
of the following reactions? a. b. c. d. Asthma attack Respiratory arrest Seizur
e Wake up on his own
15. A 77-year-old male client is admitted for elective knee surgery. Physical ex
amination reveals shallow respirations but no sign of respiratory distress. Whic
h of the following is a normal physiologic change related to aging? a. b. c. d.
Increased elastic recoil of the lungs Increased number of functional capillaries
in the alveoli Decreased residual volume Decreased vital capacity
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 arter
ial oxygen saturation (SaO2) when measured with a pulse oximeter. b. Increase in
systemic blood pressure.
50
c. Presence of premature ventricular contractions (PVCs) on a cardiac monitor. d
. Increase in intracranial pressure (ICP). 17. Nurse Ron is caring for a male cl
ient taking an anticoagulant. The nurse should teach the client to: a. b. c. d.
Report incidents of diarrhea. Avoid foods high in vitamin K Use a straight razor
when shaving. Take aspirin to pain relief.
18. Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter. T
he nurse should treat excess hair at the site by: a. b. c. d. Leaving the hair i
ntact Shaving the area Clipping the hair in the area Removing the hair with a de
pilatory.
19. Nurse Michelle is caring for an elderly female with osteoporosis. When teach
ing the client, the nurse should include information about which major complicat
ion: a. b. c. d. Bone fracture Loss of estrogen Negative calcium balance Dowager’s
hump
20. Nurse Len is teaching a group of women to perform BSE. The nurse should expl
ain that the purpose of performing the examination is to discover: a. b. c. d. C
ancerous 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 weigh
t loss during thyroid replacement therapy. c. Balance the client’s periods of acti
vity and rest. d. Encourage the client to be active to prevent constipation.
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22. Nurse Kris is teaching a client with history of atherosclerosis. To decrease
the risk of atherosclerosis, the nurse should encourage the client to: a. b. c.
d. Avoid focusing on his weight. Increase his activity level. Follow a regular
diet. Continue leading a high-stress lifestyle.
23. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a clien
t following a: a. b. c. d. Laminectomy Thoracotomy Hemorrhoidectomy Cystectomy.
24. A 55-year old client underwent cataract removal with intraocular lens implan
t. Nurse Oliver is giving the client discharge instructions. These instructions
should include which of the following? a. b. c. d. Avoid lifting objects weighin
g more than 5 lb (2.25 kg). Lie on your abdomen when in bed Keep rooms brightly
lit. Avoiding straining during bowel movement or bending at the waist.
25. George should be taught about testicular examinations during: a. b. c. d. wh
en sexual activity starts After age 69 After age 40 Before age 20.
26. A male client undergone a colon resection. While turning him, wound dehiscen
ce with evisceration occurs. Nurse Trish first response is to: a. b. c. d. Call
the physician Place a saline-soaked sterile dressing on the wound. Take a blood
pressure and pulse. Pull the dehiscence closed.
27. Nurse Audrey is caring for a client who has suffered a severe cerebrovascula
r accident. During routine assessment, the nurse notices CheyneStrokes respirati
ons. Cheyne-strokes respirations are: a. A progressively deeper breaths followed
by shallower breaths with apneic periods.
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b. Rapid, deep breathing with abrupt pauses between each breath. c. Rapid, deep
breathing and irregular breathing without pauses. d. Shallow breathing with an i
ncreased respiratory rate. 28. Nurse Bea is assessing a male client with heart f
ailure. The breath sounds commonly auscultated in clients with heart failure are
: a. b. c. d. Tracheal Fine crackles Coarse crackles Friction rubs
29. The nurse is caring for Kenneth experiencing an acute asthma attack. The cli
ent stops wheezing and breath sounds aren’t audible. The reason for this change is
that: a. b. c. d. The attack is over. The airways are so swollen that no air ca
nnot get through. The swelling has decreased. Crackles have replaced wheezes.
30. Mike with epilepsy is having a seizure. During the active seizure phase, the
nurse should: a. Place the client on his back remove dangerous objects, and ins
ert 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 object
s, 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. Infection of the lung. Kinked or obstructed chest tube Excessive water in
the water-seal chamber Excessive chest tube drainage
32. Nurse Maureen is talking to a male client, the client begins choking on his
lunch. He’s coughing forcefully. The nurse should:
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a. Stand him up and perform the abdominal thrust maneuver from behind. b. Lay hi
m 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 i
s taking a health history of an 84 year old client. Which information will be mo
st useful to the nurse for planning care? a. b. c. d. General health for the las
t 10 years. Current health promotion activities. Family history of diseases. Mar
ital status.
34. When performing oral care on a comatose client, Nurse Krina should: a. Apply
lemon glycerin to the client’s lips at least every 2 hours. b. Brush the teeth wi
th client lying supine. c. Place the client in a side lying position, with the h
ead of the bed lowered. d. Clean the client’s mouth with hydrogen peroxide. 35. A
77-year-old male client is admitted with a diagnosis of dehydration and change i
n mental status. He’s being hydrated with L.V. fluids. When the nurse takes his vi
tal signs, she notes he has a fever of 103°F (39.4°C) a cough producing yellow sputu
m and pleuritic chest pain. The nurse suspects this client may have which of the
following conditions? a. b. c. d. Adult respiratory distress syndrome (ARDS) My
ocardial infarction (MI) Pneumonia Tuberculosis
36. Nurse Oliver is working in a out patient clinic. He has been alerted that th
ere is an outbreak of tuberculosis (TB). Which of the following clients entering
the clinic today most likely to have TB? a. b. c. d. A 16-year-old female high
school student A 33-year-old day-care worker A 43-yesr-old homeless man with a h
istory of alcoholism A 54-year-old businessman
37. Virgie with a positive Mantoux test result will be sent for a chest X-ray. T
he nurse is aware that which of the following reasons this is done? a. To confir
m the diagnosis
54
b. To determine if a repeat skin test is needed c. To determine the extent of le
sions d. To determine if this is a primary or secondary infection 38. Kennedy wi
th acute asthma showing inspiratory and expiratory wheezes and a decreased force
d expiratory volume should be treated with which of the following classes of med
ication right away? a. b. c. d. 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, peripher
al edema and cyanotic nail beds. Based on this information, he most likely has w
hich of the following conditions? a. b. c. d. Adult respiratory distress syndrom
e (ARDS) Asthma Chronic obstructive bronchitis Emphysema
Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic
Lymphocytic Leukemia. 40. The treatment for patients with leukemia is bone marr
ow transplantation. Which statement about bone marrow transplantation is not cor
rect? a. b. c. d. The patient is under local anesthesia during the procedure The
aspirated bone marrow is mixed with heparin. The aspiration site is the posteri
or or anterior iliac crest. The recipient receives cyclophosphamide (Cytoxan) fo
r 4 consecutive days before the procedure.
41. After several days of admission, Francis becomes disoriented and complains o
f frequent headaches. The nurse in-charge first action would be: a. b. c. d. Cal
l the physician Document the patient’s status in his charts. Prepare oxygen treatm
ent Raise the side rails
42. During routine care, Francis asks the nurse, “How can I be anemic if this dise
ase causes increased my white blood cell production?” The nurse in-charge best res
ponse would be that the increased number of white blood cells (WBC) is:
55
a. b. c. d.
Crowd red blood cells Are not responsible for the anemia. Uses nutrients from ot
her cells Have an abnormally short life span of cells.
43. Diagnostic assessment of Francis would probably not reveal: a. b. c. d. Pred
ominance of lymhoblasts Leukocytosis Abnormal blast cells in the bone marrow Ele
vated thrombocyte counts
44. Robert, a 57-year-old client with acute arterial occlusion of the left leg u
ndergoes an emergency embolectomy. Six hours later, the nurse isn’t able to obtain
pulses in his left foot using Doppler ultrasound. The nurse immediately notifie
s the physician, and asks her to prepare the client for surgery. As the nurse en
ters the client’s room to prepare him, he states that he won’t have any more surgery
. Which of the following is the best initial response by the nurse? a. b. c. d.
Explain the risks of not having the surgery Notifying the physician immediately
Notifying the nursing supervisor Recording the client’s refusal in the nurses’ notes
45. During the endorsement, which of the following clients should the on-duty nu
rse assess first? a. The 58-year-old client who was admitted 2 days ago with hea
rt 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, bl
ood pressure of 78/50 mm Hg, and a “do not resuscitate” order c. The 62-year-old cli
ent who was admitted 1 day ago with thrombophlebitis and is receiving L.V. hepar
in d. The 75-year-old client who was admitted 1 hour ago with new-onset atrial f
ibrillation 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 “i
t’s racing out of the chest”. She reports no history of cardiac disorders. The nurse
attaches her to a cardiac monitor and notes sinus tachycardia with a rate of 13
6beats/minutes. Breath sounds are clear and the respiratory rate is 26 breaths/m
inutes. 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 t
he 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 t
hat this client s lump is cancerous? a. b. c. d. Eversion of the right nipple an
d mobile mass Nonmobile mass with irregular edges Mobile mass that is soft and e
asily delineated Nonpalpable right axillary lymph nodes
48. A 35-year-old client with vaginal cancer asks the nurse, "What is the usual
treatment for this type of cancer?" Which treatment should the nurse name? a. b.
c. d. Surgery Chemotherapy Radiation Immunotherapy
49. Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classi
fies the lesion according to the TNM staging system as follows: TIS, N0, M0. Wha
t does this classification mean? a. No evidence of primary tumor, no abnormal re
gional lymph nodes, and no evidence of distant metastasis b. Carcinoma in situ,
no abnormal regional lymph nodes, and no evidence of distant metastasis c. Can t
assess tumor or regional lymph nodes and no evidence of metastasis d. Carcinoma
in situ, no demonstrable metastasis of the regional lymph nodes, and ascending
degrees of distant metastasis 50. Lydia undergoes a laryngectomy to treat laryng
eal cancer. When teaching the client how to care for the neck stoma, the nurse s
hould include which instruction? a. "Keep the stoma uncovered." b. "Keep the sto
ma dry." c. "Have a family member perform stoma care initially until you get use
d to the procedure." d. "Keep the stoma moist."
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. Whic
h 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 t
he ribs and affects the sympathetic nerve ganglia. When assessing for signs and
symptoms of this syndrome, the nurse should note: a. miosis, partial eyelid ptos
is, and anhidrosis on the affected side of the face. b. chest pain, dyspnea, cou
gh, 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 t
he nurse what PSA is. The nurse should reply that it stands for: a. prostate-spe
cific antigen, which is used to screen for prostate cancer. b. protein serum ant
igen, which is used to determine protein levels. c. pneumococcal strep antigen,
which is a bacteria that causes pneumonia. d. Papanicolaou-specific antigen, whi
ch is used to screen for cervical cancer. 54. What is the most important postope
rative 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. "Avoid dri
nking liquids until the gag reflex returns." "Avoid eating milk products for 24
hours." "Notify a nurse if you experience blood in your urine." "Remain supine f
or the time specified by the physician."
55. A male client suspected of having colorectal cancer will require which diagn
ostic study to confirm the diagnosis? a. b. c. d. Stool Hematest Carcinoembryoni
c antigen (CEA) Sigmoidoscopy Abdominal computed tomography (CT) scan
58
56. During a breast examination, which finding most strongly suggests that the L
uz has breast cancer? a. Slight asymmetry of the breasts. b. A fixed nodular mas
s with dimpling of the overlying skin c. Bloody discharge from the nipple d. Mul
tiple 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 co
nfirm or rule out a spinal cord lesion. During the MRI scan, which of the follow
ing would pose a threat to the client? a. b. c. d. The client lies still. The cl
ient asks questions. The client hears thumping sounds. The client wears a watch
and wedding band.
59. Nurse Cecile is teaching a female client about preventing osteoporosis. Whic
h of the following teaching points is correct? a. Obtaining an X-ray of the bone
s every 3 years is recommended to detect bone loss. b. To avoid fractures, the c
lient should avoid strenuous exercise. c. The recommended daily allowance of cal
cium may be found in a wide variety of foods. d. Obtaining the recommended daily
allowance of calcium requires taking a calcium supplement. 60. Before Jacob und
ergoes arthroscopy, the nurse reviews the assessment findings for contraindicati
ons for this procedure. Which finding is a contraindication? a. Joint pain b. Jo
int deformity c. Joint flexion of less than 50% d. Joint stiffness
59
61. Mr. Rodriguez is admitted with severe pain in the knees. Which form of arthr
itis 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 Trau
matic arthritis Intermittent arthritis Gouty arthritis
62. A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old client wi
th 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 t
hromboembolic right stroke; his left arm is swollen. Which of the following cond
itions may cause swelling after a stroke? a. b. c. d. Elbow contracture secondar
y to spasticity Loss of muscle contraction decreasing venous return Deep vein th
rombosis (DVT) due to immobility of the ipsilateral side Hypoalbuminemia due to
protein escaping from an inflamed glomerulus
64. Heberden’s nodes are a common sign of osteoarthritis. Which of the following s
tatement is correct about this deformity? a. b. c. d. It appears only in men It
appears on the distal interphalangeal joint It appears on the proximal interphal
angeal joint It appears on the dorsolateral aspect of the interphalangeal joint.
65. Which of the following statements explains the main difference between rheum
atoid arthritis and osteoarthritis? a. b. c. d. Osteoarthritis is gender-specifi
c, rheumatoid arthritis isn’t Osteoarthritis is a localized disease rheumatoid art
hritis is systemic Osteoarthritis is a systemic disease, rheumatoid arthritis is
localized Osteoarthritis has dislocations and subluxations, rheumatoid arthriti
s doesn’t
66. Mrs. Cruz uses a cane for assistance in walking. Which of the following stat
ements is true about a cane or other assistive devices?
60
a. b. c. d.
A walker is a better choice than a cane. The cane should be used on the affected
side The cane should be used on the unaffected side A client with osteoarthriti
s should be encouraged to ambulate without the cane
67. A male client with type 1 diabetes is scheduled to receive 30 U of 70/30 ins
ulin. There is no 70/30 insulin available. As a substitution, the nurse may give
the client: a. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH). b
. 21 U regular insulin and 9 U NPH. c. 10 U regular insulin and 20 U NPH. d. 20
U regular insulin and 10 U NPH. 68. Nurse Len should expect to administer which
medication to a client with gout? a. b. c. d. aspirin furosemide (Lasix) colchic
ines calcium gluconate (Kalcinate)
69. Mr. Domingo with a history of hypertension is diagnosed with primary hyperal
dosteronism. This diagnosis indicates that the client s hypertension is caused b
y excessive hormone secretion from which of the following glands? a. b. c. d. Ad
renal 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. The
y contain exudate and provide a moist wound environment. They protect the wound
from mechanical trauma and promote healing. They debride the wound and promote h
ealing by secondary intention. They prevent the entrance of microorganisms and m
inimize wound discomfort.
71. Nurse Zeny is caring for a client in acute addisonian crisis. Which laborato
ry data would the nurse expect to find? a. Hyperkalemia
61
b. Reduced blood urea nitrogen (BUN) c. Hypernatremia d. Hyperglycemia 72. A cli
ent is admitted for treatment of the syndrome of inappropriate antidiuretic horm
one (SIADH). Which nursing intervention is appropriate? a. b. c. d. Infusing I.V
. fluids rapidly as ordered Encouraging increased oral intake Restricting fluids
Administering glucose-containing I.V. fluids as ordered
73. A female client tells nurse Nikki that she has been working hard for the las
t 3 months to control her type 2 diabetes mellitus with diet and exercise. To de
termine the effectiveness of the client s efforts, the nurse should check: a. b.
c. d. urine glucose level. fasting blood glucose level. serum fructosamine leve
l. glycosylated hemoglobin level.
74. Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a dia
betic client at 7 a.m. At what time would the nurse expect the client to be most
at risk for a hypoglycemic reaction? a. b. c. d. 10:00 am Noon 4:00 pm 10:00 pm
75. The adrenal cortex is responsible for producing which substances? a. b. c. d
. Glucocorticoids and androgens Catecholamines and epinephrine Mineralocorticoid
s and catecholamines Norepinephrine and epinephrine
76. On the third day after a partial thyroidectomy, Proserfina exhibits muscle t
witching and hyperirritability of the nervous system. When questioned, the clien
t reports numbness and tingling of the mouth and fingertips. Suspecting a lifeth
reatening electrolyte disturbance, the nurse notifies the surgeon immediately. W
hich electrolyte disturbance most commonly follows thyroid surgery? a. Hypocalce
mia b. Hyponatremia c. Hyperkalemia
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d. Hypermagnesemia 77. Which laboratory test value is elevated in clients who sm
oke and can t be used as a general indicator of cancer? a. b. c. d. Acid phospha
tase level Serum calcitonin level Alkaline phosphatase level Carcinoembryonic an
tigen level
78. Francis with anemia has been admitted to the medical-surgical unit. Which as
sessment findings are characteristic of iron-deficiency anemia? a. b. c. d. Nigh
ts sweats, weight loss, and diarrhea Dyspnea, tachycardia, and pallor Nausea, vo
miting, and anorexia Itching, rash, and jaundice
79. In teaching a female client who is HIV-positive about pregnancy, the nurse w
ould know more teaching is necessary when the client says: a. The baby can get t
he 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. "Pu
t on disposable gloves before bathing." "Sterilize all plates and utensils in bo
iling water." "Avoid sharing such articles as toothbrushes and razors." "Avoid e
ating foods from serving dishes shared by other family members."
81. Nurse Marie is caring for a 32-year-old client admitted with pernicious anem
ia. Which set of findings should the nurse expect when assessing the client? a.
b. c. d. Pallor, bradycardia, and reduced pulse pressure Pallor, tachycardia, an
d a sore tongue Sore tongue, dyspnea, and weight gain Angina, double vision, and
anorexia
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82. After receiving a dose of penicillin, a client develops dyspnea and hypotens
ion. Nurse Celestina suspects the client is experiencing anaphylactic shock. Wha
t should the nurse do first? a. Page an anesthesiologist immediately and prepare
to intubate the client. b. Administer epinephrine, as prescribed, and prepare t
o intubate the client if necessary. c. Administer the antidote for penicillin, a
s prescribed, and continue to monitor the client s vital signs. d. Insert an ind
welling urinary catheter and begin to infuse I.V. fluids as ordered. 83. Mr. Mar
quez with rheumatoid arthritis is about to begin aspirin therapy to reduce infla
mmation. When teaching the client about aspirin, the nurse discusses adverse rea
ctions to prolonged aspirin therapy. These include: a. b. c. d. weight gain. fin
e motor tremors. respiratory acidosis. bilateral hearing loss.
84. A 23-year-old client is diagnosed with human immunodeficiency virus (HIV). A
fter recovering from the initial shock of the diagnosis, the client expresses a
desire to learn as much as possible about HIV and acquired immunodeficiency synd
rome (AIDS). When teaching the client about the immune system, the nurse states
that adaptive immunity is provided by which type of white blood cell? a. b. c. d
. Neutrophil Basophil Monocyte Lymphocyte
85. In an individual with Sjögren s syndrome, nursing care should focus on: a. b.
c. d. moisture replacement. electrolyte balance. nutritional supplementation. ar
rhythmia management.
86. During chemotherapy for lymphocytic leukemia, Mathew develops abdominal pain
, fever, and "horse barn" smelling diarrhea. It would be most important for the
nurse to advise the physician to order: a. enzyme-linked immunosuppressant assay
(ELISA) test. b. electrolyte panel and hemogram.
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c. stool for Clostridium difficile test. d. flat plate X-ray of the abdomen. 87.
A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb w
eight loss in 6 weeks. To confirm that the client has been infected with the hum
an immunodeficiency virus (HIV), the nurse expects the physician to order: a. b.
c. d. E-rosette immunofluorescence. quantification of T-lymphocytes. enzyme-lin
ked 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 indicate
d 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 b
lood s ability to coagulate properly 89. While monitoring a client for the devel
opment of disseminated intravascular coagulation (DIC), the nurse should take no
te of what assessment parameters? a. b. c. d. Platelet count, prothrombin time,
and partial thromboplastin time Platelet count, blood glucose levels, and white
blood cell (WBC) count Thrombin time, calcium levels, and potassium levels Fibri
nogen level, WBC, and platelet count
90. When taking a dietary history from a newly admitted female client, Nurse Len
should remember that which of the following foods is a common allergen? a. b. c
. d. Bread Carrots Orange Strawberries
91. Nurse John is caring for clients in the outpatient clinic. Which of the foll
owing phone calls should the nurse return first? a. A client with hepatitis A wh
o states, “My arms and legs are itching.” b. A client with cast on the right leg who
states, “I have a funny feeling in my right leg.” c. A client with osteomyelitis of
the spine who states, “I am so nauseous that I can’t eat.”
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d. A client with rheumatoid arthritis who states, “I am having trouble sleeping.” 92
. Nurse Sarah is caring for clients on the surgical floor and has just received
report from the previous shift. Which of the following clients should the nurse
see first? a. A 35-year-old admitted three hours ago with a gunshot wound; 1.5 c
m area of dark drainage noted on the dressing. b. A 43-year-old who had a mastec
tomy two days ago; 23 ml of serosanguinous fluid noted in the Jackson-Pratt drai
n. c. A 59-year-old with a collapsed lung due to an accident; no drainage noted
in the previous eight hours. d. A 62-year-old who had an abdominal-perineal rese
ction three days ago; client complaints of chills. 93. Nurse Eve is caring for a
client who had a thyroidectomy 12 hours ago for treatment of Grave’s disease. The
nurse would be most concerned if which of the following was observed? a. Blood
pressure 138/82, respirations 16, oral temperature 99 degrees Fahrenheit. b. The
client supports his head and neck when turning his head to the right. c. The cl
ient spontaneously flexes his wrist when the blood pressure is obtained. d. The
client is drowsy and complains of sore throat. 94. Julius is admitted with compl
aints of severe pain in the lower right quadrant of the abdomen. To assist with
pain relief, the nurse should take which of the following actions? a. b. c. d. E
ncourage the client to change positions frequently in bed. Administer Demerol 50
mg IM q 4 hours and PRN. Apply warmth to the abdomen with a heating pad. Use co
mfort measures and pillows to position the client.
95. Nurse Tina prepares a client for peritoneal dialysis. Which of the following
actions should the nurse take first? a. b. c. d. Assess for a bruit and a thril
l. Warm the dialysate solution. Position the client on the left side. Insert a F
oley catheter
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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 nur
se, 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 ho
lds the cane with his left hand, moves the cane forward followed by the right le
g, 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 occ
asionally confused and her gait is often unsteady. Which of the following action
s, if taken by the nurse, is most appropriate? a. Ask the woman’s family to provid
e 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 twic
e a day. 98. Nurse Evangeline teaches an elderly client how to use a standard al
uminum walker. Which of the following behaviors, if demonstrated by the client,
indicates that the nurse’s teaching was effective? a. The client slowly pushes the
walker forward 12 inches, then takes small steps forward while leaning on the w
alker. b. The client lifts the walker, moves it forward 10 inches, and then take
s several small steps forward. c. The client supports his weight on the walker w
hile 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. Increased sensitivity to the side effects of medications. Decreased visual, a
uditory, and gustatory abilities. Isolation from their families and familiar sur
roundings. Decrease musculoskeletal function and mobility.
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100. A male client with emphysema becomes restless and confused. What step shoul
d nurse Jasmine take next? a. b. c. d. Encourage the client to perform pursed li
p breathing. Check the client’s temperature. Assess the client’s potassium level. In
crease the client’s oxygen flow rate.
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NURSING PRACTICE IV
69
TEST IV - Care of Clients with Physiologic and Psychosocial Alterations 1. Randy
has undergone kidney transplant, what assessment would prompt Nurse Katrina to
suspect organ rejection? a. b. c. d. Sudden weight loss Polyuria Hypertension Sh
ock
2. The immediate objective of nursing care for an overweight, mildly hypertensiv
e male client with ureteral colic and hematuria is to decrease: a. b. c. d. Pain
Weight Hematuria Hypertension
3. Matilda, with hyperthyroidism is to receive Lugol’s iodine solution before a su
btotal thyroidectomy is performed. The nurse is aware that this medication is gi
ven to: a. b. c. d. Decrease the total basal metabolic rate. Maintain the functi
on of the parathyroid glands. Block the formation of thyroxine by the thyroid gl
and. Decrease the size and vascularity of the thyroid gland.
4. Ricardo, was diagnosed with type I diabetes. The nurse is aware that acute hy
poglycemia also can develop in the client who is diagnosed with: a. b. c. d. Liv
er disease Hypertension Type 2 diabetes Hyperthyroidism
5. Tracy is receiving combination chemotherapy for treatment of metastatic carci
noma. Nurse Ruby should monitor the client for the systemic side effect of: a. b
. c. d. Ascites Nystagmus Leukopenia Polycythemia
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6. Norma, with recent colostomy expresses concern about the inability to control
the passage of gas. Nurse Oliver should suggest that the client plan to: a. b.
c. d. Eliminate foods high in cellulose. Decrease fluid intake at meal times. Av
oid foods that in the past caused flatus. Adhere to a bland diet prior to social
events.
7. Nurse Ron begins to teach a male client how to perform colostomy irrigations.
The nurse would evaluate that the instructions were understood when the client
states, “I should: a. Lie on my left side while instilling the irrigating solution
.” b. Keep the irrigating container less than 18 inches above the stoma.” c. Instill
a minimum of 1200 ml of irrigating solution to stimulate evacuation of the bowe
l.” d. Insert the irrigating catheter deeper into the stoma if cramping occurs dur
ing the procedure.” 8. Patrick is in the oliguric phase of acute tubular necrosis
and is experiencing fluid and electrolyte imbalances. The client is somewhat con
fused and complains of nausea and muscle weakness. As part of the prescribed the
rapy to correct this electrolyte imbalance, the nurse would expect to: a. b. c.
d. 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 upp
er arm and penis
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c. Right thigh and penis d. Upper trunk 11. Herbert, a 45 year old construction
engineer is brought to the hospital unconscious after falling from a 2-story bui
lding. When assessing the client, the nurse would be most concerned if the asses
sment revealed: a. Reactive pupils b. A depressed fontanel c. Bleeding from ears
d. An elevated temperature 12. Nurse Sherry is teaching male client regarding h
is permanent artificial pacemaker. Which information given by the nurse shows he
r knowledge deficit about the artificial cardiac pacemaker? a. take the pulse ra
te once a day, in the morning upon awakening b. May be allowed to use electrical
appliances c. Have regular follow up care d. May engage in contact sports 13. T
he nurse is ware that the most relevant knowledge about oxygen administration to
a male client with COPD is a. Oxygen at 1-2L/min is given to maintain the hypox
ic stimulus for breathing. b. Hypoxia stimulates the central chemoreceptors in t
he medulla that makes the client breath. c. Oxygen is administered best using a
non-rebreathing mask d. Blood gases are monitored using a pulse oximeter. 14. To
nny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes ar
e inserted, and one-bottle water-seal drainage is instituted in the operating ro
om. In the postanesthesia care unit Tonny is placed in Fowler s position on eith
er his right side or on his back. The nurse is aware that this position: a. b. c
. d. Reduce incisional pain. Facilitate ventilation of the left lung. Equalize p
ressure in the pleural space. Increase venous return
15. Kristine is scheduled for a bronchoscopy. When teaching Kristine what to exp
ect afterward, the nurse s highest priority of information would be:
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a. b. c. d.
Food and fluids will be withheld for at least 2 hours. Warm saline gargles will
be done q 2h. Coughing and deep-breathing exercises will be done q2h. Only ice c
hips and cold liquids will be allowed initially.
16. Nurse Tristan is caring for a male client in acute renal failure. The nurse
should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to b
e used to treat: a. b. c. d. hypernatremia. hypokalemia. hyperkalemia. hypercalc
emia.
17. Ms. X has just been diagnosed with condylomata acuminata (genital warts). Wh
at 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 (P
ap) smear annually. b. The most common treatment is metronidazole (Flagyl), whic
h should eradicate the problem within 7 to 10 days. c. The potential for transmi
ssion to her sexual partner will be eliminated if condoms are used every time th
ey have sexual intercourse. d. The human papillomavirus (HPV), which causes cond
ylomata acuminata, can t be transmitted during oral sex. 18. Maritess was recent
ly diagnosed with a genitourinary problem and is being examined in the emergency
department. When palpating the her kidneys, the nurse should keep which anatomi
cal fact in mind? a. The left kidney usually is slightly higher than the right o
ne. b. The kidneys are situated just above the adrenal glands. c. The average ki
dney is approximately 5 cm (2") long and 2 to 3 cm (¾" to 1-1/8") wide. d. The kid
neys 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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d. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%. 2
0. Katrina has an abnormal result on a Papanicolaou test. After admitting that s
he read her chart while the nurse was out of the room, Katrina asks what dysplas
ia means. Which definition should the nurse provide? a. Presence of completely u
ndifferentiated tumor cells that don t resemble cells of the tissues of their or
igin. b. Increase in the number of normal cells in a normal arrangement in a tis
sue or an organ. c. Replacement of one type of fully differentiated cell by anot
her in tissues where the second type normally isn t found. d. Alteration in the
size, shape, and organization of differentiated cells. 21. During a routine chec
kup, Nurse Mariane assesses a male client with acquired immunodeficiency syndrom
e (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related
cancer? a. b. c. d. Squamous cell carcinoma Multiple myeloma Leukemia Kaposi s s
arcoma
22. Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to
use a spinal (subarachnoid) block during surgery. In the operating room, the nur
se positions the client according to the anesthesiologist s instructions. Why do
es the client require special positioning for this type of anesthesia? a. b. c.
d. 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 abdomin
al pressure and nausea. The first nursing action should be to: a. b. c. d. Auscu
ltate bowel sounds. Palpate the abdomen. Change the client s position. Insert a
rectal tube.
24. Wilfredo with a recent history of rectal bleeding is being prepared for a co
lonoscopy. How should the nurse Patricia position the client for this test initi
ally?
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a. b. c. d.
Lying on the right side with legs straight Lying on the left side with knees ben
t Prone with the torso elevated Bent over with hands touching the floor
25. A male client with inflammatory bowel disease undergoes an ileostomy. On the
first day after surgery, Nurse Oliver notes that the client s stoma appears dus
ky. How should the nurse interpret this finding? a. b. c. d. Blood supply to the
stoma has been interrupted. This is a normal finding 1 day after surgery. The o
stomy bag should be adjusted. An intestinal obstruction has occurred.
26. Anthony suffers burns on the legs, which nursing intervention helps prevent
contractures? a. b. c. d. Applying knee splints Elevating the foot of the bed Hy
perextending the client s palms Performing shoulder range-of-motion exercises
27. Nurse Ron is assessing a client admitted with second- and third-degree burns
on the face, arms, and chest. Which finding indicates a potential problem? a. b
. c. d. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg. Urine outp
ut of 20 ml/hour. White pulmonary secretions. Rectal temperature of 100.6° F (38° C)
.
28. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to
move on his own. To help the client avoid pressure ulcers, Nurse Celia should:
a. b. c. d. Turn him frequently. Perform passive range-of-motion (ROM) exercises
. Reduce the client s fluid intake. Encourage the client to use a footboard.
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29. Nurse Maria plans to administer dexamethasone cream to a female client who h
as dermatitis over the anterior chest. How should the nurse apply this topical a
gent? a. With a circular motion, to enhance absorption. b. With an upward motion
, to increase blood supply to the affected area c. In long, even, outward, and d
ownward strokes in the direction of hair growth d. In long, even, outward, and u
pward strokes in the direction opposite hair growth 30. Nurse Kate is aware that
one of the following classes of medication protect the ischemic myocardium by b
locking catecholamines and sympathetic nerve stimulation is: a. b. c. d. Beta -a
drenergic blockers Calcium channel blocker Narcotics Nitrates
31. A male client has jugular distention. On what position should the nurse plac
e the head of the bed to obtain the most accurate reading of jugular vein disten
tion? a. b. c. d. High Fowler’s Raised 10 degrees Raised 30 degrees Supine positio
n
32. The nurse is aware that one of the following classes of medications maximize
s cardiac performance in clients with heart failure by increasing ventricular co
ntractility? a. b. c. d. Beta-adrenergic blockers Calcium channel blocker Diuret
ics Inotropic agents
33. A male client has a reduced serum high-density lipoprotein (HDL) level and a
n elevated low-density lipoprotein (LDL) level. Which of the following dietary m
odifications is not appropriate for this client? a. Fiber intake of 25 to 30 g d
aily
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b. Less than 30% of calories form fat c. Cholesterol intake of less than 300 mg
daily d. Less than 10% of calories from saturated fat 34. A 37-year-old male cli
ent was admitted to the coronary care unit (CCU) 2 days ago with an acute myocar
dial infarction. Which of the following actions would breach the client confiden
tiality? a. The CCU nurse gives a verbal report to the nurse on the telemetry un
it before transferring the client to that unit b. The CCU nurse notifies the on-
call physician about a change in the client’s condition c. The emergency departmen
t nurse calls up the latest electrocardiogram results to check the client’s progre
ss. d. At the client’s request, the CCU nurse updates the client’s wife on his condi
tion 35. A male client arriving in the emergency department is receiving cardiop
ulmonary resuscitation from paramedics who are giving ventilations through an en
dotracheal (ET) tube that they placed in the client’s home. During a pause in comp
ressions, the cardiac monitor shows narrow QRS complexes and a heart rate of bea
ts/minute with a palpable pulse. Which of the following actions should the nurse
take first? a. Start an L.V. line and administer amiodarone (Cardarone), 300 mg
L.V. over 10 minutes. b. Check endotracheal tube placement. c. Obtain an arteri
al blood gas (ABG) sample. d. Administer atropine, 1 mg L.V. 36. After cardiac s
urgery, a client’s blood pressure measures 126/80 mm Hg. Nurse Katrina determines
that mean arterial pressure (MAP) is which of the following? a. b. c. d. 46 mm H
g 80 mm Hg 95 mm Hg 90 mm Hg
37. A female client arrives at the emergency department with chest and stomach p
ain 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 thromboplas
tin time, fibrinogen and fibrin split product values.
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c. Electrocardiogram, complete blood count, testing for occult blood, comprehens
ive serum metabolic panel. d. Electroencephalogram, alkaline phosphatase and asp
artate aminotransferase levels, basic serum metabolic panel 38. Macario had coro
nary artery bypass graft (CABG) surgery 3 days ago. Which of the following condi
tions is suspected by the nurse when a decrease in platelet count from 230,000 u
l to 5,000 ul is noted? a. b. c. d. Pancytopenia Idiopathic thrombocytopemic pur
pura (ITP) Disseminated intravascular coagulation (DIC) Heparin-associated throm
bosis and thrombocytopenia (HATT)
39. Which of the following drugs would be ordered by the physician to improve th
e platelet count in a male client with idiopathic thrombocytopenic purpura (ITP)
? a. b. c. d. Acetylsalicylic acid (ASA) Corticosteroids Methotrezate Vitamin K
40. A female client is scheduled to receive a heart valve replacement with a por
cine valve. Which of the following types of transplant is this? a. b. c. d. Allo
geneic Autologous Syngeneic Xenogeneic
41. Marco falls off his bicycle and injuries his ankle. Which of the following a
ctions 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 incl
ude information about which of the following blood dyscrasias? a. Dressler’s syndr
ome b. Polycythemia c. Essential thrombocytopenia
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d. Von Willebrand’s disease 43. The nurse is aware that the following symptoms is
most commonly an early indication of stage 1 Hodgkin’s disease? a. b. c. d. Perica
rditis 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 Breat
h sounds
45. The nurse knows that neurologic complications of multiple myeloma (MM) usual
ly involve which of the following body system? a. b. c. d. Brain Muscle spasm Re
nal dysfunction Myocardial irritability
46. Nurse Patricia is aware that the average length of time from human immunodef
iciency virus (HIV) infection to the development of acquired immunodeficiency sy
ndrome (AIDS)? a. b. c. d. Less than 5 years 5 to 7 years 10 years More than 10
years
47. An 18-year-old male client admitted with heat stroke begins to show signs of
disseminated intravascular coagulation (DIC). Which of the following laboratory
findings is most consistent with DIC? a. b. c. d. Low platelet count Elevated f
ibrinogen levels Low levels of fibrin degradation products Reduced prothrombin t
ime
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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 s
ingle enlarged supraclavicular lymph node. Which of the following is the most pr
obable diagnosis? a. b. c. d. Influenza Sickle cell anemia Leukemia Hodgkin’s dise
ase
49. A male client with a gunshot wound requires an emergency blood transfusion.
His blood type is AB negative. Which blood type would be the safest for him to r
eceive? a. b. c. d. AB Rh-positive A Rh-positive A Rh-negative O Rh-positive
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning c
hemotherapy. 50. Stacy is discharged from the hospital following her chemotherap
y treatments. Which statement of Stacy’s mother indicated that she understands whe
n she will contact the physician? a. b. c. d. “I should contact the physician if S
tacy has difficulty in sleeping”. “I will call my doctor if Stacy has persistent vom
iting and diarrhea”. “My physician should be called if Stacy is irritable and unhapp
y”. “Should Stacy have continued hair loss, I need to call the doctor”.
51. Stacy’s mother states to the nurse that it is hard to see Stacy with no hair.
The best response for the nurse is: a. “Stacy looks very nice wearing a hat”. b. “You
should not worry about her hair, just be glad that she is alive”. c. “Yes it is upse
tting. But try to cover up your feelings when you are with her or else she may b
e 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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b. Apply viscous Lidocaine to oral ulcers as needed. c. Use lemon glycerine swab
s every 2 hours. d. Rinse mouth with Hydrogen Peroxide. 53. During the administr
ation of chemotherapy agents, Nurse Oliver observed that the IV site is red and
swollen, when the IV is touched Stacy shouts in pain. The first nursing action t
o take is: a. b. c. d. Notify the physician Flush the IV line with saline soluti
on Immediately discontinue the infusion Apply an ice pack to the site, followed
by warm compress.
54. The term “blue bloater” refers to a male client which of the following condition
s? a. b. c. d. Adult respiratory distress syndrome (ARDS) Asthma Chronic obstruc
tive bronchitis Emphysema
55. The term “pink puffer” refers to the female client with which of the following c
onditions? a. b. c. d. Adult respiratory distress syndrome (ARDS) Asthma Chronic
obstructive bronchitis Emphysema
56. Jose is in danger of respiratory arrest following the administration of a na
rcotic analgesic. An arterial blood gas value is obtained. Nurse Oliver would ex
pect the paco2 to be which of the following values? a. b. c. d. 15 mm Hg 30 mm H
g 40 mm Hg 80 mm Hg
57. Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 m
m Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result represents which o
f the following conditions? a. Metabolic acidosis b. Metabolic alkalosis c. Resp
iratory acidosis
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d. Respirator y alkalosis 58. Norma has started a new drug for hypertension. Thi
rty minutes after she takes the drug, she develops chest tightness and becomes s
hort 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 Pul
monary 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 ci
rrhosis? a. b. c. d. Decreased red blood cell count Decreased serum acid phospha
te level Elevated white blood cell count Elevated serum aminotransferase
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. Im
paired clotting mechanism Varix formation Inadequate nutrition Trauma of invasiv
e procedure
61. Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation i
s most common with this condition? a. b. c. d. Increased urine output Altered le
vel of consciousness Decreased tendon reflex Hypotension
62. When Mr. Gonzales regained consciousness, the physician orders 50 ml of Lact
ose p.o. every 2 hours. Mr. Gozales develops diarrhea. The nurse best action wou
ld be: a. “I’ll see if your physician is in the hospital”. b. “Maybe your reacting to th
e drug; I will withhold the next dose”.
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c. “I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”. d. “F
requently, bowel movements are needed to reduce sodium level”. 63. Which of the fo
llowing groups of symptoms indicates a ruptured abdominal aortic aneurysm? a. Lo
wer back pain, increased blood pressure, decreased re blood cell (RBC) count, in
creased white blood (WBC) count. b. Severe lower back pain, decreased blood pres
sure, decreased RBC count, increased WBC count. c. Severe lower back pain, decre
ased blood pressure, decreased RBC count, decreased RBC count, decreased WBC cou
nt. d. Intermitted lower back pain, decreased blood pressure, decreased RBC coun
t, increased WBC count. 64. After undergoing a cardiac catheterization, Tracy ha
s a large puddle of blood under his buttocks. Which of the following steps shoul
d the nurse take first? a. b. c. d. Call for help. Obtain vital signs Ask the cl
ient to “lift up” Apply gloves and assess the groin site
65. Which of the following treatment is a suitable surgical intervention for a c
lient with unstable angina? a. b. c. d. Cardiac catheterization Echocardiogram N
itroglycerin 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 infa
rction (MI)
67. A client with hypertension ask the nurse which factors can cause blood press
ure to drop to normal levels? a. Kidneys’ excretion to sodium only. b. Kidneys’ rete
ntion of sodium and water c. Kidneys’ excretion of sodium and water
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d. Kidneys’ retention of sodium and excretion of water 68. Nurse Rose is aware tha
t the statement that best explains why furosemide (Lasix) is administered to tre
at hypertension is: a. b. c. d. It dilates peripheral blood vessels. It decrease
s sympathetic cardioacceleration. It inhibits the angiotensin-coverting enzymes
It inhibits reabsorption of sodium and water in the loop of Henle.
69. Nurse Nikki knows that laboratory results supports the diagnosis of systemic
lupus erythematosus (SLE) is: a. b. c. d. Elavated serum complement level Throm
bocytosis, elevated sedimentation rate Pancytopenia, elevated antinuclear antibo
dy (ANA) titer Leukocysis, elevated blood urea nitrogen (BUN) and creatinine lev
els
70. Arnold, a 19-year-old client with a mild concussion is discharged from the e
mergency department. Before discharge, he complains of a headache. When offered
acetaminophen, his mother tells the nurse the headache is severe and she would l
ike her son to have something stronger. Which of the following responses by the
nurse is appropriate? a. “Your son had a mild concussion, acetaminophen is strong
enough.” b. “Aspirin is avoided because of the danger of Reye’s syndrome in children o
r 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 incre
ases the intracarnial pressure (ICP).” 71. When evaluating an arterial blood gas f
rom a male client with a subdural hematoma, the nurse notes the Paco2 is 30 mm H
g. Which of the following responses best describes the result? a. Appropriate; l
owering carbon dioxide (CO2) reduces intracranial pressure (ICP) b. Emergent; th
e client is poorly oxygenated c. Normal d. Significant; the client has alveolar
hypoventilation 72. When prioritizing care, which of the following clients shoul
d the nurse Olivia assess first?
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a. b. c. d.
A 17-year-old clients 24-hours postappendectomy A 33-year-old client with a rece
nt diagnosis of Guillain-Barre syndrome A 50-year-old client 3 days postmyocardi
al infarction A 50-year-old client with diverticulitis
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 wh
y it’s effective for gout? a. b. c. d. Replaces estrogen Decreases infection Decre
ases inflammation Decreases bone demineralization
74. Norma asks for information about osteoarthritis. Which of the following stat
ements about osteoarthritis is correct? a. b. c. d. Osteoarthritis is rarely deb
ilitating Osteoarthritis is a rare form of arthritis Osteoarthritis is the most
common form of arthritis Osteoarthritis afflicts people over 60
75. Ruby is receiving thyroid replacement therapy develops the flu and forgets t
o take her thyroid replacement medicine. The nurse understands that skipping thi
s medication will put the client at risk for developing which of the following l
ifethreatening complications? a. b. c. d. Exophthalmos Thyroid storm Myxedema co
ma Tibial myxedema
76. Nurse Sugar is assessing a client with Cushing s syndrome. Which observation
should the nurse report to the physician immediately? a. b. c. d. Pitting edema
of the legs An irregular apical pulse Dry mucous membranes Frequent urination
77. Cyrill with severe head trauma sustained in a car accident is admitted to th
e intensive care unit. Thirty-six hours later, the client s urine output suddenl
y rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Whic
h laboratory findings support the nurse s suspicion of diabetes insipidus?
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a. Above-normal urine and serum osmolality levels b. Below-normal urine and seru
m osmolality levels c. Above-normal urine osmolality level, below-normal serum o
smolality level d. Below-normal urine osmolality level, above-normal serum osmol
ality level 78. Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic s
yndrome (HHNS) is stabilized and prepared for discharge. When preparing the clie
nt for discharge and home management, which of the following statements indicate
s that the client understands her condition and how to control it? a. "I can avo
id getting sick by not becoming dehydrated and by paying attention to my need to
urinate, drink, or eat more than usual." b. "If I experience trembling, weaknes
s, and headache, I should drink a glass of soda that contains sugar." c. "I will
have to monitor my blood glucose level closely and notify the physician if it s
constantly elevated." d. "If I begin to feel especially hungry and thirsty, I l
l eat a snack high in carbohydrates." 79. A 66-year-old client has been complain
ing of sleeping more, increased urination, anorexia, weakness, irritability, dep
ression, and bone pain that interferes with her going outdoors. Based on these a
ssessment findings, the nurse would suspect which of the following disorders? a.
b. c. d. Diabetes mellitus Diabetes insipidus Hypoparathyroidism Hyperparathyro
idism
80. Nurse Lourdes is teaching a client recovering from addisonian crisis about t
he need to take fludrocortisone acetate and hydrocortisone at home. Which statem
ent 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 pitui
tary adenoma? a. High corticotropin and low cortisol levels
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b. Low corticotropin and high cortisol levels c. High corticotropin and high cor
tisol levels d. Low corticotropin and low cortisol levels 82. A male client is s
cheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preop
eratively, the nurse should assess for potential complications by doing which of
the following? a. b. c. d. Testing for ketones in the urine Testing urine speci
fic gravity Checking temperature every 4 hours Performing capillary glucose test
ing every 4 hours
83. Capillary glucose monitoring is being performed every 4 hours for a client d
iagnosed with diabetic ketoacidosis. Insulin is administered using a scale of re
gular insulin according to glucose results. At 2 p.m., the client has a capillar
y 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. onset to be at 2 p.m. and its pea
k to be at 3 p.m. onset to be at 2:15 p.m. and its peak to be at 3 p.m. onset to
be at 2:30 p.m. and its peak to be at 4 p.m. onset to be at 4 p.m. and its peak
to be at 6 p.m.
84. The physician orders laboratory tests to confirm hyperthyroidism in a female
client with classic signs and symptoms of this disorder. Which test result woul
d confirm the diagnosis? a. No increase in the thyroid-stimulating hormone (TSH)
level after 30 minutes during the TSH stimulation test b. A decreased TSH level
c. An increase in the TSH level after 30 minutes during the TSH stimulation tes
t d. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4)
as detected by radioimmunoassay 85. Rico with diabetes mellitus must learn how
to self-administer insulin. The physician has prescribed 10 U of U-100 regular i
nsulin and 35 U of U-100 isophane insulin suspension (NPH) to be taken before br
eakfast. When teaching the client how to select and rotate insulin injection sit
es, the nurse should provide which instruction? a. "Inject insulin into healthy
tissue with large blood vessels and nerves." b. "Rotate injection sites within t
he same anatomic region, not among different regions."
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c. "Administer insulin into areas of scar tissue or hypotrophy whenever possible
." d. "Administer insulin into sites above muscles that you plan to exercise hea
vily later that day." 86. Nurse Sarah expects to note an elevated serum glucose
level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Wh
ich other laboratory finding should the nurse anticipate? a. b. c. d. Elevated s
erum acetone level Serum ketone bodies Serum alkalosis Below-normal serum potass
ium level
87. For a client with Graves disease, which nursing intervention promotes comfo
rt? a. b. c. d. Restricting intake of oral fluids Placing extra blankets on the
client s bed Limiting intake of high-carbohydrate foods Maintaining room tempera
ture in the low-normal range
88. Patrick is treated in the emergency department for a Colles fracture sustai
ned during a fall. What is a Colles fracture? a. b. c. d. Fracture of the dista
l radius Fracture of the olecranon Fracture of the humerus Fracture of the carpa
l scaphoid
89. Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the
development of this disorder? a. b. c. d. Calcium and sodium Calcium and phospho
rous Phosphorous and potassium Potassium and sodium
90. Johnny a firefighter was involved in extinguishing a house fire and is being
treated to smoke inhalation. He develops severe hypoxia 48 hours after the inci
dent, requiring intubation and mechanical ventilation. He most likely has develo
ped which of the following conditions? a. Adult respiratory distress syndrome (A
RDS) b. Atelectasis c. Bronchitis
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d. Pneumonia 91. A 67-year-old client develops acute shortness of breath and pro
gressive hypoxia requiring right femur. The hypoxia was probably caused by which
of the following conditions? a. b. c. d. Asthma attack Atelectasis Bronchitis F
at embolism
92. A client with shortness of breath has decreased to absent breath sounds on t
he right side, from the apex to the base. Which of the following conditions woul
d best explain this? a. b. c. d. Acute asthma Chronic bronchitis Pneumonia Spont
aneous pneumothorax
93. A 62-year-old male client was in a motor vehicle accident as an unrestrained
driver. He’s now in the emergency department complaining of difficulty of breathi
ng and chest pain. On auscultation of his lung field, no breath sounds are prese
nt in the upper lobe. This client may have which of the following conditions? a.
b. c. d. Bronchitis Pneumonia Pneumothorax Tuberculosis (TB)
94. If a client requires a pneumonectomy, what fills the area of the thoracic ca
vity? a. b. c. d. The space remains filled with air only The surgeon fills the s
pace with a gel Serous fluids fills the space and consolidates the region The ti
ssue from the other lung grows over to the other side
95. Hemoptysis may be present in the client with a pulmonary embolism because of
which of the following reasons? a. Alveolar damage in the infracted area b. Inv
olvement of major blood vessels in the occluded area c. Loss of lung parenchyma
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d. Loss of lung tissue 96. Aldo with a massive pulmonary embolism will have an a
rterial blood gas analysis performed to determine the extent of hypoxia. The aci
d-base disorder that may be present is? a. b. c. d. Metabolic acidosis Metabolic
alkalosis Respiratory acidosis Respiratory alkalosis
97. After a motor vehicle accident, Armand an 22-year-old client is admitted wit
h a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest dr
ainage system. Bubbling soon appears in the water seal chamber. Which of the fol
lowing is the most likely cause of the bubbling? a. b. c. d. Air leak Adequate s
uction Inadequate suction Kinked chest tube
98. Nurse Michelle calculates the IV flow rate for a postoperative client. The c
lient receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The
IV infusion set has a drop factor of 10 drops per milliliter. The nurse should r
egulate the client’s 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. T
he 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 foll
owing statements, if made by the client, indicates to the nurse that the teachin
g was successful?
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a. b. c. d.
“I will wear the stockings until the physician tells me to remove them.” “I should wea
r the stockings even when I am sleep.” “Every four hours I should remove the stockin
gs 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
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TEST V - Care of Clients with Physiologic and Psychosocial Alterations 1. Mr. Ma
rquez reports of losing his job, not being able to sleep at night, and feeling u
pset with his wife. Nurse John responds to the client, “You may want to talk about
your employment situation in group today.” The Nurse is using which therapeutic t
echnique? a. b. c. d. Observations Restating Exploring Focusing
2. Tony refuses his evening dose of Haloperidol (Haldol), then becomes extremely
agitated in the dayroom while other clients are watching television. He begins
cursing and throwing furniture. Nurse Oliver first action is to: a. Check the cl
ient’s medical record for an order for an as-needed I.M. dose of medication for ag
itation. b. Place the client in full leather restraints. c. Call the attending p
hysician and report the behavior. d. Remove all other clients from the dayroom.
3. Tina who is manic, but not yet on medication, comes to the drug treatment cen
ter. The nurse would not let this client join the group session because: a. b. c
. d. The client is disruptive. The client is harmful to self. The client is harm
ful to others. The client needs to be on medication first.
4. Dervid, an adolescent boy was admitted for substance abuse and hallucinations
. The client’s mother asks Nurse Armando to talk with his husband when he arrives
at the hospital. The mother says that she is afraid of what the father might say
to the boy. The most appropriate nursing intervention would be to: a. Inform th
e mother that she and the father can work through this problem themselves. b. Re
fer the mother to the hospital social worker. c. Agree to talk with the mother a
nd the father together. d. Suggest that the father and son work things out. 5. W
hat is Nurse John likely to note in a male client being admitted for alcohol wit
hdrawal?
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a. b. c. d.
Perceptual disorders. Impending coma. Recent alcohol intake. Depression with mut
ism.
6. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that
it “doesn’t help” and refuses to take it. What should the nurse say or do? a. b. c. d.
Withhold the drug. Record the client’s response. Encourage the client to tell the
doctor. Suggest that it takes awhile before seeing the results.
7. Dervid, an adolescent has a history of truancy from school, running away from
home and “barrowing” other people’s things without their permission. The adolescent d
enies stealing, rationalizing instead that as long as no one was using the items
, it was all right to borrow them. It is important for the nurse to understand t
he psychodynamically, this behavior may be largely attributed to a developmental
defect related to the: a. b. c. d. Id Ego Superego Oedipal complex
8. In preparing a female client for electroconvulsive therapy (ECT), Nurse Miche
lle knows that succinylcoline (Anectine) will be administered for which therapeu
tic effect? a. b. c. d. Short-acting anesthesia Decreased oral and respiratory s
ecretions. 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 bre
ad, 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 ca
lories, carbohydrates, and protein. 10. What parental behavior toward a child du
ring an admission procedure should cause Nurse Ron to suspect child abuse?
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a. b. c. d.
Flat affect Expressing guilt Acting overly solicitous toward the child. Ignoring
the child.
11. Nurse Lynnette notices that a female client with obsessive-compulsive disord
er washes her hands for long periods each day. How should the nurse respond to t
his compulsive behavior? a. By designating times during which the client can foc
us on the behavior. b. By urging the client to reduce the frequency of the behav
ior as rapidly as possible. c. By calling attention to or attempting to prevent
the behavior. d. By discouraging the client from verbalizing anxieties. 12. Afte
r seeking help at an outpatient mental health clinic, Ruby who was raped while w
alking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three mon
ths later, Ruby returns to the clinic, complaining of fear, loss of control, and
helpless feelings. Which nursing intervention is most appropriate for Ruby? a.
Recommending a high-protein, low-fat diet. b. Giving sleep medication, as prescr
ibed, to restore a normal sleepwake cycle. c. Allowing the client time to heal.
d. Exploring the meaning of the traumatic event with the client. 13. Meryl, age
19, is highly dependent on her parents and fears leaving home to go away to coll
ege. Shortly before the semester starts, she complains that her legs are paralyz
ed and is rushed to the emergency department. When physical examination rules ou
t a physical cause for her paralysis, the physician admits her to the psychiatri
c unit where she is diagnosed with conversion disorder. Meryl asks the nurse, "W
hy has this happened to me?" What is the nurse s best response? a. "You ve devel
oped this paralysis so you can stay with your parents. You must deal with this c
onflict if you want to walk again." b. "It must be awful not to be able to move
your legs. You may feel better if you realize the problem is psychological, not
physical." c. "Your problem is real but there is no physical basis for it. We ll
work on what is going on in your life to find out why it s happened." d. "It is
n t uncommon for someone with your personality to develop a conversion disorder
during times of stress."
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14. Nurse Krina knows that the following drugs have been known to be effective i
n treating obsessive-compulsive disorder (OCD): a. b. c. d. benztropine (Cogenti
n) and diphenhydramine (Benadryl). chlordiazepoxide (Librium) and diazepam (Vali
um) fluvoxamine (Luvox) and clomipramine (Anafranil) divalproex (Depakote) and l
ithium (Lithobid)
15. Alfred was newly diagnosed with anxiety disorder. The physician prescribed b
uspirone (BuSpar). The nurse is aware that the teaching instructions for newly p
rescribed buspirone should include which of the following? a. A warning about th
e drugs delayed therapeutic effect, which is from 14 to 30 days. b. A warning ab
out 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 wa
rning that immediate sedation can occur with a resultant drop in pulse. 16. Rich
ard with agoraphobia has been symptom-free for 4 months. Classic signs and sympt
oms of phobias include: a. b. c. d. Insomnia and an inability to concentrate. Se
vere anxiety and fear. Depression and weight loss. Withdrawal and failure to dis
tinguish reality from fantasy.
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 tr
eat her atypical depression, the physician prescribes tranylcypromine sulfate (P
arnate), 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. Pro
viding emotional support and individual counseling. c. Monitoring the client to
prevent minor illnesses from turning into major problems. d. Suggesting new acti
vities for the client and family to do together. 20. The nurse is assessing a cl
ient who has just been admitted to the emergency department. Which signs would s
uggest an overdose of an antianxiety agent? a. b. c. d. Combativeness, sweating,
and confusion Agitation, hyperactivity, and grandiose ideation Emotional labili
ty, euphoria, and impaired memory Suspiciousness, dilated pupils, and increased
blood pressure
21. The nurse is caring for a client diagnosed with antisocial personality disor
der. The client has a history of fighting, cruelty to animals, and stealing. Whi
ch of the following traits would the nurse be most likely to uncover during asse
ssment? a. b. c. d. History of gainful employment Frequent expression of guilt r
egarding antisocial behavior Demonstrated ability to maintain close, stable rela
tionships A low tolerance for frustration
22. Nurse Amy is providing care for a male client undergoing opiate withdrawal.
Opiate withdrawal causes severe physical discomfort and can be life-threatening.
To minimize these effects, opiate users are commonly detoxified with: a. b. c.
d. Barbiturates Amphetamines Methadone Benzodiazepines
23. Nurse Cristina is caring for a client who experiences false sensory percepti
ons with no basis in reality. These perceptions are known as: a. Delusions b. Ha
llucinations
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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 th
e 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 th
at this diagnosis reflects a belief that one is: a. b. c. d. Highly important or
famous. Being persecuted Connected to events unrelated to oneself Responsible f
or the evil in the world.
26. Nurse Jen is caring for a male client with manic depression. The plan of car
e 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 cl
ient remain active through the day so that he’ll sleep at night. c. Allowing the c
lient to exhibit hyperactive, demanding, manipulative behavior without setting l
imits. d. Listening attentively with a neutral attitude and avoiding power strug
gles. 27. Ramon is admitted for detoxification after a cocaine overdose. The cli
ent 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 Lo
gical thinking Repression Denial
28. Richard is admitted with a diagnosis of schizotypal personality disorder. Wh
ich signs would this client exhibit during social situations? a. Aggressive beha
vior b. Paranoid thoughts
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c. Emotional affect d. Independence needs 29. Nurse Mickey is caring for a clien
t diagnosed with bulimia. The most appropriate initial goal for a client diagnos
ed with bulimia is to: a. b. c. d. Avoid shopping for large amounts of food. Con
trol eating impulses. Identify anxiety-causing situations Eat only three meals p
er day.
30. Rudolf is admitted for an overdose of amphetamines. When assessing the clien
t, the nurse should expect to see: a. b. c. d. Tension and irritability Slow pul
se Hypotension Constipation
31. Nicolas is experiencing hallucinations tells the nurse, “The voices are tellin
g me I’m no good.” The client asks if the nurse hears the voices. The most appropria
te response by the nurse would be: a. “It is the voice of your conscience, which o
nly 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, th
e voices are a symptom of your illness; don’t pay any attention to them.” 32. The nu
rse 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 t
ime after treatment Complete loss of memory for a time
33. A dying male client gradually moves toward resolution of feelings regarding
impending death. Basing care on the theory of Kubler-Ross, Nurse Trish plans to
use nonverbal interventions when assessment reveals that the client is in the: a
. Anger stage b. Denial stage c. Bargaining stage
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d. Acceptance stage 34. The outcome that is unrelated to a crisis state is: a. b
. c. d. Learning more constructive coping skills Decompensation to a lower level
of functioning. Adaptation and a return to a prior level of functioning. A high
er level of anxiety continuing for more than 3 months.
35. Miranda a psychiatric client is to be discharged with orders for haloperidol
(haldol) therapy. When developing a teaching plan for discharge, the nurse shou
ld include cautioning the client against: a. b. c. d. Driving at night Staying i
n 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 roommate’s talking and
loud music. The student’s ability to ignore distractions and to focus on studying
demonstrates: a. b. c. d. Mild-level anxiety Panic-level anxiety Severe-level a
nxiety Moderate-level anxiety
37. When assessing a premorbid personality characteristics of a client with a ma
jor depression, it would be unusual for the nurse to find that this client demon
strated: a. b. c. d. Rigidity Stubbornness Diverse interest Over meticulousness
38. Nurse Krina recognizes that the suicidal risk for depressed client is greate
st: a. b. c. d. As their depression begins to improve When their depression is m
ost severe Before nay type of treatment is started As they lose interest in the
environment
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39. Nurse Kate would expect that a client with vascular dementis would experienc
e: a. b. c. d. Loss of remote memory related to anoxia Loss of abstract thinking
related to emotional state Inability to concentrate related to decreased stimul
i Disturbance in recalling recent events related to cerebral hypoxia.
40. Josefina is to be discharged on a regimen of lithium carbonate. In the teach
ing plan for discharge the nurse should include: a. b. c. d. Advising the client
to watch the diet carefully Suggesting that the client take the pills with milk
Reminding the client that a CBC must be done once a month. Encouraging the clie
nt to have blood levels checked as ordered.
41. The psychiatrist orders lithium carbonate 600 mg p.o t.i.d for a female clie
nt. Nurse Katrina would be aware that the teaching about the side effects of thi
s drug were understood when the client state, “I will call my doctor immediately i
f I notice any: a. b. c. d. Sensitivity to bright light or sun Fine hand tremors
or slurred speech Sexual dysfunction or breast enlargement Inability to urinate
or difficulty when urinating
42. Nurse Mylene recognizes that the most important factor necessary for the est
ablishment of trust in a critical care area is: a. b. c. d. Privacy Respect Empa
thy Presence
43. When establishing an initial nurse-client relationship, Nurse Hazel should e
xplore with the client the: a. b. c. d. Client’s perception of the presenting prob
lem. Occurrence of fantasies the client may experience. Details of any ritualist
ic acts carried out by the client Client’s feelings when external; controls are in
stituted.
44. Tranylcypromine sulfate (Parnate) is prescribed for a depressed client who h
as not responded to the tricyclic antidepressants. After teaching the client abo
ut the medication, Nurse Marian evaluates that learning has occurred when the cl
ient states, “I will avoid:
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a. b. c. d.
Citrus fruit, tuna, and yellow vegetables.” Chocolate milk, aged cheese, and yogur
t’” Green leafy vegetables, chicken, and milk.” Whole grains, red meats, and carbonate
d soda.”
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. Females use more dramatic methods than males Males account for more a
ttempts than do females Females talk more about suicide before attempting it Mal
es are more likely to use lethal methods than are females
47. Dervid with paranoid schizophrenia repeatedly uses profanity during an activ
ity therapy session. Which response by the nurse would be most appropriate? a. "
Your behavior won t be tolerated. Go to your room immediately." b. "You re just
doing this to get back at me for making you come to therapy." c. "Your cursing i
s interrupting the activity. Take time out in your room for 10 minutes." d. "I m
disappointed in you. You can t control yourself even for a few minutes." 48. Nu
rse Maureen knows that the nonantipsychotic medication used to treat some client
s with schizoaffective disorder is: a. b. c. d. phenelzine (Nardil) chlordiazepo
xide (Librium) lithium carbonate (Lithane) imipramine (Tofranil)
49. Which information is most important for the nurse Trinity to include in a te
aching plan for a male schizophrenic client taking clozapine (Clozaril)? a. Mont
hly blood tests will be necessary. b. Report a sore throat or fever to the physi
cian immediately.
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c. Blood pressure must be monitored for hypertension. d. Stop the medication whe
n symptoms subside. 50. Ricky with chronic schizophrenia takes neuroleptic medic
ation is admitted to the psychiatric unit. Nursing assessment reveals rigidity,
fever, hypertension, and diaphoresis. These findings suggest which lifethreateni
ng reaction: a. b. c. d. Tardive dyskinesia. Dystonia. Neuroleptic malignant syn
drome. Akathisia.
51. Which nursing intervention would be most appropriate if a male client develo
p orthostatic hypotension while taking amitriptyline (Elavil)? a. Consulting wit
h the physician about substituting a different type of antidepressant. b. Advisi
ng the client to sit up for 1 minute before getting out of bed. c. Instructing t
he client to double the dosage until the problem resolves. d. Informing the clie
nt that this adverse reaction should disappear within 1 week. 52. Mr. Cruz visit
s the physician s office to seek treatment for depression, feelings of hopelessn
ess, poor appetite, insomnia, fatigue, low selfesteem, poor concentration, and d
ifficulty making decisions. The client states that these symptoms began at least
2 years ago. Based on this report, the nurse Tyfany suspects: a. b. c. d. Cyclo
thymic disorder. Atypical affective disorder. Major depression. Dysthymic disord
er.
53. After taking an overdose of phenobarbital (Barbita), Mario is admitted to th
e emergency department. Dr. Trinidad prescribes activated charcoal (Charcocaps)
to be administered by mouth immediately. Before administering the dose, the nurs
e verifies the dosage ordered. What is the usual minimum dose of activated charc
oal? a. b. c. d. 5 g mixed in 250 ml of water 15 g mixed in 500 ml of water 30 g
mixed in 250 ml of water 60 g mixed in 500 ml of water
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54. What herbal medication for depression, widely used in Europe, is now being p
rescribed in the United States? a. b. c. d. Ginkgo biloba Echinacea St. John s w
ort Ephedra
55. Cely with manic episodes is taking lithium. Which electrolyte level should t
he 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 la
sts about 1 week. c. It s characterized by a slowly evolving onset and lasts abo
ut 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 with
drawal from social interactions. To assess for progression to the middle stage o
f Alzheimer s disease, the nurse should observe the client for: a. b. c. d. Occa
sional irritable outbursts. Impaired communication. Lack of spontaneity. Inabili
ty to perform self-care activities.
58. Isabel with a diagnosis of depression is started on imipramine (Tofranil), 7
5 mg by mouth at bedtime. The nurse should tell the client that: a. This medicat
ion may be habit forming and will be discontinued as soon as the client feels be
tter. b. This medication has no serious adverse effects.
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c. The client should avoid eating such foods as aged cheeses, yogurt, and chicke
n livers while taking the medication. d. This medication may initially cause tir
edness, which should become less bothersome over time. 59. Kathleen is admitted
to the psychiatric clinic for treatment of anorexia nervosa. To promote the clie
nt 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. Mon
itor vital signs, serum electrolyte levels, and acid-base balance. d. Instruct t
he 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 nau
sea and vomiting 24 hours after admission. The nurse assesses the client and not
es piloerection, pupillary dilation, and lacrimation. The nurse suspects that th
e client is going through which of the following withdrawals? a. b. c. d. Alcoho
l withdrawal Cannibis withdrawal Cocaine withdrawal Opioid withdrawal
61. Mr. Garcia, an attorney who throws books and furniture around the office aft
er 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 antips
ychotic medication. During the assessment, Nurse Anne checks the client for tard
ive dyskinesia. If tardive dyskinesia is present, Nurse Anne would most likely o
bserve: a. Abnormal movements and involuntary movements of the mouth, tongue, an
d face. b. Abnormal breathing through the nostrils accompanied by a “thrill.” c. Sev
ere headache, flushing, tremors, and ataxia. d. Severe hypertension, migraine he
adache,
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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 Di
arrhea Blurred vision Fecal incontinence
64. Nurse Jannah is monitoring a male client who has been placed inrestraints be
cause of violent behavior. Nurse determines that it will be safe to remove the r
estraints 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. Increa
sed attention span and concentration Increase in appetite Sleepiness and letharg
y Bradycardia and diarrhea
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 cla
ssification: 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. Engage in diversionary activities when acting -ou
t Provide an atmosphere of acceptance Provide safety measures Rearrange the envi
ronment to activate the child
68. Jeremy is brought to the emergency room by friends who state that he took so
mething an hour ago. He is actively hallucinating, agitated, with
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irritated nasal septum. a. b. c. d. 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 perce
ptual change
70. A 35 year old female has intense fear of riding an elevator. She claims “ As i
f I will die inside.” The client is suffering from: a. Agoraphobia b. Social phobi
a c. Claustrophobia d. Xenophobia 71. Nurse Myrna develops a counter-transferenc
e reaction. This is evidenced by: a. Revealing personal information to the clien
t b. Focusing on the feelings of the client. c. Confronting the client about dis
crepancies in verbal or non-verbal behavior d. The client feels angry towards th
e nurse who resembles his mother. 72. Tristan is on Lithium has suffered from di
arrhea 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 t
hese 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 e
nvironment for all the client. Which of the following best describes a therapeut
ic milieu? a. A therapy that rewards adaptive behavior b. A cognitive approach t
o change behavior c. A living, learning or working environment.
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d. A permissive and congenial environment 74. Anthony is very hostile toward one
of the staff for no apparent reason. He is manifesting: a. b. c. d. Splitting T
ransference Countertransference Resistance
75. Marielle, 17 years old was sexually attacked while on her way home from scho
ol. She is brought to the hospital by her mother. Rape is an example of which ty
pe 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 shou
ld 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 th
e time and frequently complains of a number of vague symptoms that interfere wit
h 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 disord
er Depersonalization Hypochondriasis Somatization disorder
80. Nurse Daisy is aware that the following pharmacologic agents are sedativehyp
notic medication is used to induce sleep for a client experiencing a sleep disor
der 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 th
e following statement refers to a secondary gain? a. b. c. d. It brings some sta
bility to the family It decreases the preoccupation with the physical illness It
enables the client to avoid some unpleasant activity It promotes emotional supp
ort or attention for the client
82. Dervid is diagnosed with panic disorder with agoraphobia is talking with the
nurse in-charge about the progress made in treatment. Which of the following st
atements indicates a positive client response? a. b. c. d. “I went to the mall wit
h my friends last Saturday” “I’m hyperventilating only when I have a panic attack” “Today
I decided that I can stop taking my medication” “Last night I decided to eat more th
an a bowl of cereal”
83. The effectiveness of monoamine oxidase (MAO) inhibitor drug therapy in a cli
ent with posttraumatic stress disorder can be demonstrated by which of the follo
wing client self –reports? a. “I’m sleeping better and don’t have nightmares” b. “I’m not l
ng my temper as much” c. “I’ve lost my craving for alcohol”
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d. I’ve lost my phobia for water” 84. Mark, with a diagnosis of generalized anxiety
disorder wants to stop taking his lorazepam (Ativan). Which of the following imp
ortant facts should nurse Betty discuss with the client about discontinuing the
medication? a. b. c. d. Stopping the drug may cause depression Stopping the drug
increases cognitive abilities Stopping the drug decreases sleeping difficulties
Stopping the drug can cause withdrawal symptoms
85. Jennifer, an adolescent who is depressed and reported by his parents as havi
ng difficulty in school is brought to the community mental health center to be e
valuated. Which of the following other health problems would the nurse suspect?
a. b. c. d. Anxiety disorder Behavioral difficulties Cognitive impairment Labile
moods
86. Ricardo, an outpatient in psychiatric facility is diagnosed with dysthymic d
isorder. Which of the following statement about dysthymic disorder is true? a. b
. c. d. It involves a mood range from moderate depression to hypomania It involv
es a single manic depression It’s a form of depression that occurs in the fall and
winter It’s a mood disorder similar to major depression but of mild to moderate s
everity
87. The nurse is aware that the following ways in vascular dementia different fr
om Alzheimer’s disease is: a. b. c. d. Vascular dementia has more abrupt onset The
duration of vascular dementia is usually brief Personality change is common in
vascular dementia The inability to perform motor activities occurs in vascular d
ementia
88. Loretta, a newly admitted client was diagnosed with delirium and has history
of hypertension and anxiety. She had been taking digoxin, furosemide (Lasix), a
nd diazepam (Valium) for anxiety. This client’s 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 client’s roo
m, the client says, “They’re crawling on my sheets! Get them off my bed!” Which of the
following assessment is the most accurate? a. b. c. d. The client is experienci
ng aphasia The client is experiencing dysarthria The client is experiencing a fl
ight of ideas The client is experiencing visual hallucination
90. Which of the following descriptions of a client’s experience and behavior can
be assessed as an illusion? a. The client tries to hit the nurse when vital sign
s 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 clien
t looks at the shadow on a wall and tells the nurse she sees frightening faces o
n the wall. 91. During conversation of Nurse John with a client, he observes tha
t the client shift from one topic to the next on a regular basis. Which of the f
ollowing terms describes this disorder? a. b. c. d. Flight of ideas Concrete thi
nking 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 wi
th paranoid personality disorder taking olanzapine (Zyprexa)? a. Explain effects
of serotonin syndrome b. Teach the client to watch for extrapyramidal adverse r
eaction
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c. Explain that the drug is less affective if the client smokes d. Discuss the n
eed to report paradoxical effects such as euphoria 94. Nurse Alexandra notices o
ther clients on the unit avoiding a client diagnosed with antisocial personality
disorder. When discussing appropriate behavior in group therapy, which of the f
ollowing comments is expected about this client by his peers? a. b. c. d. Lack o
f honesty Belief in superstition Show of temper tantrums Constant need for atten
tion
95. Tommy, with dependent personality disorder is working to increase his selfes
teem. Which of the following statements by the Tommy shows teaching was successf
ul? a. b. c. d. “I’m not going to look just at the negative things about myself” “I’m most
concerned about my level of competence and progress” “I’m not as envious of the thing
s other people have as I used to be” “I find I can’t stop myself from taking over thin
gs other should be doing”
96. Norma, a 42-year-old client with a diagnosis of chronic undifferentiated sch
izophrenia lives in a rooming house that has a weekly nursing clinic. She scratc
hes while she tells the nurse she feels creatures eating away at her skin. Which
of the following interventions should be done first? a. b. c. d. Talk about his
hallucinations and fears Refer him for anticholinergic adverse reactions Assess
for possible physical problems such as rash Call his physician to get his medic
ation increased to control his psychosis
97. Ivy, who is on the psychiatric unit is copying and imitating the movements o
f 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 t
he 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 he’s
evil and deserves to die. Which of the following terms describes the client’s per
ception? a. b. c. d. Delusion Disorganized speech Hallucination Idea of referenc
e
99. Mike is admitted to a psychiatric unit with a diagnosis of undifferentiated
schizophrenia. Which of the following defense mechanisms is probably used by mik
e? a. b. c. d. Projection Rationalization Regression Repression
100. Rocky has started taking haloperidol (Haldol). Which of the following instr
uctions is most appropriate for Ricky before taking haloperidol? a. b. c. d. Sho
uld report feelings of restlessness or agitation at once Use a sunscreen outdoor
s on a year-round basis Be aware you’ll feel increased energy taking this drug Thi
s drug will indirectly control essential hypertension
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PART II
ANSWERS & RATIONALE
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TEST I Answers and Rationale – Foundation of Professional Nursing Practice 1. Answ
er: (D) The actions of a reasonably prudent nurse with similar education and exp
erience. 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/μl, the clients tends to bleed easily
. Therefore, the nurse should avoid using the I.M. route because the area is a h
ighly vascular and can bleed readily when penetrated by a needle. The bleeding c
an 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 mis
reads the figure, which could result in a dosage error. The nurse should never i
nsert a zero at the end of a dosage that includes a decimal point because this c
ould be misread, possibly leading to a tenfold increase in the dosage. 4. Answer
: (A) Ineffective peripheral tissue perfusion related to venous congestion. Rati
onale: Ineffective peripheral tissue perfusion related to venous congestion take
s the highest priority because venous inflammation and clot formation impede blo
od flow in a client with deep vein thrombosis. 5. Answer: (B) A 44 year-old myoc
ardial infarction (MI) client who is complaining of nausea. Rationale: Nausea is
a symptom of impending myocardial infarction (MI) and should be assessed immedi
ately so that treatment can be instituted and further damage to the heart is avo
ided. 6. Answer: (C) Check circulation every 15-30 minutes. Rationale: Restraint
s encircle the limbs, which place the client at risk for circulation being restr
icted to the distal areas of the extremities. Checking the client’s circulation ev
ery 15-30 minutes will allow the nurse to adjust the restraints before injury fr
om decreased blood flow occurs. 7. Answer: (A) Prevent stress ulcer Rationale: C
urling’s ulcer occurs as a generalized stress response in burn patients. This resu
lts in a decreased production of mucus and increased secretion of gastric acid.
The best treatment for this prophylactic use of antacids and H2 receptor blocker
s. 8. Answer: (D) Continue to monitor and record hourly urine output
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Rationale: Normal urine output for an adult is approximately 1 ml/minute (60 ml/
hour). Therefore, this client s output is normal. Beyond continued evaluation, n
o nursing action is warranted. 9. Answer: (B) “My ankle feels warm”. Rationale: Ice
application decreases pain and swelling. Continued or increased
pain, redness, and increased warmth are signs of inflammation that shouldn t occ
ur after ice application
10. Answer: (B) Hyperkalemia Rationale: A loop diuretic removes water and, along
with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and
hyponatremia. 11. Answer:(A) Have condescending trust and confidence in their s
ubordinates Rationale: Benevolent-authoritative managers pretentiously show thei
r trust and confidence to their followers. 12. Answer: (A) Provides continuous,
coordinated and comprehensive nursing services. Rationale: Functional nursing is
focused on tasks and activities and not on the care of the patients. 13. Answer
: (B) Standard written order Rationale: This is a standard written order. Prescr
ibers write a single order for medications given only once. A stat order is writ
ten for medications given immediately for an urgent client problem. A standing o
rder, also known as a protocol, establishes guidelines for treating a particular
disease or set of symptoms in special care areas such as the coronary care unit
. Facilities also may institute medication protocols that specifically designate
drugs that a nurse may not give. 14. Answer: (D) Liquid or semi-liquid stools R
ationale: Passage of liquid or semi-liquid stools results from seepage of unform
ed bowel contents around the impacted stool in the rectum. Clients with fecal im
paction don t pass hard, brown, formed stools because the feces can t move past
the impaction. These clients typically report the urge to defecate (although the
y can t pass stool) and a decreased appetite. 15. Answer: (C) Pulling the helix
up and back Rationale: To perform an otoscopic examination on an adult, the nurs
e grasps the helix of the ear and pulls it up and back to straighten the ear can
al. For a child, the nurse grasps the helix and pulls it down to straighten the
ear canal. Pulling the lobule in any direction wouldn t straighten the ear canal
for visualization. 16. Answer: (A) Protect the irritated skin from sunlight. Nu
rsing Crib – Student Nurses’ Community 116
Rationale: Irradiated skin is very sensitive and must be protected with clothing
or sunblock. The priority approach is the avoidance of strong sunlight. 17. Ans
wer: (C) Assist the client in removing dentures and nail polish. Rationale: Dent
ures, hairpins, and combs must be removed. Nail polish must be removed so that c
yanosis can be easily monitored by observing the nail beds. 18. Answer: (D) Sudd
en onset of continuous epigastric and back pain. Rationale: The autodigestion of
tissue by the pancreatic enzymes results in pain from inflammation, edema, and
possible hemorrhage. Continuous, unrelieved epigastric or back pain reflects the
inflammatory process in the pancreas. 19. Answer: (B) Provide high-protein, hig
h-carbohydrate diet. Rationale: A positive nitrogen balance is important for mee
ting metabolic needs, tissue repair, and resistance to infection. Caloric goals
may be as high as 5000 calories per day. 20. Answer: (A) Blood pressure and puls
e rate. Rationale: The baseline must be established to recognize the signs of an
anaphylactic or hemolytic reaction to the transfusion. 21. Answer: (D) Immobili
ze the leg before moving the client. Rationale: If the nurse suspects a fracture
, splinting the area before moving the client is imperative. The nurse should ca
ll for emergency help if the client is not hospitalized and call for a physician
for the hospitalized client. 22. Answer: (B) Admit the client into a private ro
om. Rationale: The client who has a radiation implant is placed in a private roo
m and has a limited number of visitors. This reduces the exposure of others to t
he radiation. 23. Answer: (C) Risk for infection Rationale: Agranulocytosis is c
haracterized by a reduced number of leukocytes (leucopenia) and neutrophils (neu
tropenia) in the blood. The client is at high risk for infection because of the
decreased body defenses against microorganisms. Deficient knowledge related to t
he nature of the disorder may be appropriate diagnosis but is not the priority.
24. Answer: (B) Place the client on the left side in the Trendelenburg position.
Rationale: Lying on the left side may prevent air from flowing into the pulmona
ry veins. The Trendelenburg position increases intrathoracic pressure, which dec
reases the amount of blood pulled into the vena cava during aspiration.
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25. Answer: (A) Autocratic. Rationale: The autocratic style of leadership is a t
ask-oriented and directive. 26. Answer: (D) 2.5 cc Rationale: 2.5 cc is to be ad
ded, because only a 500 cc bag of solution is being medicated instead of a 1 lit
er. 27. Answer: (A) 50 cc/ hour Rationale: A rate of 50 cc/hr. The child is to r
eceive 400 cc over a period of 8 hours = 50 cc/hr. 28. Answer: (B) Assess the cl
ient for presence of pain. Rationale: Assessing the client for pain is a very im
portant measure. Postoperative pain is an indication of complication. The nurse
should also assess the client for pain to provide for the client’s comfort. 29. An
swer: (A) BP – 80/60, Pulse – 110 irregular Rationale: The classic signs of cardioge
nic shock are low blood pressure, rapid and weak irregular pulse, cold, clammy s
kin, decreased urinary output, and cerebral hypoxia. 30. Answer: (A) Take the pr
oper equipment, place the client in a comfortable position, and record the appro
priate information in the client’s chart. Rationale: It is a general or comprehens
ive statement about the correct procedure, and it includes the basic ideas which
are found in the other options 31. Answer: (B) Evaluation Rationale: Evaluation
includes observing the person, asking questions, and comparing the patient’s beha
vioral responses with the expected outcomes. 32. Answer: (C) History of present
illness Rationale: The history of present illness is the single most important f
actor in assisting the health professional in arriving at a diagnosis or determi
ning the person’s needs. 33. Answer: (A) Trochanter roll extending from the crest
of the ileum to the mid-thigh. Rationale: A trochanter roll, properly placed, pr
ovides resistance to the external rotation of the hip. 34. Answer: (C) Stage III
118
Rationale: Clinically, a deep crater or without undermining of adjacent tissue i
s noted. 35. Answer: (A) Second intention healing Rationale: When wounds dehisce
, they will allowed to heal by secondary intention 36. Answer: (D) Tachycardia R
ationale: With an extracellular fluid or plasma volume deficit, compensatory mec
hanisms stimulate the heart, causing an increase in heart rate. 37. Answer: (A)
0.75 Rationale: To determine the number of milliliters the client should receive
, the nurse uses the fraction method in the following equation. 75 mg/X ml = 100
mg/1 ml To solve for X, cross-multiply: 75 mg x 1 ml = X ml x 100 mg 75 = 100X
75/100 = X 0.75 ml (or ¾ ml) = X 38. Answer: (D) It’s a measure of effect, not a sta
ndard measure of weight or quantity. Rationale: An insulin unit is a measure of
effect, not a standard measure of weight or quantity. Different drugs measured i
n units may have no relationship to one another in quality or quantity. 39. Answ
er: (B) 38.9 °C Rationale: To convert Fahrenheit degreed to Centigrade, use this f
ormula °C = (°F – 32) ÷ 1.8 °C = (102 – 32) ÷ 1.8 °C = 70 ÷ 1.8 °C = 38.9 40. Answer: (C) F
esight, especially close vision. Rationale: Failing eyesight, especially close v
ision, is one of the first signs of aging in middle life (ages 46 to 64). More f
requent aches and pains begin in the early late years (ages 65 to 79). Increase
in loss of muscle tone occurs in later years (age 80 and older). 41. Answer: (A)
Checking and taping all connections Rationale: Air leaks commonly occur if the
system isn’t secure. Checking all connections and taping them will prevent air lea
ks. The chest drainage system is kept lower to promote drainage – not to prevent l
eaks.
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42. Answer: (A) Check the client’s identification band. Rationale: Checking the cl
ient’s identification band is the safest way to verify a client’s identity because t
he band is assigned on admission and isn’t be removed at any time. (If it is remov
ed, it must be replaced). Asking the client’s name or having the client repeated h
is name would be appropriate only for a client who’s alert, oriented, and able to
understand what is being said, but isn’t the safe standard of practice. Names on b
ed aren’t always reliable 43. Answer: (B) 32 drops/minute Rationale: Giving 1,000
ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes). Find the
number of milliliters per minute as follows: 125/60 minutes = X/1 minute 60X = 1
25 = 2.1 ml/minute To find the number of drops per minute: 2.1 ml/X gtt = 1 ml/
15 gtt X = 32 gtt/minute, or 32 drops/minute 44. Answer: (A) Clamp the catheter
Rationale: If a central venous catheter becomes disconnected, the nurse should i
mmediately apply a catheter clamp, if available. If a clamp isn’t available, the n
urse can place a sterile syringe or catheter plug in the catheter hub. After cle
aning the hub with alcohol or povidone-iodine solution, the nurse must replace t
he I.V. extension and restart the infusion. 45. Answer: (D) Auscultation, percus
sion, and palpation. Rationale: The correct order of assessment for examining th
e abdomen is inspection, auscultation, percussion, and palpation. The reason for
this approach is that the less intrusive techniques should be performed before
the more intrusive techniques. Percussion and palpation can alter natural findin
gs during auscultation. 46. Answer: (D) Ulnar surface of the hand Rationale: The
nurse uses the ulnar surface, or ball, of the hand to asses tactile fremitus, t
hrills, and vocal vibrations through the chest wall. The fingertips and finger p
ads best distinguish texture and shape. The dorsal surface best feels warmth. 47
. Answer: (C) Formative Rationale: Formative (or concurrent) evaluation occurs c
ontinuously throughout the teaching and learning process. One benefit is that th
e nurse can adjust teaching strategies as necessary to enhance learning. Summati
ve, or retrospective, evaluation occurs at the conclusion of the teaching and le
arning session. Informative is not a type of evaluation.
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48. Answer: (B) Once per year Rationale: Yearly mammograms should begin at age 4
0 and continue for as long as the woman is in good health. If health risks, such
as family history, genetic tendency, or past breast cancer, exist, more frequen
t examinations may be necessary. 49. Answer: (A) Respiratory acidosis Rationale:
The client has a below-normal (acidic) blood pH value and an above-normal parti
al pressure of arterial carbon dioxide (Paco2) value, indicating respiratory aci
dosis. In respiratory alkalosis, the pH value is above normal and in the Paco2 v
alue is below normal. In metabolic acidosis, the pH and bicarbonate (Hco3) value
s are below normal. In metabolic alkalosis, the pH and Hco3 values are above nor
mal. 50. Answer: (B) To provide support for the client and family in coping with
terminal illness. Rationale: Hospices provide supportive care for terminally il
l clients and their families. Hospice care doesn’t focus on counseling regarding h
ealth care costs. Most client referred to hospices have been treated for their d
isease without success and will receive only palliative care in the hospice. 51.
Answer: (C) Using normal saline solution to clean the ulcer and applying a prot
ective dressing as necessary. Rationale: Washing the area with normal saline sol
ution and applying a protective dressing are within the nurse’s realm of intervent
ions and will protect the area. Using a povidone-iodine wash and an antibiotic c
ream require a physician’s order. Massaging with an astringent can further damage
the skin. 52. Answer: (D) Foot Rationale: An elastic bandage should be applied f
orm the distal area to the proximal area. This method promotes venous return. In
this case, the nurse should begin applying the bandage at the client’s foot. Begi
nning at the ankle, lower thigh, or knee does not promote venous return. 53. Ans
wer: (B) Hypokalemia Rationale: Insulin administration causes glucose and potass
ium to move into the cells, causing hypokalemia. 54. Answer: (A) Throbbing heada
che or dizziness Rationale: Headache and dizziness often occur when nitroglyceri
n is taken at the beginning of therapy. However, the client usually develops tol
erance
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55. Answer: (D) Check the client’s level of consciousness Rationale: Determining u
nresponsiveness is the first step assessment action to take. When a client is in
ventricular tachycardia, there is a significant decrease in cardiac output. How
ever, checking the unresponsiveness ensures whether the client is affected by th
e decreased cardiac output. 56. Answer: (B) On the affected side of the client.
Rationale: When walking with clients, the nurse should stand on the affected sid
e and grasp the security belt in the midspine area of the small of the back. The
nurse should position the free hand at the shoulder area so that the client can
be pulled toward the nurse in the event that there is a forward fall. The clien
t is instructed to look up and outward rather than at his or her feet. 57. Answe
r: (A) Urine output: 45 ml/hr Rationale: Adequate perfusion must be maintained t
o all vital organs in order for the client to remain visible as an organ donor.
A urine output of 45 ml per hour indicates adequate renal perfusion. Low blood p
ressure and delayed capillary refill time are circulatory system indicators of i
nadequate perfusion. A serum pH of 7.32 is acidotic, which adversely affects all
body tissues. 58. Answer: (D ) Obtaining the specimen from the urinary drainage
bag. Rationale: A urine specimen is not taken from the urinary drainage bag. Ur
ine undergoes chemical changes while sitting in the bag and does not necessarily
reflect the current client status. In addition, it may become contaminated with
bacteria from opening the system. 59. Answer: (B) Cover the client, place the c
all light within reach, and answer the phone call. Rationale: Because telephone
call is an emergency, the nurse may need to answer it. The other appropriate act
ion is to ask another nurse to accept the call. However, is not one of the optio
ns. To maintain privacy and safety, the nurse covers the client and places the c
all light within the client’s reach. Additionally, the client’s door should be close
d or the room curtains pulled around the bathing area. 60. Answer: (C) Use a ste
rile plastic container for obtaining the specimen. Rationale: Sputum specimens f
or culture and sensitivity testing need to be obtained using sterile techniques
because the test is done to determine the presence of organisms. If the procedur
e for obtaining the specimen is not sterile, then the specimen is not sterile, t
hen the specimen would be contaminated and the results of the test would be inva
lid.
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61. Answer: (A) Puts all the four points of the walker flat on the floor, puts w
eight on the hand pieces, and then walks into it. Rationale: When the client use
s a walker, the nurse stands adjacent to the affected side. The client is instru
cted to put all four points of the walker 2 feet forward flat on the floor befor
e putting weight on hand pieces. This will ensure client safety and prevent stre
ss cracks in the walker. The client is then instructed to move the walker forwar
d and walk into it. 62. Answer: (C) Draws one line to cross out the incorrect in
formation and then initials the change. Rationale: To correct an error documente
d in a medical record, the nurse draws one line through the incorrect informatio
n 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 belt
s after transferring to the stretcher. Rationale: During the transfer of the cli
ent 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 r
apid changes in the position should be avoided because these predispose the clie
nt to hypotension. At the time of the transfer from the surgery table to the str
etcher, 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 fall
ing off the stretcher. 64. Answer: (B) Gown and gloves Rationale: Contact precau
tions require the use of gloves and a gown if direct client contact is anticipat
ed. Goggles are not necessary unless the nurse anticipates the splashes of blood
, body fluids, secretions, or excretions may occur. Shoe protectors are not nece
ssary. 65. Answer: (C) Quad cane Rationale: Crutches and a walker can be difficu
lt to maneuver for a client with weakness on one side. A cane is better suited f
or client with weakness of the arm and leg on one side. However, the quad cane w
ould 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 che
st wall, the client is positioned sitting at the edge of the bed leaning over th
e bedside table with the feet supported on a stool. If the client is unable to s
it up, the client is positioned lying in bed on the unaffected side with the hea
d of the bed elevated 30 to 45 degrees.
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67. Answer: (D) Reliability Rationale: Reliability is consistency of the researc
h instrument. It refers to the repeatability of the instrument in extracting the
same responses upon its repeated administration. 68. Answer: (A) Keep the ident
ities of the subject secret Rationale: Keeping the identities of the research su
bject secret will ensure anonymity because this will hinder providing link betwe
en the information given to whoever is its source. 69. Answer: (A) Descriptive-
correlational Rationale: Descriptive- correlational study is the most appropriat
e for this study because it studies the variables that could be the antecedents
of the increased incidence of nosocomial infection. 70. Answer: (C) Use of labor
atory data Rationale: Incidence of nosocomial infection is best collected throug
h the use of biophysiologic measures, particularly in vitro measurements, hence
laboratory data is essential. 71. Answer: (B) Quasi-experiment Rationale: Quasi-
experiment is done when randomization and control of the variables are not possi
ble. 72. Answer: (C) Primary source Rationale: This refers to a primary source w
hich is a direct account of the investigation done by the investigator. In contr
ast to this is a secondary source, which is written by someone other than the or
iginal researcher. 73. Answer: (A) Non-maleficence Rationale: Non-maleficence me
ans do not cause harm or do any action that will cause any harm to the patient/c
lient. To do good is referred as beneficence. 74. Answer: (C) Res ipsa loquitor
Rationale: Res ipsa loquitor literally means the thing speaks for itself. This m
eans in operational terms that the injury caused is the proof that there was a n
egligent act. 75. Answer: (B) The Board can investigate violations of the nursin
g law and code of ethics Rationale: Quasi-judicial power means that the Board of
Nursing has the authority to investigate violations of the nursing law and can
issue summons, subpoena or subpoena duces tecum as needed.
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76. Answer: (C) May apply for re-issuance of his/her license based on certain co
nditions 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 cond
itions are met: a) the cause for revocation of license has already been correcte
d 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 relate
d literature to determine the extent of what has been done on the study by previ
ous researchers. 78. Answer: (B) Hawthorne effect Rationale: Hawthorne effect is
based on the study of Elton Mayo and company about the effect of an interventio
n done to improve the working conditions of the workers on their productivity. I
t resulted to an increased productivity but not due to the intervention but due
to the psychological effects of being observed. They performed differently becau
se they were under observation. 79. Answer: (B) Determines the different nationa
lity 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. Answe
r: (B) Madeleine Leininger Rationale: Madeleine Leininger developed the theory o
n transcultural theory based on her observations on the behavior of selected peo
ple within a culture. 81. Answer: (A) Random Rationale: Random sampling gives eq
ual chance for all the elements in the population to be picked as part of the sa
mple. 82. Answer: (A) Degree of agreement and disagreement Rationale: Likert sca
le is a 5-point summated scale used to determine the degree of agreement or disa
greement of the respondents to a statement in a study 83. Answer: (B) Sr. Callis
ta 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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Rationale: Span of control refers to the number of workers who report directly t
o a manager. 85. Answer: (B) Autonomy Rationale: Informed consent means that the
patient fully understands about the surgery, including the risks involved and t
he alternative solutions. In giving consent it is done with full knowledge and i
s given freely. The action of allowing the patient to decide whether a surgery i
s to be done or not exemplifies the bioethical principle of autonomy. 86. Answer
: (C) Avoid wearing canvas shoes. Rationale: The client should be instructed to
avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, which may,
in turn, cause skin irritation and breakdown. Both cotton and cornstarch absorb
perspiration. The client should be instructed to cut toenails straight across wi
th nail clippers. 87. Answer: (D) Ground beef patties Rationale: Meat is an exce
llent source of complete protein, which this client needs to repair the tissue b
reakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but no
t protein. Ice cream supplies only some incomplete protein, making it less helpf
ul in tissue repair. 88. Answer: (D) Sims’ left lateral Rationale: The Sims left
lateral position is the most common position used to administer a cleansing enem
a because it allows gravity to aid the flow of fluid along the curve of the sigm
oid colon. If the client can t assume this position nor has poor sphincter contr
ol, the dorsal recumbent or right lateral position may be used. The supine and p
rone positions are inappropriate and uncomfortable for the client. 89. Answer: (
A) Arrange for typing and cross matching of the client’s blood. Rationale: The nur
se first arranges for typing and cross matching of the client s blood to ensure
compatibility with donor blood. The other options, although appropriate when pre
paring to administer a blood transfusion, come later. 90. Answer: (A) Independen
t Rationale: Nursing interventions are classified as independent, interdependent
, or dependent. Altering the drug schedule to coincide with the client s daily r
outine represents an independent intervention, whereas consulting with the physi
cian and pharmacist to change a client s medication because of adverse reactions
represents an interdependent intervention. Administering an already-prescribed
drug on time is a dependent intervention. An intradependent nursing intervention
doesn t exist.
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91. Answer: (D) Evaluation Rationale: The nursing actions described constitute e
valuation of the expected outcomes. The findings show that the expected outcomes
have been achieved. Assessment consists of the client s history, physical exami
nation, and laboratory studies. Analysis consists of considering assessment info
rmation to derive the appropriate nursing diagnosis. Implementation is the phase
of the nursing process where the nurse puts the plan of care into action. 92. A
nswer: (B) To observe the lower extremities Rationale: Elastic stockings are use
d to promote venous return. The nurse needs to remove them once per day to obser
ve the condition of the skin underneath the stockings. Applying the stockings in
creases blood flow to the heart. When the stockings are in place, the leg muscle
s can still stretch and relax, and the veins can fill with blood. 93. Answer:(A)
Instructing the client to report any itching, swelling, or dyspnea. Rationale:
Because administration of blood or blood products may cause serious adverse effe
cts such as allergic reactions, the nurse must monitor the client for these effe
cts. Signs and symptoms of life-threatening allergic reactions include itching,
swelling, and dyspnea. Although the nurse should inform the client of the durati
on of the transfusion and should document its administration, these actions are
less critical to the client s immediate health. The nurse should assess vital si
gns at least hourly during the transfusion. 94. Answer: (B) Decrease the rate of
feedings and the concentration of the formula. Rationale: Complaints of abdomin
al discomfort and nausea are common in clients receiving tube feedings. Decreasi
ng the rate of the feeding and the concentration of the formula should decrease
the client s discomfort. Feedings are normally given at room temperature to mini
mize abdominal cramping. To prevent aspiration during feeding, the head of the c
lient s bed should be elevated at least 30 degrees. Also, to prevent bacterial g
rowth, feeding containers should be routinely changed every 8 to 12 hours. 95. A
nswer: (D) Roll the vial gently between the palms. Rationale: Rolling the vial g
ently between the palms produces heat, which helps dissolve the medication. Doin
g nothing or inverting the vial wouldn t help dissolve the medication. Shaking t
he vial vigorously could cause the medication to break down, altering its action
. 96. Answer: (B) Assist the client to the semi-Fowler position if possible.
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Rationale: By assisting the client to the semi-Fowler position, the nurse promot
es easier chest expansion, breathing, and oxygen intake. The nurse should secure
the elastic band so that the face mask fits comfortably and snugly rather than
tightly, which could lead to irritation. The nurse should apply the face mask fr
om the client s nose down to the chin — not vice versa. The nurse should check the
connectors between the oxygen equipment and humidifier to ensure that they re a
irtight; loosened connectors can cause loss of oxygen. 97. Answer: (B) 4 hours R
ationale: A unit of packed RBCs may be given over a period of between 1 and 4 ho
urs. It shouldn t infuse for longer than 4 hours because the risk of contaminati
on and sepsis increases after that time. Discard or return to the blood bank any
blood not given within this time, according to facility policy. 98. Answer: (B)
Immediately before administering the next dose. Rationale: Measuring the blood
drug concentration helps determine whether the dosing has achieved the therapeut
ic goal. For measurement of the trough, or lowest, blood level of a drug, the nu
rse draws a blood sample immediately before administering the next dose. Dependi
ng on the drug s duration of action and half-life, peak blood drug levels typica
lly are drawn after administering the next dose. 99. Answer: (A) The nurse can i
mplement medication orders quickly. Rationale: A floor stock system enables the
nurse to implement medication orders quickly. It doesn t allow for pharmacist in
put, nor does it minimize transcription errors or reinforce accurate calculation
s. 100. Answer: (C) Shifting dullness over the abdomen. Rationale: Shifting dull
ness over the abdomen indicates ascites, an abnormal finding. The other options
are normal abdominal findings.
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TEST II Answers and Rationale – Community Health Nursing and Care of the Mother an
d Child 1. Answer: (A) Inevitable Rationale: An inevitable abortion is terminati
on 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. Answe
r: (B) History of syphilis Rationale: Maternal infections such as syphilis, toxo
plasmosis, and rubella are causes of spontaneous abortion. 3. Answer: (C) Monito
ring apical pulse Rationale: Nursing care for the client with a possible ectopic
pregnancy is focused on preventing or identifying hypovolemic shock and control
ling pain. An elevated pulse rate is an indicator of shock. 4. Answer: (B) Incre
ased caloric intake Rationale: Glucose crosses the placenta, but insulin does no
t. High fetal demands for glucose, combined with the insulin resistance caused b
y hormonal changes in the last half of pregnancy can result in elevation of mate
rnal blood glucose levels. This increases the mother’s demand for insulin and is r
eferred to as the diabetogenic effect of pregnancy. 5. Answer: (A) Excessive fet
al activity. Rationale: The most common signs and symptoms of hydatidiform mole
includes elevated levels of human chorionic gonadotropin, vaginal bleeding, larg
er than normal uterus for gestational age, failure to detect fetal heart activit
y even with sensitive instruments, excessive nausea and vomiting, and early deve
lopment 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 gluco
nate. 7. Answer: (C) Presenting part in 2 cm below the plane of the ischial spin
es. 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 ½ m
inutes lasting 70-80 seconds. Rationale: Contractions every 1 ½ 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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9. Answer: (C) EKG tracings Rationale: A potential side effect of calcium glucon
ate administration is cardiac arrest. Continuous monitoring of cardiac activity
(EKG) throught administration of calcium gluconate is an essential part of care.
10. Answer: (D) First low transverse caesarean was for breech position. Fetus i
n this pregnancy is in a vertex presentation. Rationale: This type of client has
no obstetrical indication for a caesarean section as she did with her first cae
sarean delivery. 11. Answer: (A) Talk to the mother first and then to the toddle
r. Rationale: When dealing with a crying toddler, the best approach is to talk t
o the mother and ignore the toddler first. This approach helps the toddler get u
sed to the nurse before she attempts any procedures. It also gives the toddler a
n opportunity to see that the mother trusts the nurse. 12. Answer: (D) Place the
infant’s arms in soft elbow restraints. Rationale: Soft restraints from the upper
arm to the wrist prevent the infant from touching her lip but allow him to hold
a favorite item such as a blanket. Because they could damage the operative site
, such as objects as pacifiers, suction catheters, and small spoons shouldn’t be p
laced in a baby’s mouth after cleft repair. A baby in a prone position may rub her
face on the sheets and traumatize the operative site. The suture line should be
cleaned gently to prevent infection, which could interfere with healing and dam
age the cosmetic appearance of the repair. 13. Answer: (B) Allow the infant to r
est before feeding. Rationale: Because feeding requires so much energy, an infan
t with heart failure should rest before feeding. 14. Answer: (C) Iron-rich formu
la only. Rationale: The infants at age 5 months should receive iron-rich formula
and that they shouldn’t receive solid food, even baby food until age 6 months. 15
. Answer: (D) 10 months Rationale: A 10 month old infant can sit alone and under
stands object permanence, so he would look for the hidden toy. At age 4 to 6 mon
ths, infants can’t sit securely alone. At age 8 months, infants can sit securely a
lone but cannot understand the permanence of objects. 16. Answer: (D) Public hea
lth nursing focuses on preventive, not curative, services. Rationale: The catchm
ents area in PHN consists of a residential
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community, many of whom are well individuals who have greater need for preventiv
e rather than curative services. 17. Answer: (B) Efficiency Rationale: Efficienc
y 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 servic
es to local government units (LGU’s ). The public health nurse is an employee of t
he LGU. 19. Answer: (A) Mayor Rationale: The local executive serves as the chair
man of the Municipal Health Board. 20. Answer: (A) 1 Rationale: Each rural healt
h midwife is given a population assignment of about 5,000. 21. Answer: (B) Healt
h 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. Answ
er: (B) Measles Rationale: Presidential Proclamation No. 4 is on the Ligtas Tigd
as Program. 23. Answer: (D) Core group formation Rationale: In core group format
ion, 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 community’s resources in dealing with health problems. Ration
ale: Community organizing is a developmental service, with the goal of developin
g the people’s self-reliance in dealing with community health problems. A, B and C
are objectives of contributory objectives to this goal. 25. Answer: (D) Termina
l Rationale: Tertiary prevention involves rehabilitation, prevention of permanen
t disability and disability limitation appropriate for convalescents, the disabl
ed, complicated cases and the terminally ill (those in the terminal stage of a d
isease).
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26. Answer: (A) Intrauterine fetal death. Rationale: Intrauterine fetal death, a
bruptio placentae, septic shock, and amniotic fluid embolism may trigger normal
clotting mechanisms; if clotting factors are depleted, DIC may occur. Placenta a
ccreta, dysfunctional labor, and premature rupture of the membranes aren t assoc
iated with DIC. 27. Answer: (C) 120 to 160 beats/minute Rationale: A rate of 120
to 160 beats/minute in the fetal heart appropriate for filling the heart with b
lood and pumping it out to the system. 28. Answer: (A) Change the diaper more of
ten. Rationale: Decreasing the amount of time the skin comes contact with wet so
iled diapers will help heal the irritation. 29. Answer: (D) Endocardial cushion
defect Rationale: Endocardial cushion defects are seen most in children with Dow
n syndrome, asplenia, or polysplenia. 30. Answer: (B) Decreased urine output Rat
ionale: Decreased urine output may occur in clients receiving I.V. magnesium and
should be monitored closely to keep urine output at greater than 30 ml/hour, be
cause magnesium is excreted through the kidneys and can easily accumulate to tox
ic levels. 31. Answer: (A) Menorrhagia Rationale: Menorrhagia is an excessive me
nstrual period. 32. Answer: (C) Blood typing Rationale: Blood type would be a cr
itical value to have because the risk of blood loss is always a potential compli
cation during the labor and delivery process. Approximately 40% of a woman’s cardi
ac output is delivered to the uterus, therefore, blood loss can occur quite rapi
dly in the event of uncontrolled bleeding. 33. Answer: (D) Physiologic anemia Ra
tionale: Hemoglobin values and hematocrit decrease during pregnancy as the incre
ase in plasma volume exceeds the increase in red blood cell production. 34. Answ
er: (D) A 2 year old infant with stridorous breath sounds, sitting up in his mot
her’s arms and drooling. Rationale: The infant with the airway emergency should be
treated first, because of the risk of epiglottitis. 35. Answer: (A) Placenta pr
evia
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Rationale: Placenta previa with painless vaginal bleeding. 36. Answer: (D) Early
in the morning Rationale: Based on the nurse’s knowledge of microbiology, the spe
cimen should be collected early in the morning. The rationale for this timing is
that, because the female worm lays eggs at night around the perineal area, the
first bowel movement of the day will yield the best results. The specific type o
f stool specimen used in the diagnosis of pinworms is called the tape test. 37.
Answer: (A) Irritability and seizures Rationale: Lead poisoning primarily affect
s the CNS, causing increased intracranial pressure. This condition results in ir
ritability and changes in level of consciousness, as well as seizure disorders,
hyperactivity, and learning disabilities. 38. Answer: (D) “I really need to use th
e diaphragm and jelly most during the middle of my menstrual cycle”. Rationale: Th
e woman must understand that, although the “fertile” period is approximately mid-cyc
le, hormonal variations do occur and can result in early or late ovulation. To b
e effective, the diaphragm should be inserted before every intercourse. 39. Answ
er: (C) Restlessness Rationale: In a child, restlessness is the earliest sign of
hypoxia. Late signs of hypoxia in a child are associated with a change in color
, such as pallor or cyanosis. 40. Answer: (B) Walk one step ahead, with the chil
d’s hand on the nurse’s elbow. Rationale: This procedure is generally recommended to
follow in guiding a person who is blind. 41. Answer: (A) Loud, machinery-like m
urmur. Rationale: A loud, machinery-like murmur is a characteristic finding asso
ciated with patent ductus arteriosus. 42. Answer: (C) More oxygen, and the newbo
rn’s metabolic rate increases. Rationale: When cold, the infant requires more oxyg
en and there is an increase in metabolic rate. Non-shievering thermogenesis is a
complex process that increases the metabolic rate and rate of oxygen consumptio
n, therefore, the newborn increase heat production. 43. Answer: (D) Voided Ratio
nale: Before administering potassium I.V. to any client, the nurse must first ch
eck that the client’s kidneys are functioning and that the client
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is voiding. If the client is not voiding, the nurse should withhold the potassiu
m 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 fo
rmula by gravity, but the flow will be slow enough not to overload the stomach t
oo 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 seve
re in adults than in children. Complications, such as pneumonia, are higher in i
ncidence in adults. 47. Answer: (D) Consult a physician who may give them rubell
a immunoglobulin. Rationale: Rubella vaccine is made up of attenuated German mea
sles 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 reliab
le 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 majo
r symptom of cholera. Both amebic and bacillary dysentery are characterized by t
he presence of blood and/or mucus in the stools. Giardiasis is characterized by
fat malabsorption and, therefore, steatorrhea. 51. Answer: (A) Hemophilus influe
nzae Rationale: Hemophilus meningitis is unusual over the age of 5 years. In dev
eloping 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 youn
g children.
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52. Answer: (B) Buccal mucosa Rationale: Koplik’s spot may be seen on the mucosa o
f the mouth or the throat. 53. Answer: (A) 3 seconds Rationale: Adequate blood s
upply to the area allows the return of the color of the nailbed within 3 seconds
. 54. Answer: (B) Severe dehydration Rationale: The order of priority in the man
agement of severe dehydration is as follows: intravenous fluid therapy, referral
to a facility where IV fluids can be initiated within 30 minutes, Oresol or nas
ogastric tube. When the foregoing measures are not possible or effective, then u
rgent referral to the hospital is done. 55. Answer: (A) 45 infants Rationale: To
estimate the number of infants, multiply total population by 3%. 56. Answer: (A
) DPT Rationale: DPT is sensitive to freezing. The appropriate storage temperatu
re of DPT is 2 to 8° C only. OPV and measles vaccine are highly sensitive to heat
and require freezing. MMR is not an immunization in the Expanded Program on Immu
nization. 57. Answer: (C) Proper use of sanitary toilets Rationale: The ova of t
he parasite get out of the human body together with feces. Cutting the cycle at
this stage is the most effective way of preventing the spread of the disease to
susceptible hosts. 58. Answer: (D) 5 skin lesions, positive slit skin smear Rati
onale: A multibacillary leprosy case is one who has a positive slit skin smear a
nd at least 5 skin lesions. 59. Answer: (C) Thickened painful nerves Rationale:
The lesion of leprosy is not macular. It is characterized by a change in skin co
lor (either reddish or whitish) and loss of sensation, sweating and hair growth
over the lesion. Inability to close the eyelids (lagophthalmos) and sinking of t
he nosebridge are late symptoms. 60. Answer: (B) Ask where the family resides. R
ationale: Because malaria is endemic, the first question to determine malaria ri
sk is where the client’s family resides. If the area of residence is not a known e
ndemic area, ask if the child had traveled within the past 6 months, where she w
as brought and whether she stayed overnight in that area.
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61. Answer: (A) Inability to drink Rationale: A sick child aged 2 months to 5 ye
ars must be referred urgently to a hospital if he/she has one or more of the fol
lowing signs: not able to feed or drink, vomits everything, convulsions, abnorma
lly sleepy or difficult to awaken. 62. Answer: (A) Refer the child urgently to a
hospital for confinement. Rationale: “Baggy pants” is a sign of severe marasmus. Th
e best management is urgent referral to a hospital. 63. Answer: (D) Let the chil
d rest for 10 minutes then continue giving Oresol more slowly. Rationale: If the
child vomits persistently, that is, he vomits everything that he takes in, he h
as to be referred urgently to a hospital. Otherwise, vomiting is managed by lett
ing the child rest for 10 minutes and then continuing with Oresol administration
. Teach the mother to give Oresol more slowly. 64. Answer: (B) Some dehydration
Rationale: Using the assessment guidelines of IMCI, a child (2 months to 5 years
old) with diarrhea is classified as having SOME DEHYDRATION if he shows 2 or mo
re of the following signs: restless or irritable, sunken eyes, the skin goes bac
k slow after a skin pinch. 65. Answer: (C) Normal Rationale: In IMCI, a respirat
ory rate of 50/minute or more is fast breathing for an infant aged 2 to 12 month
s. 66. Answer: (A) 1 year Rationale: The baby will have passive natural immunity
by placental transfer of antibodies. The mother will have active artificial imm
unity lasting for about 10 years. 5 doses will give the mother lifetime protecti
on. 67. Answer: (B) 4 hours Rationale: While the unused portion of other biologi
cals in EPI may be given until the end of the day, only BCG is discarded 4 hours
after reconstitution. This is why BCG immunization is scheduled only in the mor
ning. 68. Answer: (B) 6 months Rationale: After 6 months, the baby’s nutrient need
s, especially the baby’s iron requirement, can no longer be provided by mother’s mil
k alone. 69. Answer: (C) 24 weeks
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Rationale: At approximately 23 to 24 weeks’ gestation, the lungs are developed eno
ugh to sometimes maintain extrauterine life. The lungs are the most immature sys
tem during the gestation period. Medical care for premature labor begins much ea
rlier (aggressively at 21 weeks’ gestation) 70. Answer: (B) Sudden infant death sy
ndrome (SIDS) Rationale: Supine positioning is recommended to reduce the risk of
SIDS in infancy. The risk of aspiration is slightly increased with the supine p
osition. Suffocation would be less likely with an infant supine than prone and t
he position for GER requires the head of the bed to be elevated. 71. Answer: (C)
Decreased temperature Rationale: Temperature instability, especially when it re
sults in a low temperature in the neonate, may be a sign of infection. The neona
te’s color often changes with an infection process but generally becomes ashen or
mottled. The neonate with an infection will usually show a decrease in activity
level or lethargy. 72. Answer: (D) Polycythemia probably due to chronic fetal hy
poxia Rationale: The small-for-gestation neonate is at risk for developing polyc
ythemia during the transitional period in an attempt to decrease hypoxia. The ne
onates are also at increased risk for developing hypoglycemia and hypothermia du
e to decreased glycogen stores. 73. Answer: (C) Desquamation of the epidermis Ra
tionale: Postdate fetuses lose the vernix caseosa, and the epidermis may become
desquamated. These neonates are usually very alert. Lanugo is missing in the pos
tdate neonate. 74. Answer: (C) Respiratory depression Rationale: Magnesium sulfa
te crosses the placenta and adverse neonatal effects are respiratory depression,
hypotonia, and bradycardia. The serum blood sugar isn’t affected by magnesium sul
fate. The neonate would be floppy, not jittery. 75. Answer: (C) Respiratory rate
40 to 60 breaths/minute Rationale: A respiratory rate 40 to 60 breaths/minute i
s normal for a neonate during the transitional period. Nasal flaring, respirator
y rate more than 60 breaths/minute, and audible grunting are signs of respirator
y distress. 76. Answer: (C) Keep the cord dry and open to air Rationale: Keeping
the cord dry and open to air helps reduce infection and hastens drying. Infants
aren’t given tub bath but are sponged off until the cord falls off. Petroleum jel
ly prevents the cord from drying and encourages infection. Peroxide could be pai
nful and isn’t recommended.
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77. Answer: (B) Conjunctival hemorrhage Rationale: Conjunctival hemorrhages are
commonly seen in neonates secondary to the cranial pressure applied during the b
irth process. Bulging fontanelles are a sign of intracranial pressure. Simian cr
eases are present in 40% of the neonates with trisomy 21. Cystic hygroma is a ne
ck mass that can affect the airway. 78. Answer: (B) To assess for prolapsed cord
Rationale: After a client has an amniotomy, the nurse should assure that the co
rd isn t prolapsed and that the baby tolerated the procedure well. The most effe
ctive way to do this is to check the fetal heart rate. Fetal well-being is asses
sed via a nonstress test. Fetal position is determined by vaginal examination. A
rtificial rupture of membranes doesn t indicate an imminent delivery. 79. Answer
: (D) The parents’ interactions with each other. Rationale: Parental interaction w
ill provide the nurse with a good assessment of the stability of the family s ho
me life but it has no indication for parental bonding. Willingness to touch and
hold the newborn, expressing interest about the newborn s size, and indicating a
desire to see the newborn are behaviors indicating parental bonding. 80. Answer
: (B) Instructing the client to use two or more peripads to cushion the area Rat
ionale: Using two or more peripads would do little to reduce the pain or promote
perineal healing. Cold applications, sitz baths, and Kegel exercises are import
ant measures when the client has a fourth-degree laceration. 81. Answer: (C) “What
is your expected due date?” Rationale: When obtaining the history of a client who
may be in labor, the nurse s highest priority is to determine her current statu
s, particularly her due date, gravidity, and parity. Gravidity and parity affect
the duration of labor and the potential for labor complications. Later, the nur
se should ask about chronic illnesses, allergies, and support persons. 82. Answe
r: (D) Aspirate the neonate’s nose and mouth with a bulb syringe. Rationale: The n
urse s first action should be to clear the neonate s airway with a bulb syringe.
After the airway is clear and the neonate s color improves, the nurse should co
mfort and calm the neonate. If the problem recurs or the neonate s color doesn t
improve readily, the nurse should notify the physician. Administering oxygen wh
en the airway isn t clear would be ineffective. 83. Answer: (C) Conducting a bed
side ultrasound for an amniotic fluid index.
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Rationale: It isn t within a nurse s scope of practice to perform and interpret
a bedside ultrasound under these conditions and without specialized training. Ob
serving for pooling of straw-colored fluid, checking vaginal discharge with nitr
azine paper, and observing for flakes of vernix are appropriate assessments for
determining whether a client has ruptured membranes. 84. Answer: (C) Monitor par
tial pressure of oxygen (Pao2) levels. Rationale: Monitoring PaO2 levels and red
ucing the oxygen concentration to keep PaO2 within normal limits reduces the ris
k of retinopathy of prematurity in a premature infant receiving oxygen. Covering
the infant s eyes and humidifying the oxygen don t reduce the risk of retinopat
hy of prematurity. Because cooling increases the risk of acidosis, the infant sh
ould be kept warm so that his respiratory distress isn t aggravated. 85. Answer:
(A) 110 to 130 calories per kg. Rationale: Calories per kg is the accepted way
of determined appropriate nutritional intake for a newborn. The recommended calo
rie requirement is 110 to 130 calories per kg of newborn body weight. This level
will maintain a consistent blood glucose level and provide enough calories for
continued growth and development. 86. Answer: (C) 30 to 32 weeks Rationale: Indi
vidual twins usually grow at the same rate as singletons until 30 to 32 weeks’ ges
tation, then twins don’t’ gain weight as rapidly as singletons of the same gestation
al age. The placenta can no longer keep pace with the nutritional requirements o
f both fetuses after 32 weeks, so there’s some growth retardation in twins if they
remain in utero at 38 to 40 weeks. 87. Answer: (A) conjoined twins Rationale: T
he type of placenta that develops in monozygotic twins depends on the time at wh
ich cleavage of the ovum occurs. Cleavage in conjoined twins occurs more than 13
days after fertilization. Cleavage that occurs less than 3 day after fertilizat
ion results in diamniotic dicchorionic twins. Cleavage that occurs between days
3 and 8 results in diamniotic monochorionic twins. Cleavage that occurs between
days 8 to 13 result in monoamniotic monochorionic twins. 88. Answer: (D) Ultraso
und Rationale: Once the mother and the fetus are stabilized, ultrasound evaluati
on of the placenta should be done to determine the cause of the bleeding. Amnioc
entesis is contraindicated in placenta previa. A digital or speculum examination
shouldn’t be done as this may lead to severe
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bleeding or hemorrhage. External fetal monitoring won’t detect a placenta previa,
although it will detect fetal distress, which may result from blood loss or plac
enta separation. 89. Answer: (A) Increased tidal volume Rationale: A pregnant cl
ient breathes deeper, which increases the tidal volume of gas moved in and out o
f the respiratory tract with each breath. The expiratory volume and residual vol
ume decrease as the pregnancy progresses. The inspiratory capacity increases dur
ing pregnancy. The increased oxygen consumption in the pregnant client is 15% to
20% greater than in the nonpregnant state. 90. Answer: (A) Diet Rationale: Clie
nts with gestational diabetes are usually managed by diet alone to control their
glucose intolerance. Oral hypoglycemic drugs are contraindicated in pregnancy.
Long-acting insulin usually isn’t needed for blood glucose control in the client w
ith gestational diabetes. 91. Answer: (D) Seizure Rationale: The anticonvulsant
mechanism of magnesium is believes to depress seizure foci in the brain and peri
pheral neuromuscular blockade. Hypomagnesemia isn’t a complication of preeclampsia
. Antihypertensive drug other than magnesium are preferred for sustained hyperte
nsion. Magnesium doesn’t help prevent hemorrhage in preeclamptic clients. 92. Answ
er: (C) I.V. fluids Rationale: A sickle cell crisis during pregnancy is usually
managed by exchange transfusion oxygen, and L.V. Fluids. The client usually need
s a stronger analgesic than acetaminophen to control the pain of a crisis. Antih
ypertensive drugs usually aren’t necessary. Diuretic wouldn’t be used unless fluid o
verload resulted. 93. Answer: (A) Calcium gluconate (Kalcinate) Rationale: Calci
um gluconate is the antidote for magnesium toxicity. Ten milliliters of 10% calc
ium gluconate is given L.V. push over 3 to 5 minutes. Hydralazine is given for s
ustained elevated blood pressure in preeclamptic clients. Rho (D) immune globuli
n is given to women with Rh-negative blood to prevent antibody formation from RH
-positive conceptions. Naloxone is used to correct narcotic toxicity. 94. Answer
: (B) An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. Ratio
nale: A positive PPD result would be an indurated wheal over 10 mm in diameter t
hat appears in 48 to 72 hours. The area must be a raised wheal, not a flat circu
mcised area to be considered positive.
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95. Answer: (C) Pyelonephritis Rational: The symptoms indicate acute pyelonephri
tis, a serious condition in a pregnant client. UTI symptoms include dysuria, urg
ency, frequency, and suprapubic tenderness. Asymptomatic bacteriuria doesn’t cause
symptoms. Bacterial vaginosis causes milky white vaginal discharge but no syste
mic symptoms. 96. Answer: (B) Rh-positive fetal blood crosses into maternal bloo
d, stimulating maternal antibodies. Rationale: Rh isoimmunization occurs when Rh
-positive fetal blood cells cross into the maternal circulation and stimulate ma
ternal antibody production. In subsequent pregnancies with Rh-positive fetuses,
maternal antibodies may cross back into the fetal circulation and destroy the fe
tal blood cells. 97. Answer: (C) Supine position Rationale: The supine position
causes compression of the client s aorta and inferior vena cava by the fetus. Th
is, in turn, inhibits maternal circulation, leading to maternal hypotension and,
ultimately, fetal hypoxia. The other positions promote comfort and aid labor pr
ogress. For instance, the lateral, or side-lying, position improves maternal and
fetal circulation, enhances comfort, increases maternal relaxation, reduces mus
cle tension, and eliminates pressure points. The squatting position promotes com
fort by taking advantage of gravity. The standing position also takes advantage
of gravity and aligns the fetus with the pelvic angle. 98. Answer: (B) Irritabil
ity and poor sucking. Rationale: Neonates of heroin-addicted mothers are physica
lly dependent on the drug and experience withdrawal when the drug is no longer s
upplied. Signs of heroin withdrawal include irritability, poor sucking, and rest
lessness. Lethargy isn t associated with neonatal heroin addiction. A flattened
nose, small eyes, and thin lips are seen in infants with fetal alcohol syndrome.
Heroin use during pregnancy hasn t been linked to specific congenital anomalies
. 99. Answer: (A) 7th to 9th day postpartum Rationale: The normal involutional p
rocess returns the uterus to the pelvic cavity in 7 to 9 days. A significant inv
olutional complication is the failure of the uterus to return to the pelvic cavi
ty within the prescribed time period. This is known as subinvolution. 100. Answe
r: (B) Uterine atony Rationale: Multiple fetuses, extended labor stimulation wit
h oxytocin, and traumatic delivery commonly are associated with uterine atony, w
hich may lead to postpartum hemorrhage. Uterine inversion may precede or follow
delivery and commonly results from apparent excessive traction on the
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umbilical cord and attempts to deliver the placenta manually. Uterine involution
and some uterine discomfort are normal after delivery.
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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 s
oft-formed stool usually do not occur until around the seventh day following sur
gery. The stool consistency is related to how much water is being absorbed. 2. A
nswer: (A) On the client’s right side Rationale: The client has left visual field
blindness. The client will see only from the right side. 3. Answer: (C) Check re
spirations, stabilize spine, and check circulation Rationale: Checking the airwa
y would be priority, and a neck injury should be suspected. 4. Answer: (D) Decre
asing venous return through vasodilation. Rationale: The significant effect of n
itroglycerin 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: Ha
ving established, by stimulating the client, that the client is unconscious rath
er than sleep, the nurse should immediately call for help. This may be done by d
ialing the operator from the client’s phone and giving the hospital code for cardi
ac arrest and the client’s room number to the operator, of if the phone is not ava
ilable, by pulling the emergency call button. Noting the time is important basel
ine information for cardiac arrest procedure. 6. Answer: (C) Make sure that the
client takes food and medications at prescribed intervals. Rationale: Food and d
rug therapy will prevent the accumulation of hydrochloric acid, or will neutrali
ze and buffer the acid that does accumulate. 7. Answer: (B) Continue treatment a
s ordered. Rationale: The effects of heparin are monitored by the PTT is normall
y 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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enzymes even for a short time becomes reddened, painful, and excoriated. 9. Answ
er: (B) Flat on back. Rationale: To avoid the complication of a painful spinal h
eadache that can last for several days, the client is kept in flat in a supine p
osition for approximately 4 to 12 hours postoperatively. Headaches are believed
to be causes by the seepage of cerebral spinal fluid from the puncture site. By
keeping the client flat, cerebral spinal fluid pressures are equalized, which av
oids trauma to the neurons. 10. Answer: (C) The client is oriented when aroused
from sleep, and goes back to sleep immediately. Rationale: This finding suggest
that the level of consciousness is decreasing. 11. Answer: (A) Altered mental st
atus and dehydration Rationale: Fever, chills, hemortysis, dyspnea, cough, and p
leuritic chest pain are the common symptoms of pneumonia, but elderly clients ma
y first appear with only an altered lentil status and dehydration due to a blunt
ed immune response. 12. Answer: (B) Chills, fever, night sweats, and hemoptysis
Rationale: Typical signs and symptoms are chills, fever, night sweats, and hemop
tysis. Chest pain may be present from coughing, but isn’t usual. Clients with TB t
ypically have low-grade fevers, not higher than 102°F (38.9°C). Nausea, headache, an
d photophobia aren’t usual TB symptoms. 13. Answer:(A) Acute asthma Rationale: Bas
ed on the client’s history and symptoms, acute asthma is the most likely diagnosis
. He’s unlikely to have bronchial pneumonia without a productive cough and fever a
nd he’s too young to have developed (COPD) and emphysema. 14. Answer: (B) Respirat
ory arrest Rationale: Narcotics can cause respiratory arrest if given in large q
uantities. It’s unlikely the client will have asthma attack or a seizure or wake u
p on his own. 15. Answer: (D) Decreased vital capacity Rationale: Reduction in v
ital capacity is a normal physiologic changes include decreased elastic recoil o
f the lungs, fewer functional capillaries in the alveoli, and an increased in re
sidual volume.
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16. Answer: (C) Presence of premature ventricular contractions (PVCs) on a cardi
ac monitor. Rationale: Lidocaine drips are commonly used to treat clients whose
arrhythmias haven’t been controlled with oral medication and who are having PVCs t
hat are visible on the cardiac monitor. SaO2, blood pressure, and ICP are import
ant factors but aren’t as significant as PVCs in the situation. 17. Answer: (B) Av
oid foods high in vitamin K Rationale: The client should avoid consuming large a
mounts of vitamin K because vitamin K can interfere with anticoagulation. The cl
ient may need to report diarrhea, but isn’t effect of taking an anticoagulant. An
electric razor-not a straight razor-should be used to prevent cuts that cause bl
eeding. Aspirin may increase the risk of bleeding; acetaminophen should be used
to pain relief. 18. Answer: (C) Clipping the hair in the area Rationale: Hair ca
n be a source of infection and should be removed by clipping. Shaving the area c
an cause skin abrasions and depilatories can irritate the skin. 19. Answer: (A)
Bone fracture Rationale: Bone fracture is a major complication of osteoporosis t
hat results when loss of calcium and phosphate increased the fragility of bones.
Estrogen deficiencies result from menopause-not osteoporosis. Calcium and vitam
in D supplements may be used to support normal bone metabolism, But a negative c
alcium balance isn’t a complication of osteoporosis. Dowager’s hump results from bon
e fractures. It develops when repeated vertebral fractures increase spinal curva
ture. 20. Answer: (C) Changes from previous examinations. Rationale: Women are i
nstructed to examine themselves to discover changes that have occurred in the br
east. Only a physician can diagnose lumps that are cancerous, areas of thickness
or fullness that signal the presence of a malignancy, or masses that are fibroc
ystic as opposed to malignant. 21. Answer: (C) Balance the client’s periods of act
ivity and rest. Rationale: A client with hyperthyroidism needs to be encouraged
to balance periods of activity and rest. Many clients with hyperthyroidism are h
yperactive and complain of feeling very warm. 22. Answer: (B) Increase his activ
ity level. Rationale: The client should be encouraged to increase his activity l
evel. Maintaining an ideal weight; following a low-cholesterol, low sodium diet;
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and avoiding stress are all important factors in decreasing the risk of atherosc
lerosis. 23. Answer: (A) Laminectomy Rationale: The client who has had spinal su
rgery, such as laminectomy, must be log rolled to keep the spinal column straigh
t when turning. Thoracotomy and cystectomy may turn themselves or may be assiste
d into a comfortable position. Under normal circumstances, hemorrhoidectomy is a
n outpatient procedure, and the client may resume normal activities immediately
after surgery. 24. Answer: (D) Avoiding straining during bowel movement or bendi
ng at the waist. Rationale: The client should avoid straining, lifting heavy obj
ects, and coughing harshly because these activities increase intraocular pressur
e. Typically, the client is instructed to avoid lifting objects weighing more th
an 15 lb (7kg) – not 5lb. instruct the client when lying in bed to lie on either t
he 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 s
hould first place saline-soaked sterile dressings on the open wound to prevent t
issue drying and possible infection. Then the nurse should call the physician an
d take the client’s vital signs. The dehiscence needs to be surgically closed, so
the nurse should never try to close it. 27. Answer: (A) A progressively deeper b
reaths followed by shallower breaths with apneic periods. Rationale: Cheyne-Stro
kes respirations are breaths that become progressively deeper fallowed by shallo
wer respirations with apneas periods. Biot’s respirations are rapid, deep breathin
g with abrupt pauses between each breath, and equal depth between each breath. K
ussmaul’s respirationa are rapid, deep breathing without pauses. Tachypnea is shal
low breathing with increased respiratory rate. 28. Answer: (B) Fine crackles Rat
ionale: Fine crackles are caused by fluid in the alveoli and commonly occur in c
lients with heart failure. Tracheal breath sounds are auscultated over the trach
ea. Coarse crackles are caused by secretion accumulation in the airways. Frictio
n rubs occur with pleural inflammation.
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29. Answer: (B) The airways are so swollen that no air cannot get through Ration
ale: During an acute attack, wheezing may stop and breath sounds become inaudibl
e because the airways are so swollen that air can’t get through. If the attack is
over and swelling has decreased, there would be no more wheezing and less emerge
nt concern. Crackles do not replace wheezes during an acute asthma attack. 30. A
nswer: (D) Place the client on his side, remove dangerous objects, and protect h
is head. Rationale: During the active seizure phase, initiate precautions by pla
cing 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 ph
ase. Insertion can break the teeth and lead to aspiration. 31. Answer: (B) Kinke
d or obstructed chest tube Rationales: Kinking and blockage of the chest tube is
a common cause of a tension pneumothorax. Infection and excessive drainage won’t
cause a tension pneumothorax. Excessive water won’t affect the chest tube drainage
. 32. Answer: (D) Stay with him but not intervene at this time. Rationale: If th
e client is coughing, he should be able to dislodge the object or cause a comple
te obstruction. If complete obstruction occurs, the nurse should perform the abd
ominal thrust maneuver with the client standing. If the client is unconscious, s
he should lay him down. A nurse should never leave a choking client alone. 33. A
nswer: (B) Current health promotion activities Rationale: Recognizing an individ
ual’s positive health measures is very useful. General health in the previous 10 y
ears 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 lat
er years is of minor significance. Marital status information may be important f
or discharge planning but is not as significant for addressing the immediate med
ical problem. 34. Answer: (C) Place the client in a side lying position, with th
e 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 a
mount 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. Br
ushing the teeth with the client lying supine may lead to aspiration. Hydrogen p
eroxide is caustic to tissues and should not be used.
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35. Answer: (C) Pneumonia Rationale: Fever productive cough and pleuritic chest
pain are common signs and symptoms of pneumonia. The client with ARDS has dyspne
a and hypoxia with worsening hypoxia over time, if not treated aggressively. Ple
uritic chest pain varies with respiration, unlike the constant chest pain during
an MI; so this client most likely isn’t having an MI. the client with TB typicall
y has a cough producing blood-tinged sputum. A sputum culture should be obtained
to confirm the nurse’s suspicions. 36. Answer: (C) A 43-yesr-old homeless man wit
h a history of alcoholism Rationale: Clients who are economically disadvantaged,
malnourished, and have reduced immunity, such as a client with a history of alc
oholism, are at extremely high risk for developing TB. A high school student, da
ycare worker, and businessman probably have a much low risk of contracting TB. 3
7. Answer: (C ) To determine the extent of lesions Rationale: If the lesions are
large enough, the chest X-ray will show their presence in the lungs. Sputum cul
ture confirms the diagnosis. There can be false-positive and false-negative skin
test results. A chest X-ray can’t determine if this is a primary or secondary inf
ection. 38. Answer: (B) Bronchodilators Rationale: Bronchodilators are the first
line of treatment for asthma because broncho-constriction is the cause of reduc
ed airflow. Betaadrenergic blockers aren’t used to treat asthma and can cause bron
choconstriction. Inhaled oral steroids may be given to reduce the inflammation b
ut aren’t used for emergency relief. 39. Answer: (C) Chronic obstructive bronchiti
s Rationale: Because of this extensive smoking history and symptoms the client m
ost likely has chronic obstructive bronchitis. Client with ARDS have acute sympt
oms of hypoxia and typically need large amounts of oxygen. Clients with asthma a
nd emphysema tend not to have chronic cough or peripheral edema. 40. Answer: (A)
The patient is under local anesthesia during the procedure Rationale: Before th
e procedure, the patient is administered with drugs that would help to prevent i
nfection and rejection of the transplanted cells such as antibiotics, cytotoxic,
and corticosteroids. During the transplant, the patient is placed under general
anesthesia. 41. Answer: (D) Raise the side rails
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Rationale: A patient who is disoriented is at risk of falling out of bed. The in
itial action of the nurse should be raising the side rails to ensure patients sa
fety. 42. Answer: (A) Crowd red blood cells Rationale: The excessive production
of white blood cells crowd out red blood cells production which causes anemia to
occur. 43. Answer: (B) Leukocytosis Rationale: Chronic Lymphocytic leukemia (CL
L) is characterized by increased production of leukocytes and lymphocytes result
ing in leukocytosis, and proliferation of these cells within the bone marrow, sp
leen and liver. 44. Answer: (A) Explain the risks of not having the surgery Rati
onale: The best initial response is to explain the risks of not having the surge
ry. If the client understands the risks but still refuses the nurse should notif
y the physician and the nurse supervisor and then record the client’s refusal in t
he nurses’ notes. 45. Answer: (D) The 75-year-old client who was admitted 1 hour a
go with new-onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem
) Rationale: The client with atrial fibrillation has the greatest potential to b
ecome unstable and is on L.V. medication that requires close monitoring. After a
ssessing this client, the nurse should assess the client with thrombophlebitis w
ho is receiving a heparin infusion, and then the 58year-old client admitted 2 da
ys ago with heart failure (his signs and symptoms are resolving and don’t require
immediate attention). The lowest priority is the 89-year-old with end-stage righ
t-sided heart failure, who requires time-consuming supportive measures. 46. Answ
er: (C) Cocaine Rationale: Because of the client’s age and negative medical histor
y, the nurse should question her about cocaine use. Cocaine increases myocardial
oxygen consumption and can cause coronary artery spasm, leading to tachycardia,
ventricular fibrillation, myocardial ischemia, and myocardial infarction. Barbi
turate overdose may trigger respiratory depression and slow pulse. Opioids can c
ause marked respiratory depression, while benzodiazepines can cause drowsiness a
nd confusion. 47. Answer: (B) Nonmobile mass with irregular edges Rationale: Bre
ast cancer tumors are fixed, hard, and poorly delineated with irregular edges. A
mobile mass that is soft and easily delineated is most often a fluid-filled ben
ign cyst. Axillary lymph nodes may or may not be palpable on initial detection o
f a cancerous mass. Nipple retraction — not eversion — may be a sign of cancer.
149
48. Answer: (C) Radiation Rationale: The usual treatment for vaginal cancer is e
xternal or intravaginal radiation therapy. Less often, surgery is performed. Che
motherapy typically is prescribed only if vaginal cancer is diagnosed in an earl
y stage, which is rare. Immunotherapy isn t used to treat vaginal cancer. 49. An
swer: (B) Carcinoma in situ, no abnormal regional lymph nodes, and no evidence o
f distant metastasis Rationale: TIS, N0, M0 denotes carcinoma in situ, no abnorm
al regional lymph nodes, and no evidence of distant metastasis. No evidence of p
rimary tumor, no abnormal regional lymph nodes, and no evidence of distant metas
tasis is classified as T0, N0, M0. If the tumor and regional lymph nodes can t b
e assessed and no evidence of metastasis exists, the lesion is classified as TX,
NX, M0. A progressive increase in tumor size, no demonstrable metastasis of the
regional lymph nodes, and ascending degrees of distant metastasis is classified
as T1, T2, T3, or T4; N0; and M1, M2, or M3. 50. Answer: (D) "Keep the stoma mo
ist." Rationale: The nurse should instruct the client to keep the stoma moist, s
uch as by applying a thin layer of petroleum jelly around the edges, because a d
ry stoma may become irritated. The nurse should recommend placing a stoma bib ov
er the stoma to filter and warm air before it enters the stoma. The client shoul
d begin performing stoma care without assistance as soon as possible to gain ind
ependence in self-care activities. 51. Answer: (B) Lung cancer Rationale: Lung c
ancer is the most deadly type of cancer in both women and men. Breast cancer ran
ks second in women, followed (in descending order) by colon and rectal cancer, p
ancreatic cancer, ovarian cancer, uterine cancer, lymphoma, leukemia, liver canc
er, brain cancer, stomach cancer, and multiple myeloma. 52. Answer: (A) miosis,
partial eyelid ptosis, and anhidrosis on the affected side of the face. Rational
e: Horner s syndrome, which occurs when a lung tumor invades the ribs and affect
s the sympathetic nerve ganglia, is characterized by miosis, partial eyelid ptos
is, and anhidrosis on the affected side of the face. Chest pain, dyspnea, cough,
weight loss, and fever are associated with pleural tumors. Arm and shoulder pai
n and atrophy of the arm and hand muscles on the affected side suggest Pancoast
s tumor, a lung tumor involving the first thoracic and eighth cervical nerves wi
thin the brachial plexus. Hoarseness in a client with lung cancer suggests that
the
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tumor has extended to the recurrent laryngeal nerve; dysphagia suggests that the
lung tumor is compressing the esophagus. 53. Answer: (A) prostate-specific anti
gen, which is used to screen for prostate cancer. Rationale: PSA stands for pros
tate-specific antigen, which is used to screen for prostate cancer. The other an
swers are incorrect. 54. Answer: (D) "Remain supine for the time specified by th
e physician." Rationale: The nurse should instruct the client to remain supine f
or the time specified by the physician. Local anesthetics used in a subarachnoid
block don t alter the gag reflex. No interactions between local anesthetics and
food occur. Local anesthetics don t cause hematuria. 55. Answer: (C) Sigmoidosc
opy Rationale: Used to visualize the lower GI tract, sigmoidoscopy and proctosco
py aid in the detection of two-thirds of all colorectal cancers. Stool Hematest
detects blood, which is a sign of colorectal cancer; however, the test doesn t c
onfirm the diagnosis. CEA may be elevated in colorectal cancer but isn t conside
red a confirming test. An abdominal CT scan is used to stage the presence of col
orectal cancer. 56. Answer: (B) A fixed nodular mass with dimpling of the overly
ing skin Rationale: A fixed nodular mass with dimpling of the overlying skin is
common during late stages of breast cancer. Many women have slightly asymmetrica
l breasts. Bloody nipple discharge is a sign of intraductal papilloma, a benign
condition. Multiple firm, round, freely movable masses that change with the mens
trual cycle indicate fibrocystic breasts, a benign condition. 57. Answer: (A) Li
ver Rationale: The liver is one of the five most common cancer metastasis sites.
The others are the lymph nodes, lung, bone, and brain. The colon, reproductive
tract, and WBCs are occasional metastasis sites. 58. Answer: (D) The client wear
s a watch and wedding band. Rationale: During an MRI, the client should wear no
metal objects, such as jewelry, because the strong magnetic field can pull on th
em, causing injury to the client and (if they fly off) to others. The client mus
t lie still during the MRI but can talk to those performing the test by way of t
he microphone inside the scanner tunnel. The client should hear thumping sounds,
which are caused by the sound waves thumping on the magnetic field. 59. Answer:
(C) The recommended daily allowance of calcium may be found in a wide variety o
f foods.
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Rationale: Premenopausal women require 1,000 mg of calcium per day. Postmenopaus
al women require 1,500 mg per day. It s often, though not always, possible to ge
t the recommended daily requirement in the foods we eat. Supplements are availab
le but not always necessary. Osteoporosis doesn t show up on ordinary X-rays unt
il 30% of the bone loss has occurred. Bone densitometry can detect bone loss of
3% or less. This test is sometimes recommended routinely for women over 35 who a
re at risk. Strenuous exercise won t cause fractures. 60. Answer: (C) Joint flex
ion of less than 50% Rationale: Arthroscopy is contraindicated in clients with j
oint flexion of less than 50% because of technical problems in inserting the ins
trument into the joint to see it clearly. Other contraindications for this proce
dure include skin and wound infections. Joint pain may be an indication, not a c
ontraindication, for arthroscopy. Joint deformity and joint stiffness aren t con
traindications for this procedure. 61. Answer: (D) Gouty arthritis Rationale: Go
uty arthritis, a metabolic disease, is characterized by urate deposits and pain
in the joints, especially those in the feet and legs. Urate deposits don t occur
in septic or traumatic arthritis. Septic arthritis results from bacterial invas
ion of a joint and leads to inflammation of the synovial lining. Traumatic arthr
itis results from blunt trauma to a joint or ligament. Intermittent arthritis is
a rare, benign condition marked by regular, recurrent joint effusions, especial
ly in the knees. 62. Answer: (B) 30 ml/hou Rationale: An infusion prepared with
25,000 units of heparin in 500 ml of saline solution yields 50 units of heparin
per milliliter of solution. The equation is set up as 50 units times X (the unkn
own quantity) equals 1,500 units/hour, X equals 30 ml/hour. 63. Answer: (B) Loss
of muscle contraction decreasing venous return Rationale: In clients with hemip
legia or hemiparesis loss of muscle contraction decreases venous return and may
cause swelling of the affected extremity. Contractures, or bony calcifications m
ay occur with a stroke, but don’t appear with swelling. DVT may develop in clients
with a stroke but is more likely to occur in the lower extremities. A stroke is
n’t linked to protein loss. 64. Answer: (B) It appears on the distal interphalange
al joint Rationale: Heberden’s nodes appear on the distal interphalageal joint on
both men and women. Bouchard’s node appears on the dorsolateral aspect of the prox
imal interphalangeal joint.
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65. Answer: (B) Osteoarthritis is a localized disease rheumatoid arthritis is sy
stemic Rationale: Osteoarthritis is a localized disease, rheumatoid arthritis is
systemic. Osteoarthritis isn’t gender-specific, but rheumatoid arthritis is. Clie
nts have dislocations and subluxations in both disorders. 66. Answer: (C) The ca
ne should be used on the unaffected side Rationale: A cane should be used on the
unaffected side. A client with osteoarthritis should be encouraged to ambulate
with a cane, walker, or other assistive device as needed; their use takes weight
and stress off joints. 67. Answer: (A) a. 9 U regular insulin and 21 U neutral
protamine Hagedorn (NPH). Rationale: A 70/30 insulin preparation is 70% NPH and
30% regular insulin. Therefore, a correct substitution requires mixing 21 U of N
PH and 9 U of regular insulin. The other choices are incorrect dosages for the p
rescribed insulin. 68. Answer: (C) colchicines Rationale: A disease characterize
d by joint inflammation (especially in the great toe), gout is caused by urate c
rystal deposits in the joints. The physician prescribes colchicine to reduce the
se deposits and thus ease joint inflammation. Although aspirin is used to reduce
joint inflammation and pain in clients with osteoarthritis and rheumatoid arthr
itis, it isn t indicated for gout because it has no effect on urate crystal form
ation. Furosemide, a diuretic, doesn t relieve gout. Calcium gluconate is used t
o reverse a negative calcium balance and relieve muscle cramps, not to treat gou
t. 69. Answer: (A) Adrenal cortex Rationale: Excessive secretion of aldosterone
in the adrenal cortex is responsible for the client s hypertension. This hormone
acts on the renal tubule, where it promotes reabsorption of sodium and excretio
n of potassium and hydrogen ions. The pancreas mainly secretes hormones involved
in fuel metabolism. The adrenal medulla secretes the catecholamines — epinephrine
and norepinephrine. The parathyroids secrete parathyroid hormone. 70. Answer: (
C) They debride the wound and promote healing by secondary intention Rationale:
For this client, wet-to-dry dressings are most appropriate because they clean th
e foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by
secondary intention. Moist, transparent dressings contain exudate and provide a
moist wound environment. Hydrocolloid dressings prevent the entrance of microor
ganisms and
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minimize wound discomfort. Dry sterile dressings protect the wound from mechanic
al trauma and promote healing. 71. Answer: (A) Hyperkalemia Rationale: In adrena
l insufficiency, the client has hyperkalemia due to reduced aldosterone secretio
n. BUN increases as the glomerular filtration rate is reduced. Hyponatremia is c
aused by reduced aldosterone secretion. Reduced cortisol secretion leads to impa
ired glyconeogenesis and a reduction of glycogen in the liver and muscle, causin
g hypoglycemia. 72. Answer: (C) Restricting fluids Rationale: To reduce water re
tention in a client with the SIADH, the nurse should restrict fluids. Administer
ing fluids by any route would further increase the client s already heightened f
luid load. 73. Answer: (D) glycosylated hemoglobin level. Rationale: Because som
e 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 hemoglob
in levels provide information about blood glucose levels during the previous 3 m
onths. Fasting blood glucose and urine glucose levels only give information abou
t glucose levels at the point in time when they were obtained. Serum fructosamin
e levels provide information about blood glucose control over the past 2 to 3 we
eks. 74. Answer: (C) 4:00 pm Rationale: NPH is an intermediate-acting insulin th
at 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. t
o 7 p.m. 75. Answer: (A) Glucocorticoids and androgens Rationale: The adrenal gl
ands have two divisions, the cortex and medulla. The cortex produces three types
of hormones: glucocorticoids, mineralocorticoids, and androgens. The medulla pr
oduces catecholamines — epinephrine and norepinephrine. 76. Answer: (A) Hypocalcem
ia 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 in
advertently received too much fluid; however, this can happen to any surgical cl
ient receiving I.V. fluid therapy, not just one recovering from thyroid surgery.
Hyperkalemia and
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hypermagnesemia usually are associated with reduced renal excretion of potassium
and magnesium, not thyroid surgery. 77. Answer: (D) Carcinoembryonic antigen le
vel Rationale: In clients who smoke, the level of carcinoembryonic antigen is el
evated. Therefore, it can t be used as a general indicator of cancer. However, i
t is helpful in monitoring cancer treatment because the level usually falls to n
ormal within 1 month if treatment is successful. An elevated acid phosphatase le
vel may indicate prostate cancer. An elevated alkaline phosphatase level may ref
lect bone metastasis. An elevated serum calcitonin level usually signals thyroid
cancer. 78. Answer: (B) Dyspnea, tachycardia, and pallor Rationale: Signs of ir
on-deficiency anemia include dyspnea, tachycardia, and pallor as well as fatigue
, listlessness, irritability, and headache. Night sweats, weight loss, and diarr
hea may signal acquired immunodeficiency syndrome (AIDS). Nausea, vomiting, and
anorexia may be signs of hepatitis B. Itching, rash, and jaundice may result fro
m an allergic or hemolytic reaction. 79. Answer: (D) "I ll need to have a C-sect
ion if I become pregnant and have a baby." Rationale: The human immunodeficiency
virus (HIV) is transmitted from mother to child via the transplacental route, b
ut a Cesarean section delivery isn t necessary when the mother is HIV-positive.
The use of birth control will prevent the conception of a child who might have H
IV. It s true that a mother who s HIV positive can give birth to a baby who s HI
V negative. 80. Answer: (C) "Avoid sharing such articles as toothbrushes and raz
ors." Rationale: The human immunodeficiency virus (HIV), which causes AIDS, is m
ost concentrated in the blood. For this reason, the client shouldn t share perso
nal articles that may be blood-contaminated, such as toothbrushes and razors, wi
th other family members. HIV isn t transmitted by bathing or by eating from plat
es, utensils, or serving dishes used by a person with AIDS. 81. Answer: (B) Pall
or, tachycardia, and a sore tongue Rationale: Pallor, tachycardia, and a sore to
ngue are all characteristic findings in pernicious anemia. Other clinical manife
stations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse
pressure; palpitations; angina; weakness; fatigue; and paresthesia of the hands
and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision a
ren t characteristic findings in pernicious anemia.
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82. Answer: (B) Administer epinephrine, as prescribed, and prepare to intubate t
he client if necessary. Rationale: To reverse anaphylactic shock, the nurse firs
t should administer epinephrine, a potent bronchodilator as prescribed. The phys
ician is likely to order additional medications, such as antihistamines and cort
icosteroids; if these medications don t relieve the respiratory compromise assoc
iated with anaphylaxis, the nurse should prepare to intubate the client. No anti
dote for penicillin exists; however, the nurse should continue to monitor the cl
ient s vital signs. A client who remains hypotensive may need fluid resuscitatio
n and fluid intake and output monitoring; however, administering epinephrine is
the first priority. 83. Answer: (D) bilateral hearing loss. Rationale: Prolonged
use of aspirin and other salicylates sometimes causes bilateral hearing loss of
30 to 40 decibels. Usually, this adverse effect resolves within 2 weeks after t
he therapy is discontinued. Aspirin doesn t lead to weight gain or fine motor tr
emors. Large or toxic salicylate doses may cause respiratory alkalosis, not resp
iratory acidosis. 84. Answer: (D) Lymphocyte Rationale: The lymphocyte provides
adaptive immunity — recognition of a foreign antigen and formation of memory cells
against the antigen. Adaptive immunity is mediated by B and T lymphocytes and c
an be acquired actively or passively. The neutrophil is crucial to phagocytosis.
The basophil plays an important role in the release of inflammatory mediators.
The monocyte functions in phagocytosis and monokine production. 85. Answer: (A)
moisture replacement. Rationale: Sjogren s syndrome is an autoimmune disorder le
ading to progressive loss of lubrication of the skin, GI tract, ears, nose, and
vagina. Moisture replacement is the mainstay of therapy. Though malnutrition and
electrolyte imbalance may occur as a result of Sjogren s syndrome s effect on t
he GI tract, it isn t the predominant problem. Arrhythmias aren t a problem asso
ciated with Sjogren s syndrome. 86. Answer: (C) stool for Clostridium difficile
test. Rationale: Immunosuppressed clients — for example, clients receiving chemoth
erapy, — are at risk for infection with C. difficile, which causes "horse barn" sm
elling diarrhea. Successful treatment begins with an accurate diagnosis, which i
ncludes a stool test. The ELISA test is diagnostic for human immunodeficiency vi
rus (HIV) and isn t indicated in this case. An electrolyte panel and hemogram ma
y be useful in the overall evaluation of a client but aren t diagnostic for spec
ific causes of diarrhea. A flat plate of the abdomen may provide useful informat
ion about bowel function but isn t indicated in the case of "horse barn" smellin
g diarrhea.
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87. Answer: (D) Western blot test with ELISA. Rationale: HIV infection is detect
ed by analyzing blood for antibodies to HIV, which form approximately 2 to 12 we
eks after exposure to HIV and denote infection. The Western blot test — electropho
resis of antibody proteins — is more than 98% accurate in detecting HIV antibodies
when used in conjunction with the ELISA. It isn t specific when used alone. Ero
sette immunofluorescence is used to detect viruses in general; it doesn t confir
m HIV infection. Quantification of T-lymphocytes is a useful monitoring test but
isn t diagnostic for HIV. The ELISA test detects HIV antibody particles but may
yield inaccurate results; a positive ELISA result must be confirmed by the West
ern blot test. 88. Answer: (C) Abnormally low hematocrit (HCT) and hemoglobin (H
b) levels Rationale: Low preoperative HCT and Hb levels indicate the client may
require a blood transfusion before surgery. If the HCT and Hb levels decrease du
ring surgery because of blood loss, the potential need for a transfusion increas
es. Possible renal failure is indicated by elevated BUN or creatinine levels. Ur
ine constituents aren t found in the blood. Coagulation is determined by the pre
sence of appropriate clotting factors, not electrolytes. 89. Answer: (A) Platele
t count, prothrombin time, and partial thromboplastin time Rationale: The diagno
sis of DIC is based on the results of laboratory studies of prothrombin time, pl
atelet count, thrombin time, partial thromboplastin time, and fibrinogen level a
s well as client history and other assessment factors. Blood glucose levels, WBC
count, calcium levels, and potassium levels aren t used to confirm a diagnosis
of DIC. 90. Answer: (D) Strawberries Rationale: Common food allergens include be
rries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots, and o
ranges rarely cause allergic reactions. 91. Answer: (B) A client with cast on th
e right leg who states, “I have a funny feeling in my right leg.” Rationale: It may
indicate neurovascular compromise, requires immediate assessment. 92. Answer: (D
) A 62-year-old who had an abdominal-perineal resection three days ago; client c
omplaints of chills. Rationale: The client is at risk for peritonitis; should be
assessed for further symptoms and infection.
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93. Answer: (C) The client spontaneously flexes his wrist when the blood pressur
e is obtained. Rationale: Carpal spasms indicate hypocalcemia. 94. Answer: (D) U
se 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 dialy
sate increases discomfort. The solution should be warmed to body temperature in
warmer or heating pad; don’t use microwave oven. 96. Answer: (C) The client holds
the cane with his left hand, moves the cane forward followed by the right leg, a
nd then moves the left leg. Rationale: The cane acts as a support and aids in we
ight bearing for the weaker right leg. 97. Answer: (A) Ask the woman’s family to p
rovide personal items such as photos or mementos. Rationale: Photos and mementos
provide visual stimulation to reduce sensory deprivation. 98. Answer: (B) The c
lient 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 le
gs. 99. Answer: (C) Isolation from their families and familiar surroundings. Rat
ionale: Gradual loss of sight, hearing, and taste interferes with normal functio
ning. 100. Answer: (A) Encourage the client to perform pursed lip breathing. Rat
ionale: 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 feve
r, and tenderness over the grafted kidney, reflects acute rejection. 2. Answer:
(A) Pain Rationale: Sharp, severe pain (renal colic) radiating toward the genita
lia 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 t
he thyroid gland. Rationale: Lugol’s solution provides iodine, which aids in decre
asing the vascularity of the thyroid gland, which limits the risk of hemorrhage
when surgery is performed. 4. Answer: (A) Liver Disease Rationale: The client wi
th liver disease has a decreased ability to metabolize carbohydrates because of
a decreased ability to form glycogen (glycogenesis) and to form glucose from gly
cogen. 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 p
erson preoperatively will continue to do so after a colostomy. 7. Answer: (B) Ke
ep 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 p
eristalsis is not immediately precipitated. 8. Answer: (A) Administer Kayexalate
Rationale: Kayexalate,a potassium exchange resin, permits sodium to be exchange
d 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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10. Answer: (D) Upper trunk Rationale: The percentage designated for each burned
part of the body using the rule of nines: Head and neck 9%; Right upper extremi
ty 9%; Left upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right l
ower extremity 18%; Left lower extremity 18%; Perineum 1%. 11. Answer: (C) Bleed
ing from ears Rationale: The nurse needs to perform a thorough assessment that c
ould indicate alterations in cerebral function, increased intracranial pressures
, fractures and bleeding. Bleeding from the ears occurs only with basal skull fr
actures that can easily contribute to increased intracranial pressure and brain
herniation. 12. Answer: (D) may engage in contact sports Rationale: The client s
hould be advised by the nurse to avoid contact sports. This will prevent trauma
to the area of the pacemaker generator. 13. Answer: (A) Oxygen at 1-2L/min is gi
ven to maintain the hypoxic stimulus for breathing. Rationale: COPD causes a chr
onic CO2 retention that renders the medulla insensitive to the CO2 stimulation f
or breathing. The hypoxic state of the client then becomes the stimulus for brea
thing. Giving the client oxygen in low concentrations will maintain the client’s h
ypoxic drive. 14. Answer: (B) Facilitate ventilation of the left lung. Rationale
: Since only a partial pneumonectomy is done, there is a need to promote expansi
on of this remaining Left lung by positioning the client on the opposite unopera
ted side. 15. Answer: (A) Food and fluids will be withheld for at least 2 hours.
Rationale: Prior to bronchoscopy, the doctors sprays the back of the throat wit
h anesthetic to minimize the gag reflex and thus facilitate the insertion of the
bronchoscope. Giving the client food and drink after the procedure without chec
king on the return of the gag reflex can cause the client to aspirate. The gag r
eflex usually returns after two hours. 16. Answer: (C) hyperkalemia. Rationale:
Hyperkalemia is a common complication of acute renal failure. It s life-threaten
ing if immediate action isn t taken to reverse it. The administration of glucose
and regular insulin, with sodium bicarbonate if necessary, can temporarily prev
ent cardiac arrest by moving potassium into the cells and temporarily reducing s
erum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don t usual
ly occur with acute renal failure and aren t treated with glucose, insulin, or s
odium bicarbonate.
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17. Answer: (A) This condition puts her at a higher risk for cervical cancer; th
erefore, she should have a Papanicolaou (Pap) smear annually. Rationale: Women w
ith condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly
Pap smears are very important for early detection. Because condylomata acuminat
a is a virus, there is no permanent cure. Because condylomata acuminata can occu
r on the vulva, a condom won t protect sexual partners. HPV can be transmitted t
o 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 2¼") wide, and 2.5 cm (1") thick. The kidneys are located
retroperitoneally, in the posterior aspect of the abdomen, on either side of th
e 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 crea
tinine level ranges from 0.7 to 1.5 mg/dl. The test results in option C are abno
rmally elevated, reflecting CRF and the kidneys decreased ability to remove non
protein nitrogen waste from the blood. CRF causes decreased pH and increased hyd
rogen ions — not vice versa. CRF also increases serum levels of potassium, magnesi
um, 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 o
f 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: Dysplas
ia refers to an alteration in the size, shape, and organization of differentiate
d cells. The presence of completely undifferentiated tumor cells that don t rese
mble cells of the tissues of their origin is called anaplasia. An increase in th
e number of normal cells in a normal arrangement in a tissue or an organ is call
ed 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 canc
er 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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Rationale: The client receiving a subarachnoid block requires special positionin
g to prevent CSF leakage and headache and to ensure proper anesthetic distributi
on. Proper positioning doesn t help prevent confusion, seizures, or cardiac arrh
ythmias. 23. Answer: (A) Auscultate bowel sounds. Rationale: If abdominal disten
tion is accompanied by nausea, the nurse must first auscultate bowel sounds. If
bowel sounds are absent, the nurse should suspect gastric or small intestine dil
ation and these findings must be reported to the physician. Palpation should be
avoided postoperatively with abdominal distention. If peristalsis is absent, cha
nging positions and inserting a rectal tube won t relieve the client s discomfor
t. 24. Answer: (B) Lying on the left side with knees bent Rationale: For a colon
oscopy, the nurse initially should position the client on the left side with kne
es bent. Placing the client on the right side with legs straight, prone with the
torso elevated, or bent over with hands touching the floor wouldn t allow prope
r visualization of the large intestine. 25. Answer: (A) Blood supply to the stom
a has been interrupted Rationale: An ileostomy stoma forms as the ileum is broug
ht through the abdominal wall to the surface skin, creating an artificial openin
g for waste elimination. The stoma should appear cherry red, indicating adequate
arterial perfusion. A dusky stoma suggests decreased perfusion, which may resul
t from interruption of the stoma s blood supply and may lead to tissue damage or
necrosis. A dusky stoma isn t a normal finding. Adjusting the ostomy bag wouldn
t affect stoma color, which depends on blood supply to the area. An intestinal
obstruction also wouldn t change stoma color. 26. Answer: (A) Applying knee spli
nts Rationale: Applying knee splints prevents leg contractures by holding the jo
ints in a position of function. Elevating the foot of the bed can t prevent cont
ractures because this action doesn t hold the joints in a position of function.
Hyperextending a body part for an extended time is inappropriate because it can
cause contractures. Performing shoulder range-of-motion exercises can prevent co
ntractures in the shoulders, but not in the legs. 27. Answer: (B) Urine output o
f 20 ml/hour. Rationale: A urine output of less than 40 ml/hour in a client with
burns indicates a fluid volume deficit. This client s PaO2 value falls within t
he normal range (80 to 100 mm Hg). White pulmonary secretions also are normal. T
he client s rectal temperature isn t significantly elevated and probably results
from the fluid volume deficit. 28. Answer: (A) Turn him frequently.
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Rationale: The most important intervention to prevent pressure ulcers is frequen
t position changes, which relieve pressure on the skin and underlying tissues. I
f pressure isn t relieved, capillaries become occluded, reducing circulation and
oxygenation of the tissues and resulting in cell death and ulcer formation. Dur
ing passive ROM exercises, the nurse moves each joint through its range of movem
ent, which improves joint mobility and circulation to the affected area but does
n t prevent pressure ulcers. Adequate hydration is necessary to maintain healthy
skin and ensure tissue repair. A footboard prevents plantar flexion and footdro
p by maintaining the foot in a dorsiflexed position. 29. Answer: (C) In long, ev
en, outward, and downward strokes in the direction of hair growth Rationale: Whe
n applying a topical agent, the nurse should begin at the midline and use long,
even, outward, and downward strokes in the direction of hair growth. This applic
ation pattern reduces the risk of follicle irritation and skin inflammation. 30.
Answer: (A) Beta -adrenergic blockers Rationale: Beta-adrenergic blockers work
by blocking beta receptors in the myocardium, reducing the response to catechola
mines and sympathetic nerve stimulation. They protect the myocardium, helping to
reduce the risk of another infraction by decreasing myocardial oxygen demand. C
alcium channel blockers reduce the workload of the heart by decreasing the heart
rate. Narcotics reduce myocardial oxygen demand, promote vasodilation, and decr
ease anxiety. Nitrates reduce myocardial oxygen consumption bt decreasing left v
entricular end diastolic pressure (preload) and systemic vascular resistance (af
terload). 31. Answer: (C) Raised 30 degrees Rationale: Jugular venous pressure i
s measured with a centimeter ruler to obtain the vertical distance between the s
ternal angle and the point of highest pulsation with the head of the bed incline
d between 15 to 30 degrees. Increased pressure can’t be seen when the client is su
pine or when the head of the bed is raised 10 degrees because the point that mar
ks the pressure level is above the jaw (therefore, not visible). In high Fowler’s
position, the veins would be barely discernible above the clavicle. 32. Answer:
(D) Inotropic agents Rationale: Inotropic agents are administered to increase th
e force of the heart’s contractions, thereby increasing ventricular contractility
and ultimately increasing cardiac output. Beta-adrenergic blockers and calcium c
hannel blockers decrease the heart rate and ultimately decreased the workload of
the heart. Diuretics are administered to decrease the overall vascular volume,
also decreasing the workload of the heart.
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33. Answer: (B) Less than 30% of calories form fat Rationale: A client with low
serum HDL and high serum LDL levels should get less than 30% of daily calories f
rom fat. The other modifications are appropriate for this client. 34. Answer: (C
) The emergency department nurse calls up the latest electrocardiogram results t
o check the client’s progress Rationale: The emergency department nurse is no long
er directly involved with the client’s care and thus has no legal right to informa
tion about his present condition. Anyone directly involved in his care (such as
the telemetry nurse and the on-call physician) has the right to information abou
t his condition. Because the client requested that the nurse update his wife on
his condition, doing so doesn’t breach confidentiality. 35. Answer: (B) Check endo
tracheal tube placement. Rationale: ET tube placement should be confirmed as soo
n as the client arrives in the emergency department. Once the airways is secured
, oxygenation and ventilation should be confirmed using an end-tidal carbon diox
ide monitor and pulse oximetry. Next, the nurse should make sure L.V. access is
established. If the client experiences symptomatic bradycardia, atropine is admi
nistered as ordered 0.5 to 1 mg every 3 to 5 minutes to a total of 3 mg. Then th
e nurse should try to find the cause of the client’s arrest by obtaining an ABG sa
mple. Amiodarone is indicated for ventricular tachycardia, ventricular fibrillat
ion and atrial flutter – not symptomatic bradycardia. 36. Answer: (C) 95 mm Hg Rat
ionale: Use the following formula to calculate MAP MAP = systolic + 2 (diastolic
) 3 MAP=126 mm Hg + 2 (80 mm Hg) 3 MAP=286 mm HG 3 MAP=95 mm Hg 37. Answer: (C)
Electrocardiogram, complete blood count, testing for occult blood, comprehensive
serum metabolic panel. Rationale: An electrocardiogram evaluates the complaints
of chest pain, laboratory tests determines anemia, and the stool test for occul
t blood determines blood in the stool. Cardiac monitoring, oxygen, and creatine
kinase and lactate dehydrogenase levels are appropriate for a cardiac primary pr
oblem. A basic metabolic panel and alkaline phosphatase and aspartate aminotrans
ferase levels assess liver function. Prothrombin time, partial thromboplastin ti
me, fibrinogen and fibrin split products are
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measured to verify bleeding dyscrasias, An electroencephalogram evaluates brain
electrical activity. 38. Answer: (D) Heparin-associated thrombosis and thrombocy
topenia (HATT) Rationale: HATT may occur after CABG surgery due to heparin use d
uring surgery. Although DIC and ITP cause platelet aggregation and bleeding, nei
ther is common in a client after revascularization surgery. Pancytopenia is a re
duction in all blood cells. 39. Answer: (B) Corticosteroids Rationale: Corticost
eroid therapy can decrease antibody production and phagocytosis of the antibody-
coated platelets, retaining more functioning platelets. Methotrexate can cause t
hrombocytopenia. Vitamin K is used to treat an excessive anticoagulate state fro
m warfarin overload, and ASA decreases platelet aggregation. 40. Answer: (D) Xen
ogeneic Rationale: An xenogeneic transplant is between is between human and anot
her species. A syngeneic transplant is between identical twins, allogeneic trans
plant is between two humans, and autologous is a transplant from the same indivi
dual. 41. Answer: (B) Rationale: Tissue thromboplastin is released when damaged
tissue comes in contact with clotting factors. Calcium is released to assist the
conversion of factors X to Xa. Conversion of factors XII to XIIa and VIII to VI
IIa are part of the intrinsic pathway. 42. Answer: (C) Essential thrombocytopeni
a Rationale: Essential thrombocytopenia is linked to immunologic disorders, such
as SLE and human immunodeficiency vitus. The disorder known as von Willebrand’s d
isease is a type of hemophilia and isn’t linked to SLE. Moderate to severe anemia
is associated with SLE, not polycythermia. Dressler’s syndrome is pericarditis tha
t occurs after a myocardial infarction and isn’t linked to SLE. 43. Answer: (B) Ni
ght sweat Rationale: In stage 1, symptoms include a single enlarged lymph node (
usually), unexplained fever, night sweats, malaise, and generalized pruritis. Al
though splenomegaly may be present in some clients, night sweats are generally m
ore prevalent. Pericarditis isn’t associated with Hodgkin’s disease, nor is hypother
mia. Moreover, splenomegaly and pericarditis aren’t symptoms. Persistent hypotherm
ia is associated with Hodgkin’s but isn’t an early sign of the disease.
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44. Answer: (D) Breath sounds Rationale: Pneumonia, both viral and fungal, is a
common cause of death in clients with neutropenia, so frequent assessment of res
piratory rate and breath sounds is required. Although assessing blood pressure,
bowel sounds, and heart sounds is important, it won’t help detect pneumonia. 45. A
nswer: (B) Muscle spasm Rationale: Back pain or paresthesia in the lower extremi
ties may indicate impending spinal cord compression from a spinal tumor. This sh
ould be recognized and treated promptly as progression of the tumor may result i
n paraplegia. The other options, which reflect parts of the nervous system, aren’t
usually affected by MM. 46. Answer: (C)10 years Rationale: Epidermiologic studi
es show the average time from initial contact with HIV to the development of AID
S is 10 years. 47. Answer: (A) Low platelet count Rationale: In DIC, platelets a
nd clotting factors are consumed, resulting in microthrombi and excessive bleedi
ng. As clots form, fibrinogen levels decrease and the prothrombin time increases
. Fibrin degeneration products increase as fibrinolysis takes places. 48. Answer
: (D) Hodgkin’s disease Rationale: Hodgkin’s disease typically causes fever night sw
eats, weight loss, and lymph mode enlargement. Influenza doesn’t last for months.
Clients with sickle cell anemia manifest signs and symptoms of chronic anemia wi
th pallor of the mucous membrane, fatigue, and decreased tolerance for exercise;
they don’t show fever, night sweats, weight loss or lymph node enlargement. Leuke
mia doesn’t cause lymph node enlargement. 49. Answer: (C) A Rh-negative Rationale:
Human blood can sometimes contain an inherited D antigen. Persons with the D an
tigen have Rh-positive blood type; those lacking the antigen have Rh-negative bl
ood. It’s important that a person with Rhnegative blood receives Rh-negative blood
. If Rh-positive blood is administered to an Rh-negative person, the recipient d
evelops anti-Rh agglutinins, and sub sequent transfusions with Rh-positive blood
may cause serious reactions with clumping and hemolysis of red blood cells. 50.
Answer: (B) “I will call my doctor if Stacy has persistent vomiting and diarrhea”.
Rationale: Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are
signs of toxicity and the patient should stop the medication
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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-gr
ow new hair in 3-6 months, but may be different in texture”. Rationale: This is th
e appropriate response. The nurse should help the mother how to cope with her ow
n feelings regarding the child’s disease so as not to affect the child negatively.
When the hair grows back, it is still of the same color and texture. 52. Answer
: (B) Apply viscous Lidocaine to oral ulcers as needed. Rationale: Stomatitis ca
n cause pain and this can be relieved by applying topical anesthetics such as li
docaine before mouth care. When the patient is already comfortable, the nurse ca
n proceed with providing the patient with oral rinses of saline solution mixed w
ith equal part of water or hydrogen peroxide mixed water in 1:3 concentrations t
o 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 nee
dle has been dislodged and the IV solution is leaking into the tissues causing t
he 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) Chr
onic obstructive bronchitis Rationale: Clients with chronic obstructive bronchit
is appear bloated; they have large barrel chest and peripheral edema, cyanotic n
ail beds, and at times, circumoral cyanosis. Clients with ARDS are acutely short
of breath and frequently need intubation for mechanical ventilation and large a
mount of oxygen. Clients with asthma don’t exhibit characteristics of chronic dise
ase, and clients with emphysema appear pink and cachectic. 55. Answer: (D) Emphy
sema Rationale: Because of the large amount of energy it takes to breathe, clien
ts with emphysema are usually cachectic. They’re pink and usually breathe through
pursed lips, hence the term “puffer.” Clients with ARDS are usually acutely short of
breath. Clients with asthma don’t have any particular characteristics, and client
s 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 wil
l have inefficient ventilation and will be retaining carbon dioxide. The value e
xpected would be around 80 mm Hg. All other values are lower than expected.
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57. Answer: (C) Respiratory acidosis Rationale: Because Paco2 is high at 80 mm H
g and the metabolic measure, HCO3- is normal, the client has respiratory acidosi
s. The pH is less than 7.35, academic, which eliminates metabolic and respirator
y alkalosis as possibilities. If the HCO3- was below 22 mEq/L the client would h
ave metabolic acidosis. 58. Answer: (C) Respiratory failure Rationale: The clien
t was reacting to the drug with respiratory signs of impending anaphylaxis, whic
h could lead to eventually respiratory failure. Although the signs are also rela
ted to an asthma attack or a pulmonary embolism, consider the new drug first. Rh
eumatoid arthritis doesn’t manifest these signs. 59. Answer: (D) Elevated serum am
inotransferase Rationale: Hepatic cell death causes release of liver enzymes ala
nine aminotransferase (ALT), aspartate aminotransferase (AST) and lactate dehydr
ogenase (LDH) into the circulation. Liver cirrhosis is a chronic and irreversibl
e disease of the liver characterized by generalized inflammation and fibrosis of
the liver tissues. 60. Answer: (A) Impaired clotting mechanism Rationale: Cirrh
osis of the liver results in decreased Vitamin K absorption and formation of clo
tting factors resulting in impaired clotting mechanism. 61. Answer: (B) Altered
level of consciousness Rationale: Changes in behavior and level of consciousness
are the first sins of hepatic encephalopathy. Hepatic encephalopathy is caused
by liver failure and develops when the liver is unable to convert protein metabo
lic product ammonia to urea. This results in accumulation of ammonia and other t
oxic in the blood that damages the cells. 62. Answer: (C) “I’ll lower the dosage as
ordered so the drug causes only 2 to 4 stools a day”. Rationale: Lactulose is give
n to a patients with hepatic encephalopathy to reduce absorption of ammonia in t
he intestines by binding with ammonia and promoting more frequent bowel movement
s. If the patient experience diarrhea, it indicates over dosage and the nurse mu
st reduce the amount of medication given to the patient. The stool will be mashy
or soft. Lactulose is also very sweet and may cause cramping and bloating. 63.
Answer: (B) Severe lower back pain, decreased blood pressure, decreased RBC coun
t, increased WBC count. Rationale: Severe lower back pain indicates an aneurysm
rupture, secondary to pressure being applied within the abdominal cavity. When r
uptured occurs, the pain is constant because it can’t be alleviated until
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the aneurysm is repaired. Blood pressure decreases due to the loss of blood. Aft
er the aneurysm ruptures, the vasculature is interrupted and blood volume is los
t, so blood pressure wouldn’t increase. For the same reason, the RBC count is decr
eased – not increased. The WBC count increases as cell migrate to the site of inju
ry. 64. Answer: (D) Apply gloves and assess the groin site Rationale: Observing
standard precautions is the first priority when dealing with any blood fluid. As
sessment of the groin site is the second priority. This establishes where the bl
ood is coming from and determines how much blood has been lost. The goal in this
situation is to stop the bleeding. The nurse would call for help if it were war
ranted after the assessment of the situation. After determining the extent of th
e bleeding, vital signs assessment is important. The nurse should never move the
client, in case a clot has formed. Moving can disturb the clot and cause reblee
ding. 65. Answer: (D) Percutaneous transluminal coronary angioplasty (PTCA) Rati
onale: PTCA can alleviate the blockage and restore blood flow and oxygenation. A
n echocardiogram is a noninvasive diagnosis test. Nitroglycerin is an oral subli
ngual medication. Cardiac catheterization is a diagnostic tool – not a treatment.
66. Answer: (B) Cardiogenic shock Rationale: Cardiogenic shock is shock related
to ineffective pumping of the heart. Anaphylactic shock results from an allergic
reaction. Distributive shock results from changes in the intravascular volume d
istribution and is usually associated with increased cardiac output. MI isn’t a sh
ock state, though a severe MI can lead to shock. 67. Answer: (C) Kidneys’ excretio
n of sodium and water Rationale: The kidneys respond to rise in blood pressure b
y excreting sodium and excess water. This response ultimately affects sysmolic b
lood pressure by regulating blood volume. Sodium or water retention would only f
urther increase blood pressure. Sodium and water travel together across the memb
rane in the kidneys; one can’t travel without the other. 68. Answer: (D) It inhibi
ts reabsorption of sodium and water in the loop of Henle. Rationale: Furosemide
is a loop diuretic that inhibits sodium and water reabsorption in the loop Henle
, thereby causing a decrease in blood pressure. Vasodilators cause dilation of p
eripheral blood vessels, directly relaxing vascular smooth muscle and decreasing
blood pressure. Adrenergic blockers decrease sympathetic cardioacceleration and
decrease blood pressure. Angiotensin-converting enzyme inhibitors decrease bloo
d pressure due to their action on angiotensin.
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69. Answer: (C) Pancytopenia, elevated antinuclear antibody (ANA) titer Rational
e: Laboratory findings for clients with SLE usually show pancytopenia, elevated
ANA titer, and decreased serum complement levels. Clients may have elevated BUN
and creatinine levels from nephritis, but the increase does not indicate SLE. 70
. Answer: (C) Narcotics are avoided after a head injury because they may hide a
worsening condition. Rationale: Narcotics may mask changes in the level of consc
iousness that indicate increased ICP and shouldn’t acetaminophen is strong enough
ignores the mother’s question and therefore isn’t appropriate. Aspirin is contraindi
cated in conditions that may have bleeding, such as trauma, and for children or
young adults with viral illnesses due to the danger of Reye’s syndrome. Stronger m
edications may not necessarily lead to vomiting but will sedate the client, ther
eby masking changes in his level of consciousness. 71. Answer: (A) Appropriate;
lowering carbon dioxide (CO2) reduces intracranial pressure (ICP) Rationale: A n
ormal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating properties; therefore,
lowering Paco2 through hyperventilation will lower ICP caused by dilated cerebra
l vessels. Oxygenation is evaluated through Pao2 and oxygen saturation. Alveolar
hypoventilation would be reflected in an increased Paco2. 72. Answer: (B) A 33-
year-old client with a recent diagnosis of Guillain-Barre syndrome Rationale: Gu
illain-Barre syndrome is characterized by ascending paralysis and potential resp
iratory failure. The order of client assessment should follow client priorities,
with disorder of airways, breathing, and then circulation. There’s no information
to suggest the postmyocardial infarction client has an arrhythmia or other comp
lication. There’s no evidence to suggest hemorrhage or perforation for the remaini
ng clients as a priority of care. 73. Answer: (C) Decreases inflammation Rationa
le: Then action of colchicines is to decrease inflammation by reducing the migra
tion of leukocytes to synovial fluid. Colchicine doesn’t replace estrogen, decreas
e infection, or decrease bone demineralization. 74. Answer: (C) Osteoarthritis i
s the most common form of arthritis Rationale: Osteoarthritis is the most common
form of arthritis and can be extremely debilitating. It can afflict people of a
ny age, although most are elderly. 75. Answer: (C) Myxedema coma
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Rationale: Myxedema coma, severe hypothyroidism, is a life-threatening condition
that may develop if thyroid replacement medication isn t taken. Exophthalmos, p
rotrusion of the eyeballs, is seen with hyperthyroidism. Thyroid storm is life-t
hreatening but is caused by severe hyperthyroidism. Tibial myxedema, peripheral
mucinous edema involving the lower leg, is associated with hypothyroidism but is
n t life-threatening. 76. Answer: (B) An irregular apical pulse Rationale: Becau
se Cushing s syndrome causes aldosterone overproduction, which increases urinary
potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse shou
ld immediately report signs and symptoms of hypokalemia, such as an irregular ap
ical pulse, to the physician. Edema is an expected finding because aldosterone o
verproduction causes sodium and fluid retention. Dry mucous membranes and freque
nt urination signal dehydration, which isn t associated with Cushing s syndrome.
77. Answer: (D) Below-normal urine osmolality level, above-normal serum osmolal
ity level Rationale: In diabetes insipidus, excessive polyuria causes dilute uri
ne, resulting in a below-normal urine osmolality level. At the same time, polyur
ia depletes the body of water, causing dehydration that leads to an above-normal
serum osmolality level. For the same reasons, diabetes insipidus doesn t cause
above-normal urine osmolality or below-normal serum osmolality levels. 78. Answe
r: (A) "I can avoid getting sick by not becoming dehydrated and by paying attent
ion to my need to urinate, drink, or eat more than usual." Rationale: Inadequate
fluid intake during hyperglycemic episodes often leads to HHNS. By recognizing
the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing
fluid intake, the client may prevent HHNS. Drinking a glass of nondiet soda wou
ld be appropriate for hypoglycemia. A client whose diabetes is controlled with o
ral antidiabetic agents usually doesn t need to monitor blood glucose levels. A
highcarbohydrate diet would exacerbate the client s condition, particularly if f
luid intake is low. 79. Answer: (D) Hyperparathyroidism Rationale: Hyperparathyr
oidism is most common in older women and is characterized by bone pain and weakn
ess from excess parathyroid hormone (PTH). Clients also exhibit hypercaliuria-ca
using polyuria. While clients with diabetes mellitus and diabetes insipidus also
have polyuria, they don t have bone pain and increased sleeping. Hypoparathyroi
dism is characterized by urinary frequency rather than polyuria.
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80. Answer: (C) "I ll take two-thirds of the dose when I wake up and one-third i
n the late afternoon." Rationale: Hydrocortisone, a glucocorticoid, should be ad
ministered according to a schedule that closely reflects the body s own secretio
n 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 le
vels Rationale: A corticotropin-secreting pituitary tumor would cause high corti
cotropin and high cortisol levels. A high corticotropin level with a low cortiso
l level and a low corticotropin level with a low cortisol level would be associa
ted with hypocortisolism. Low corticotropin and high cortisol levels would be se
en if there was a primary defect in the adrenal glands. 82. Answer: (D) Performi
ng capillary glucose testing every 4 hours Rationale: The nurse should perform c
apillary 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. Temperatur
e 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 ho
rmone (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 hypert
hyroidism. A decreased TSH level indicates a pituitary deficiency of this hormon
e. Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hyp
othyroidism. A below-normal T4 level also occurs in malnutrition and liver disea
se and may result from administration of phenytoin and certain other drugs. 85.
Answer: (B) "Rotate injection sites within the same anatomic region, not among d
ifferent regions." Rationale: The nurse should instruct the client to rotate inj
ection sites within the same anatomic region. Rotating sites among different reg
ions 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 sca
r tissue or other deviations. Injecting insulin into areas of hypertrophy may de
lay absorption. The client shouldn t inject insulin into areas of lipodystrophy
(such as hypertrophy or atrophy); to prevent lipodystrophy, the client should ro
tate injection sites systematically. Exercise speeds drug absorption, so the cli
ent shouldn t inject insulin into sites above muscles that will be exercised hea
vily. 86. Answer: (D) Below-normal serum potassium level Rationale: A client wit
h HHNS has an overall body deficit of potassium resulting from diuresis, which o
ccurs 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-nor
mal range Rationale: Graves disease causes signs and symptoms of hypermetabolis
m, such as heat intolerance, diaphoresis, excessive thirst and appetite, and wei
ght 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 di
aphoresis, the nurse should encourage, not restrict, intake of oral fluids. Plac
ing extra blankets on the bed of a client with heat intolerance would cause disc
omfort. To provide needed energy and calories, the nurse should encourage the cl
ient to eat high-carbohydrate foods. 88. Answer: (A) Fracture of the distal radi
us 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 does
n t refer to a fracture of the olecranon, humerus, or carpal scaphoid. 89. Answe
r: (B) Calcium and phosphorous Rationale: In osteoporosis, bones lose calcium an
d phosphate salts, becoming porous, brittle, and abnormally vulnerable to fractu
re. Sodium and potassium aren t involved in the development of osteoporosis. 90.
Answer: (A) Adult respiratory distress syndrome (ARDS) Rationale: Severe hypoxi
a after smoke inhalation is typically related to ARDS. The other conditions list
ed aren’t typically associated with smoke inhalation and severe hypoxia. 91. Answe
r: (D) Fat embolism Rationale: Long bone fractures are correlated with fat embol
i, which cause shortness of breath and hypoxia. It’s unlikely the client has
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developed asthma or bronchitis without a previous history. He could develop atel
ectasis but it typically doesn’t produce progressive hypoxia. 92. Answer: (D) Spon
taneous pneumothorax Rationale: A spontaneous pneumothorax occurs when the clien
t’s lung collapses, causing an acute decreased in the amount of functional lung us
ed in oxygenation. The sudden collapse was the cause of his chest pain and short
ness of breath. An asthma attack would show wheezing breath sounds, and bronchit
is would have rhonchi. Pneumonia would have bronchial breath sounds over the are
a of consolidation. 93. Answer: (C) Pneumothorax Rationale: From the trauma the
client experienced, it’s unlikely he has bronchitis, pneumonia, or TB; rhonchi wit
h bronchitis, bronchial breath sounds with TB would be heard. 94. Answer: (C) Se
rous fluids fills the space and consolidates the region Rationale: Serous fluid
fills the space and eventually consolidates, preventing extensive mediastinal sh
ift of the heart and remaining lung. Air can’t be left in the space. There’s no gel
that can be placed in the pleural space. The tissue from the other lung can’t cros
s the mediastinum, although a temporary mediastinal shift exits until the space
is filled. 95. Answer: (A) Alveolar damage in the infracted area Rationale: The
infracted area produces alveolar damage that can lead to the production of blood
y sputum, sometimes in massive amounts. Clot formation usually occurs in the leg
s. There’s a loss of lung parenchyma and subsequent scar tissue formation. 96. Ans
wer: (D) Respiratory alkalosis Rationale: A client with massive pulmonary emboli
sm will have a large region and blow off large amount of carbon dioxide, which c
rosses the unaffected alveolar-capillary membrane more readily than does oxygen
and results in respiratory alkalosis. 97. Answer: (A) Air leak Rationale: Bubbli
ng in the water seal chamber of a chest drainage system stems from an air leak.
In pneumothorax an air leak can occur as air is pulled from the pleural space. B
ubbling doesn’t normally occur with either adequate or inadequate suction or any p
reexisting bubbling in the water seal chamber. 98. Answer: (B) 21 Rationale: 300
0 x 10 divided by 24 x 60. 99. Answer: (B) 2.4 ml
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Rationale: .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml. 100. Answer: (D) “I
should put on the stockings before getting out of bed in the morning. Rationale
: Promote venous return by applying external pressure on veins.
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TEST V Answers and Rationale – Care of Clients with Physiologic and Psychosocial A
lterations 1. Answer: (D) Focusing Rationale: The nurse is using focusing by sug
gesting that the client discuss a specific issue. The nurse didn’t restate the que
stion, make observation, or ask further question (exploring). 2. Answer: (D) Rem
ove all other clients from the dayroom. Rationale: The nurse’s first priority is t
o consider the safety of the clients in the therapeutic setting. The other actio
ns are appropriate responses after ensuring the safety of other clients. 3. Answ
er: (A) The client is disruptive. Rationale: Group activity provides too much st
imulation, 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 mot
her and the father together. Rationale: By agreeing to talk with both parents, t
he nurse can provide emotional support and further assess and validate the famil
y’s needs. 5. Answer: (A) Perceptual disorders. Rationale: Frightening visual hall
ucinations are especially common in clients experiencing alcohol withdrawal. 6.
Answer: (D) Suggest that it takes awhile before seeing the results. Rationale: T
he client needs a specific response; that it takes 2 to 3 weeks (a delayed effec
t) until the therapeutic blood level is reached. 7. Answer: (C) Superego Rationa
le: This behavior shows a weak sense of moral consciousness. According to Freudi
an theory, personality disorders stem from a weak superego. 8. Answer: (C) Skele
tal muscle paralysis. Rationale: Anectine is a depolarizing muscle relaxant caus
ing 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 w
hat is burned up (usually via carbohydrates).
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10. Answer: (C) Acting overly solicitous toward the child. Rationale: This behav
ior is an example of reaction formation, a coping mechanism. 11. Answer: (A) By
designating times during which the client can focus on the behavior. Rationale:
The nurse should designate times during which the client can focus on the compul
sive behavior or obsessive thoughts. The nurse should urge the client to reduce
the frequency of the compulsive behavior gradually, not rapidly. She shouldn t c
all attention to or try to prevent the behavior. Trying to prevent the behavior
may cause pain and terror in the client. The nurse should encourage the client t
o verbalize anxieties to help distract attention from the compulsive behavior. 1
2. Answer: (D) Exploring the meaning of the traumatic event with the client. Rat
ionale: The client with PTSD needs encouragement to examine and understand the m
eaning of the traumatic event and consequent losses. Otherwise, symptoms may wor
sen and the client may become depressed or engage in self-destructive behavior s
uch as substance abuse. The client must explore the meaning of the event and won
t heal without this, no matter how much time passes. Behavioral techniques, suc
h as relaxation therapy, may help decrease the client s anxiety and induce sleep
. The physician may prescribe antianxiety agents or antidepressants cautiously t
o avoid dependence; sleep medication is rarely appropriate. A special diet isn t
indicated unless the client also has an eating disorder or a nutritional proble
m. 13. Answer: (C) "Your problem is real but there is no physical basis for it.
We ll work on what is going on in your life to find out why it s happened." Rati
onale: The nurse must be honest with the client by telling her that the paralysi
s has no physiologic cause while also conveying empathy and acknowledging that h
er symptoms are real. The client will benefit from psychiatric treatment, which
will help her understand the underlying cause of her symptoms. After the psychol
ogical conflict is resolved, her symptoms will disappear. Saying that it must be
awful not to be able to move her legs wouldn t answer the client s question; kn
owing that the cause is psychological wouldn t necessarily make her feel better.
Telling her that she has developed paralysis to avoid leaving her parents or th
at her personality caused her disorder wouldn t help her understand and resolve
the underlying conflict. 14. Answer: (C) fluvoxamine (Luvox) and clomipramine (A
nafranil) Rationale: The antidepressants fluvoxamine and clomipramine have been
effective in the treatment of OCD. Librium and Valium may be helpful in treating
anxiety related to OCD but aren t drugs of choice to treat the
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illness. The other medications mentioned aren t effective in the treatment of OC
D. 15. Answer: (A) A warning about the drugs delayed therapeutic effect, which i
s from 14 to 30 days. Rationale: The client should be informed that the drug s t
herapeutic effect might not be reached for 14 to 30 days. The client must be ins
tructed to continue taking the drug as directed. Blood level checks aren t neces
sary. NMS hasn t been reported with this drug, but tachycardia is frequently rep
orted. 16. Answer: (B) Severe anxiety and fear. Rationale: Phobias cause severe
anxiety (such as a panic attack) that is out of proportion to the threat of the
feared object or situation. Physical signs and symptoms of phobias include profu
se sweating, poor motor control, tachycardia, and elevated blood pressure. Insom
nia, an inability to concentrate, and weight loss are common in depression. With
drawal and failure to distinguish reality from fantasy occur in schizophrenia. 1
7. Answer: (A) Antidepressants Rationale: Tricyclic and monoamine oxidase (MAO)
inhibitor antidepressants have been found to be effective in treating clients wi
th panic attacks. Why these drugs help control panic attacks isn t clearly under
stood. Anticholinergic agents, which are smooth-muscle relaxants, relieve physic
al symptoms of anxiety but don t relieve the anxiety itself. Antipsychotic drugs
are inappropriate because clients who experience panic attacks aren t psychotic
. Mood stabilizers aren t indicated because panic attacks are rarely associated
with mood changes. 18. Answer: (B) 3 to 5 days Rationale: Monoamine oxidase inhi
bitors, such as tranylcypromine, have an onset of action of approximately 3 to 5
days. A full clinical response may be delayed for 3 to 4 weeks. The therapeutic
effects may continue for 1 to 2 weeks after discontinuation. 19. Answer: (B) Pr
oviding emotional support and individual counseling. Rationale: Clients in the f
irst stage of Alzheimer s disease are aware that something is happening to them
and may become overwhelmed and frightened. Therefore, nursing care typically foc
uses on providing emotional support and individual counseling. The other options
are appropriate during the second stage of Alzheimer s disease, when the client
needs continuous monitoring to prevent minor illnesses from progressing into ma
jor problems and when maintaining adequate nutrition may become a challenge. Dur
ing this stage, offering nourishing finger foods helps clients to feed themselve
s and maintain adequate nutrition.
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20. Answer: (C) Emotional lability, euphoria, and impaired memory Rationale: Sig
ns of antianxiety agent overdose include emotional lability, euphoria, and impai
red memory. Phencyclidine overdose can cause combativeness, sweating, and confus
ion. Amphetamine overdose can result in agitation, hyperactivity, and grandiose
ideation. Hallucinogen overdose can produce suspiciousness, dilated pupils, and
increased blood pressure. 21. Answer: (D) A low tolerance for frustration Ration
ale: Clients with an antisocial personality disorder exhibit a low tolerance for
frustration, emotional immaturity, and a lack of impulse control. They commonly
have a history of unemployment, miss work repeatedly, and quit work without oth
er plans for employment. They don t feel guilt about their behavior and commonly
perceive themselves as victims. They also display a lack of responsibility for
the outcome of their actions. Because of a lack of trust in others, clients with
antisocial personality disorder commonly have difficulty developing stable, clo
se relationships. 22. Answer: (C) Methadone Rationale: Methadone is used to deto
xify opiate users because it binds with opioid receptors at many sites in the ce
ntral nervous system but doesn’t have the same deterious effects as other opiates,
such as cocaine, heroin, and morphine. Barbiturates, amphetamines, and benzodia
zepines are highly addictive and would require detoxification treatment. 23. Ans
wer: (B) Hallucinations Rationale: Hallucinations are visual, auditory, gustator
y, tactile, or olfactory perceptions that have no basis in reality. Delusions ar
e false beliefs, rather than perceptions, that the client accepts as real. Loose
associations are rapid shifts among unrelated ideas. Neologisms are bizarre wor
ds that have meaning only to the client. 24. Answer: (C) Set up a strict eating
plan for the client. Rationale: Establishing a consistent eating plan and monito
ring the client’s weight are very important in this disorder. The family and frien
ds should be included in the client’s care. The client should be monitored during
meals-not given privacy. Exercise must be limited and supervised. 25. Answer: (A
) Highly important or famous. Rationale: A delusion of grandeur is a false belie
f that one is highly important or famous. A delusion of persecution is a false b
elief that one is being persecuted. A delusion of reference is a false belief th
at one is connected to events unrelated to oneself or a belief that one is respo
nsible for the evil in the world.
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26. Answer: (D) Listening attentively with a neutral attitude and avoiding power
struggles. Rationale: The nurse should listen to the client’s requests, express w
illingness to seriously consider the request, and respond later. The nurse shoul
d encourage the client to take short daytime naps because he expends so much ene
rgy. The nurse shouldn’t try to restrain the client when he feels the need to move
around as long as his activity isn’t harmful. High calorie finger foods should be
offered to supplement the client’s diet, if he can’t remain seated long enough to e
at a complete meal. The nurse shouldn’t be forced to stay seated at the table to f
inid=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 ackn
owledge feelings, desires, impulses, or external facts that are consciously into
lerable. Withdrawal is a common response to stress, characterized by apathy. Log
ical 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 personali
ty disorder experience excessive social anxiety that can lead to paranoid though
ts. Aggressive behavior is uncommon, although these clients may experience agita
tion with anxiety. Their behavior is emotionally cold with a flattened affect, r
egardless of the situation. These clients demonstrate a reduced capacity for clo
se or dependent relationships. 29. Answer: (C) Identify anxiety-causing situatio
ns Rationale: Bulimic behavior is generally a maladaptive coping response to str
ess and underlying issues. The client must identify anxiety-causing situations t
hat stimulate the bulimic behavior and then learn new ways of coping with the an
xiety. 30. Answer: (A) Tension and irritability Rationale: An amphetamine is a n
ervous system stimulant that is subject to abuse because of its ability to produ
ce wakefulness and euphoria. An overdose increases tension and irritability. Opt
ions B and C are incorrect because amphetamines stimulate norepinephrine, which
increase the heart rate and blood flow. Diarrhea is a common adverse effect so o
ption 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”. Ra
tionale: The nurse, demonstrating knowledge and understanding, accepts the clien
t’s perceptions even though they are hallucinatory. 32. Answer: (C) Confusion for
a time after treatment Rationale: The electrical energy passing through the cere
bral cortex during ECT results in a temporary state of confusion after treatment
. 33. Answer: (D) Acceptance stage Rationale: Communication and intervention dur
ing this stage are mainly nonverbal, as when the client gestures to hold the nur
se’s hand. 34. Answer: (D) A higher level of anxiety continuing for more than 3 mo
nths. Rationale: This is not an expected outcome of a crisis because by definiti
on a crisis would be resolved in 6 weeks. 35. Answer: (B) Staying in the sun Rat
ionale: 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 usual
ly have very narrow, limited interest. 38. Answer: (A) As their depression begin
s 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 r
elated to cerebral hypoxia. Rationale: Cell damage seems to interfere with regis
tering input stimuli, which affects the ability to register and recall recent ev
ents; 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 monthl
y 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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41. Answer: (B) Fine hand tremors or slurred speech Rationale: These are common
side effects of lithium carbonate. 42. Answer: (D) Presence Rationale: The const
ant presence of a nurse provides emotional support because the client knows that
someone is attentive and available in case of an emergency. 43. Answer: (A) Cli
ent’s perception of the presenting problem. Rationale: The nurse can be most thera
peutic by starting where the client is, because it is the client’s concept of the
problem that serves as the starting point of the relationship. 44. Answer: (B) C
hocolate milk, aged cheese, and yogurt’” Rationale: These high-tyramine foods, when
ingested in the presence of an MAO inhibitor, cause a severe hypertensive respon
se. 45. Answer: (B) 4 to 6 weeks Rationale: Crisis is self-limiting and lasts fr
om 4 to 6 weeks. 46. Answer: (D) Males are more likely to use lethal methods tha
n are females Rationale: This finding is supported by research; females account
for 90% of suicide attempts but males are three times more successful because of
methods used. 47. Answer: (C) "Your cursing is interrupting the activity. Take
time out in your room for 10 minutes." Rationale: The nurse should set limits on
client behavior to ensure a comfortable environment for all clients. The nurse
should accept hostile or quarrelsome client outbursts within limits without beco
ming personally offended, as in option A. Option B is incorrect because it impli
es that the client s actions reflect feelings toward the staff instead of the cl
ient s own misery. Judgmental remarks, such as option D, may decrease the client
s self-esteem. 48. Answer: (C) lithium carbonate (Lithane) Rationale: Lithium c
arbonate, an antimania drug, is used to treat clients with cyclical schizoaffect
ive disorder, a psychotic disorder once classified under schizophrenia that caus
es affective symptoms, including maniclike activity. Lithium helps control the a
ffective component of this disorder. Phenelzine is a monoamine oxidase inhibitor
prescribed for clients who don t respond to other antidepressant drugs such as
imipramine. Chlordiazepoxide, an antianxiety agent, generally is contraindicated
in psychotic clients. Imipramine, primarily considered an antidepressant agent,
is also used to treat clients with agoraphobia and that undergoing cocaine deto
xification.
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49. Answer: (B) Report a sore throat or fever to the physician immediately. Rati
onale: A sore throat and fever are indications of an infection caused by agranul
ocytosis, a potentially life-threatening complication of clozapine. Because of t
he risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly,
not monthly. If the WBC count drops below 3,000/μl, the medication must be stopped
. Hypotension may occur in clients taking this medication. Warn the client to st
and up slowly to avoid dizziness from orthostatic hypotension. The medication sh
ould be continued, even when symptoms have been controlled. If the medication mu
st 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. Rati
onale: The client s signs and symptoms suggest neuroleptic malignant syndrome, a
life-threatening reaction to neuroleptic medication that requires immediate tre
atment. Tardive dyskinesia causes involuntary movements of the tongue, mouth, fa
cial muscles, and arm and leg muscles. Dystonia is characterized by cramps and r
igidity of the tongue, face, neck, and back muscles. Akathisia causes restlessne
ss, 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 amitri
ptyline-induced orthostatic hypotension, the nurse should advise the client to s
it up for 1 minute before getting out of bed. Orthostatic hypotension commonly o
ccurs with tricyclic antidepressant therapy. In these cases, the dosage may be r
educed or the physician may prescribe nortriptyline, another tricyclic antidepre
ssant. Orthostatic hypotension disappears only when the drug is discontinued. 52
. Answer: (D) Dysthymic disorder. Rationale: Dysthymic disorder is marked by fee
lings of depression lasting at least 2 years, accompanied by at least two of the
following symptoms: sleep disturbance, appetite disturbance, low energy or fati
gue, low selfesteem, poor concentration, difficulty making decisions, and hopele
ssness. 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 characterize
d by manic signs and symptoms. Major depression is a recurring, persistent sadne
ss or loss of interest or pleasure in almost all activities, with signs and symp
toms recurring for at least 2 weeks. 53. Answer: (C) 30 g mixed in 250 ml of wat
er
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Rationale: The usual adult dosage of activated charcoal is 5 to 10 times the est
imated weight of the drug or chemical ingested, or a minimum dose of 30 g, mixed
in 250 ml of water. Doses less than this will be ineffective; doses greater tha
n this can increase the risk of adverse reactions, although toxicity doesn t occ
ur with activated charcoal, even at the maximum dose. 54. Answer: (C) St. John s
wort Rationale: St. John s wort has been found to have serotonin-elevating prop
erties, similar to prescription antidepressants. Ginkgo biloba is prescribed to
enhance mental acuity. Echinacea has immune-stimulating properties. Ephedra is a
naturally occurring stimulant that is similar to ephedrine. 55. Answer: (B) Sod
ium Rationale: Lithium is chemically similar to sodium. If sodium levels are red
uced, such as from sweating or diuresis, lithium will be reabsorbed by the kidne
ys, increasing the risk of toxicity. Clients taking lithium shouldn t restrict t
heir intake of sodium and should drink adequate amounts of fluid each day. The o
ther electrolytes are important for normal body functions but sodium is most imp
ortant to the absorption of lithium. 56. Answer: (D) It s characterized by an ac
ute onset and lasts hours to a number of days Rationale: Delirium has an acute o
nset and typically can last from several hours to several days. 57. Answer: (B)
Impaired communication. Rationale: Initially, memory impairment may be the only
cognitive deficit in a client with Alzheimer s disease. During the early stage o
f this disease, subtle personality changes may also be present. However, other t
han occasional irritable outbursts and lack of spontaneity, the client is usuall
y cooperative and exhibits socially appropriate behavior. Signs of advancement t
o the middle stage of Alzheimer s disease include exacerbated cognitive impairme
nt with obvious personality changes and impaired communication, such as inapprop
riate conversation, actions, and responses. During the late stage, the client ca
n t perform self-care activities and may become mute. 58. Answer: (D) This medic
ation may initially cause tiredness, which should become less bothersome over ti
me. Rationale: Sedation is a common early adverse effect of imipramine, a tricyc
lic antidepressant, and usually decreases as tolerance develops. Antidepressants
aren t habit forming and don t cause physical or psychological dependence. Howe
ver, after a long course of high-dose therapy, the dosage should be decreased gr
adually to avoid mild
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withdrawal symptoms. Serious adverse effects, although rare, include myocardial
infarction, heart failure, and tachycardia. Dietary restrictions, such as avoidi
ng aged cheeses, yogurt, and chicken livers, are necessary for a client taking a
monoamine oxidase inhibitor, not a tricyclic antidepressant. 59. Answer: (C) Mo
nitor vital signs, serum electrolyte levels, and acid-base balance. Rationale: A
n anorexic client who requires hospitalization is in poor physical condition fro
m starvation and may die as a result of arrhythmias, hypothermia, malnutrition,
infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefo
re, monitoring the client s vital signs, serum electrolyte level, and acid base
balance is crucial. Option A may worsen anxiety. Option B is incorrect because a
weight obtained after breakfast is more accurate than one obtained after the ev
ening meal. Option D would reward the client with attention for not eating and r
einforce the control issues that are central to the underlying psychological pro
blem; also, the client may record food and fluid intake inaccurately. 60. Answer
: (D) Opioid withdrawal Rationale: The symptoms listed are specific to opioid wi
thdrawal. Alcohol withdrawal would show elevated vital signs. There is no real w
ithdrawal from cannibis. Symptoms of cocaine withdrawal include depression, anxi
ety, and agitation. 61. Answer: (A) Regression Rationale: An adult who throws te
mper tantrums, such as this one, is displaying regressive behavior, or behavior
that is appropriate at a younger age. In projection, the client blames someone o
r something other than the source. In reaction formation, the client acts in opp
osition to his feelings. In intellectualization, the client overuses rational ex
planations or abstract thinking to decrease the significance of a feeling or eve
nt. 62. Answer: (A) Abnormal movements and involuntary movements of the mouth, t
ongue, and face. Rationale: Tardive dyskinesia is a severe reaction associated w
ith long term use of antipsychotic medication. The clinical manifestations inclu
de abnormal movements (dyskinesia) and involuntary movements of the mouth, tongu
e (fly catcher tongue), and face. 63. Answer: (C) Blurred vision Rationale: At l
ithium levels of 2 to 2.5 mEq/L the client will experienced blurred vision, musc
le twitching, severe hypotension, and persistent nausea and vomiting. With level
s between 1.5 and 2 mEq/L the client experiencing vomiting, diarrhea, muscle wea
kness, ataxia, dizziness, slurred speech, and confusion. At lithium levels of 2.
5 to 3 mEq/L or
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higher, urinary and fecal incontinence occurs, as well as seizures, cardiac dysr
ythmias, peripheral vascular collapse, and death. 64. Answer: (C) No acts of agg
ression have been observed within 1 hour after the release of two of the extremi
ty restraints. Rationale: The best indicator that the behavior is controlled, if
the client exhibits no signs of aggression after partial release of restraints.
Options A, B, and D do not ensure that the client has controlled the behavior.
65. Answer: (A) increased attention span and concentration Rationale: The medica
tion has a paradoxic effect that decrease hyperactivity and impulsivity among ch
ildren with ADHD. B, C, D. Side effects of Ritalin include anorexia, insomnia, d
iarrhea and irritability. 66. Answer: (C) Moderate Rationale: The child with mod
erate mental retardation has an I.Q. of 3550 Profound Mental retardation has an
I.Q. of below 20; Mild mental retardation 50-70 and Severe mental retardation ha
s an I.Q. of 20-35. 67. Answer: (D) Rearrange the environment to activate the ch
ild Rationale: The child with autistic disorder does not want change. Maintainin
g a consistent environment is therapeutic. A. Angry outburst can be re-channelin
g through safe activities. B. Acceptance enhances a trusting relationship. C. En
sure safety from self-destructive behaviors like head banging and hair pulling.
68. Answer: (B) cocaine Rationale: The manifestations indicate intoxication with
cocaine, a CNS stimulant. A. Intoxication with heroine is manifested by euphori
a then impairment in judgment, attention and the presence of papillary constrict
ion. C. Intoxication with hallucinogen like LSD is manifested by grandiosity, ha
llucinations, synesthesia and increase in vital signs D. Intoxication with Marij
uana, a cannabinoid is manifested by sensation of slowed time, conjunctival redn
ess, social withdrawal, impaired judgment and hallucinations. 69. Answer: (B) in
sidious onset Rationale: Dementia has a gradual onset and progressive deteriorat
ion. It causes pronounced memory and cognitive disturbances. A,C and D are all c
haracteristics of delirium. 70. Answer: (C) Claustrophobia Rationale: Claustroph
obia is fear of closed space. A. Agoraphobia is fear of open space or being a si
tuation where escape is difficult. B. Social phobia is fear of performing in the
presence of others in a way that will be humiliating or embarrassing. D. Xenoph
obia is fear of strangers.
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71. Answer: (A) Revealing personal information to the client Rationale: Counter-
transference is an emotional reaction of the nurse on the client based on her un
conscious needs and conflicts. B and C. These are therapeutic approaches. D. Thi
s is transference reaction where a client has an emotional reaction towards the
nurse based on her past. 72. Answer: (D) Hold the next dose and obtain an order
for a stat serum lithium level Rationale: Diarrhea and vomiting are manifestatio
ns of Lithium toxicity. The next dose of lithium should be withheld and test is
done to validate the observation. A. The manifestations are not due to drug inte
raction. B. Cogentin is used to manage the extra pyramidal symptom side effects
of antipsychotics. C. The common side effects of Lithium are fine hand tremors,
nausea, polyuria and polydipsia. 73. Answer: (C) A living, learning or working e
nvironment. Rationale: A therapeutic milieu refers to a broad conceptual approac
h in which all aspects of the environment are channeled to provide a therapeutic
environment for the client. The six environmental elements include structure, s
afety, norms; limit setting, balance and unit modification. A. Behavioral approa
ch in psychiatric care is based on the premise that behavior can be learned or u
nlearned through the use of reward and punishment. B. Cognitive approach to chan
ge behavior is done by correcting distorted perceptions and irrational beliefs t
o correct maladaptive behaviors. D. This is not congruent with therapeutic milie
u. 74. Answer: (B) Transference Rationale: Transference is a positive or negativ
e feeling associated with a significant person in the client’s past that are uncon
sciously assigned to another A. Splitting is a defense mechanism commonly seen i
n a client with personality disorder in which the world is perceived as all good
or all bad C. Countert-transference is a phenomenon where the nurse shifts feel
ings assigned to someone in her past to the patient D. Resistance is the client’s
refusal to submit himself to the care of the nurse 75. Answer: (B) Adventitious
Rationale: Adventitious crisis is a crisis involving a traumatic event. It is no
t part of everyday life. A. Situational crisis is from an external source that u
pset ones psychological equilibrium C and D. Are the same. They are transitional
or developmental periods in life 76. Answer: (C) Major depression Rationale: Th
e DSM-IV-TR classifies major depression as an Axis I disorder. Borderline person
ality disorder as an Axis II; obesity and hypertension, Axis III.
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77. Answer: (B) Transference Rationale: Transference is the unconscious assignme
nt of negative or positive feelings evoked by a significant person in the client’s
past to another person. Intellectualization is a defense mechanism in which the
client avoids dealing with emotions by focusing on facts. Triangulation refers
to conflicts involving three family members. Splitting is a defense mechanism co
mmonly seen in clients with personality disorder in which the world is perceived
as all good or all bad. 78. Answer: (B) Hypochondriasis Rationale: Complains of
vague physical symptoms that have no apparent medical causes are characteristic
of clients with hypochondriasis. In many cases, the GI system is affected. Conv
ersion disorders are characterized by one or more neurologic symptoms. The clien
t’s symptoms don’t suggest severe anxiety. A client experiencing sublimation channel
s maladaptive feelings or impulses into socially acceptable behavior 79. Answer:
(C) Hypochondriasis Rationale: Hypochodriasis in this case is shown by the clie
nt’s belief that she has a serious illness, although pathologic causes have been e
liminated. The disturbance usually lasts at lease 6 with identifiable life stres
sor such as, in this case, course examinations. Conversion disorder s are charac
terized by one or more neurologic symptoms. Depersonalization refers to persiste
nt recurrent episodes of feeling detached from one’s self or body. Somatoform diso
rders generally have a chronic course with few remissions. 80. Answer: (A) Triaz
olam (Halcion) Rationale: Triazolam is one of a group of sedative hypnotic medic
ation that can be used for a limited time because of the risk of dependence. Par
oxetine is a scrotonin-specific reutake inhibitor used for treatment of depressi
on panic disorder, and obsessive-compulsive disorder. Fluoxetine is a scrotonin-
specific reuptake inhibitor used for depressive disorders and obsessive-compulsi
ve disorders. Risperidome is indicated for psychotic disorders. 81. Answer: (D)
It promotes emotional support or attention for the client Rationale: Secondary g
ain refers to the benefits of the illness that allow the client to receive emoti
onal support or attention. Primary gain enables the client to avoid some unpleas
ant activity. A dysfunctional family may disregard the real issue, although some
conflict is relieved. Somatoform pain disorder is a preoccupation with pain in
the absence of physical disease. 82. Answer: (A) “I went to the mall with my frien
ds last Saturday”
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Rationale: Clients with panic disorder tent to be socially withdrawn. Going to t
he mall is a sign of working on avoidance behaviors. Hyperventilating is a key s
ymptom of panic disorder. Teaching breathing control is a major intervention for
clients with panic disorder. The client taking medications for panic disorder;
such as tricylic antidepressants and benzodiazepines, must be weaned off these d
rugs. Most clients with panic disorder with agoraphobia don’t have nutritional pro
blems. 83. Answer: (A) “I’m sleeping better and don’t have nightmares” Rationale:MAO inh
ibitors are used to treat sleep problems, nightmares, and intrusive daytime thou
ghts in individual with posttraumatic stress disorder. MAO inhibitors aren’t used
to help control flashbacks or phobias or to decrease the craving for alcohol. 84
. Answer: (D) Stopping the drug can cause withdrawal symptoms Rationale: Stoppin
g antianxiety drugs such as benzodiazepines can cause the client to have withdra
wal symptoms. Stopping a benzodiazepine doesn’t tend to cause depression, increase
cognitive abilities, or decrease sleeping difficulties. 85. Answer: (B) Behavio
ral difficulties Rationale: Adolescents tend to demonstrate severe irritability
and behavioral problems rather than simply a depressed mood. Anxiety disorder is
more commonly associated with small children rather than with adolescents. Cogn
itive impairment is typically associated with delirium or dementia. Labile mood
is more characteristic of a client with cognitive impairment or bipolar disorder
. 86. Answer: (D) It’s a mood disorder similar to major depression but of mild to
moderate severity Rationale: Dysthymic disorder is a mood disorder similar to ma
jor depression but it remains mild to moderate in severity. Cyclothymic disorder
is a mood disorder characterized by a mood range from moderate depression to hy
pomania. Bipolar I disorder is characterized by a single manic episode with no p
ast major depressive episodes. Seasonalaffective disorder is a form of depressio
n occurring in the fall and winter. 87. Answer: (A) Vascular dementia has more a
brupt onset Rationale: Vascular dementia differs from Alzheimer’s disease in that
it has a more abrupt onset and runs a highly variable course. Personally change
is common in Alzheimer’s disease. The duration of delirium is usually brief. The i
nability to carry out motor activities is common in Alzheimer’s disease. 88. Answe
r: (C) Drug intoxication
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Rationale: This client was taking several medications that have a propensity for
producing delirium; digoxin (a digitalis glycoxide), furosemide (a thiazide diu
retic), and diazepam (a benzodiazepine). Sufficient supporting data don’t exist to
suspect the other options as causes. 89. Answer: (D) The client is experiencing
visual hallucination Rationale: The presence of a sensory stimulus correlates w
ith the definition of a hallucination, which is a false sensory perception. Apha
sia refers to a communication problem. Dysarthria is difficulty in speech produc
tion. Flight of ideas is rapid shifting from one topic to another. 90. Answer: (
D) The client looks at the shadow on a wall and tells the nurse she sees frighte
ning faces on the wall. Rationale: Minor memory problems are distinguished from
dementia by their minor severity and their lack of significant interference with
the client’s social or occupational lifestyle. Other options would be included in
the history data but don’t directly correlate with the client’s lifestyle. 91. Answ
er: (D) Loose association Rationale: Loose associations are conversations that c
onstantly shift in topic. Concrete thinking implies highly definitive thought pr
ocesses. Flight of ideas is characterized by conversation that’s disorganized from
the onset. Loose associations don’t necessarily start in a cogently, then becomes
loose. 92. Answer: (C) Paranoid Rationale: Because of their suspiciousness, par
anoid personalities ascribe malevolent activities to others and tent to be defen
sive, becoming quarrelsome and argumentative. Clients with antisocial personalit
y disorder can also be antagonistic and argumentative but are less suspicious th
an paranoid personalities. Clients with histrionic personality disorder are dram
atic, not suspicious and argumentative. Clients with schizoid personality disord
er are usually detached from other and tend to have eccentric behavior. 93. Answ
er: (C) Explain that the drug is less affective if the client smokes Rationale:
Olanzapine (Zyprexa) is less effective for clients who smoke cigarettes. Seroton
in syndrome occurs with clients who take a combination of antidepressant medicat
ions. Olanzapine doesn’t cause euphoria, and extrapyramidal adverse reactions aren’t
a problem. However, the client should be aware of adverse effects such as tardi
ve dyskinesia. 94. Answer: (A) Lack of honesty
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Rationale: Clients with antisocial personality disorder tent to engage in acts o
f dishonesty, shown by lying. Clients with schizotypal personality disorder tend
to be superstitious. Clients with histrionic personality disorders tend to over
react to frustrations and disappointments, have temper tantrums, and seek attent
ion. 95. Answer: (A) “I’m not going to look just at the negative things about myself”
Rationale: As the clients makes progress on improving self-esteem, selfblame and
negative self evaluation will decrease. Clients with dependent personality diso
rder tend to feel fragile and inadequate and would be extremely unlikely to disc
uss their level of competence and progress. These clients focus on self and aren’t
envious or jealous. Individuals with dependent personality disorders don’t take o
ver situations because they see themselves as inept and inadequate. 96. Answer:
(C) Assess for possible physical problems such as rash Rationale: Clients with s
chizophrenia generally have poor visceral recognition because they live so fully
in their fantasy world. They need to have as in-depth assessment of physical co
mplaints that may spill over into their delusional symptoms. Talking with the cl
ient won’t provide as assessment of his itching, and itching isn’t as adverse reacti
on of antipsychotic drugs, calling the physician to get the client’s medication in
creased doesn’t address his physical complaints. 97. Answer: (B) Echopraxia Ration
ale: Echopraxia is the copying of another’s behaviors and is the result of the los
s of ego boundaries. Modeling is the conscious copying of someone’s behaviors. Ego
-syntonicity refers to behaviors that correspond with the individual’s sense of se
lf. Ritualism behaviors are repetitive and compulsive. 98. Answer: (C) Hallucina
tion Rationale: Hallucinations are sensory experiences that are misrepresentatio
ns of reality or have no basis in reality. Delusions are beliefs not based in re
ality. Disorganized speech is characterized by jumping from one topic to the nex
t or using unrelated words. An idea of reference is a belief that an unrelated s
ituation holds special meaning for the client. 99. Answer: (C) Regression Ration
ale: Regression, a return to earlier behavior to reduce anxiety, is the basic de
fense mechanism in schizophrenia. Projection is a defense mechanism in which one
blames others and attempts to justify actions; it’s used primarily by people with
paranoid schizophrenia and delusional disorder. Rationalization is a defense me
chanism used to justify one’s action. Repression is the basic defense mechanism in
the neuroses; it’s
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an involuntary exclusion of painful thoughts, feelings, or experiences from awar
eness. 100.Answer: (A) Should report feelings of restlessness or agitation at on
ce Rationale: Agitation and restlessness are adverse effect of haloperidol and c
an be treated with antocholinergic drugs. Haloperidol isn’t likely to cause photos
ensitivity or control essential hypertension. Although the client may experience
increased concentration and activity, these effects are due to a decreased in s
ymptoms, not the drug itself.
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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 transm
ission d. Portal of entry 2. Which of the following will probably result in a br
eak in sterile technique for respiratory isolation? a. Opening the patient’s windo
w to the outside environment b. Turning on the patient’s room ventilator c. Openin
g the door of the patient’s 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 a
t least: a. 30 seconds b. 1 minute c. 2 minute d. 3 minutes 6. Which of the foll
owing procedures always requires surgical asepsis? a. Vaginal instillation of co
njugated estrogen b. Urinary catheterization c. Nasogastric tube insertion d. Co
lostomy irrigation 7. Sterile technique is used whenever: a. Strict isolation is
required b. Terminal disinfection is performed c. Invasive procedures are perfo
rmed d. Protective isolation is necessary 8. Which of the following constitutes
a break in sterile technique while preparing a sterile field for a dressing chan
ge? a. Using sterile forceps, rather than sterile gloves, to handle a sterile it
em
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b. Touching the outside wrapper of sterilized material without sterile gloves c.
Placing a sterile object on the edge of the sterile field d. Pouring out a smal
l amount of solution (15 to 30 ml) before pouring the solution into a sterile co
ntainer 9. A natural body defense that plays an active role in preventing infect
ion is: a. Yawning b. Body hair c. Hiccupping d. Rapid eye movements 10. All of
the following statement are true about donning sterile gloves except: a. The fir
st glove should be picked up by grasping the inside of the cuff. b. The second g
love should be picked up by inserting the gloved fingers under the cuff outside
the glove. c. The gloves should be adjusted by sliding the gloved fingers under
the sterile cuff and pulling the glove over the wrist d. The inside of the glove
is considered sterile 11. When removing a contaminated gown, the nurse should b
e careful that the first thing she touches is the: a. Waist tie and neck tie at
the back of the gown b. Waist tie in front of the gown c. Cuffs of the gown d. I
nside of the gown 12. Which of the following nursing interventions is considered
the most effective form or universal precautions? a. Cap all used needles befor
e removing them from their syringes b. Discard all used uncapped needles and syr
inges in an impenetrable protective container c. Wear gloves when administering
IM injections d. Follow enteric precautions 13. All of the following measures ar
e recommended to prevent pressure ulcers except: a. Massaging the reddened are w
ith lotion b. Using a water or air mattress c. Adhering to a schedule for positi
oning and turning d. Providing meticulous skin care 14. Which of the following b
lood tests should be performed before a blood transfusion? a. Prothrombin and co
agulation time b. Blood typing and cross-matching c. Bleeding and clotting time
d. Complete blood count (CBC) and electrolyte levels. 15. The primary purpose of
a platelet count is to evaluate the: a. Potential for clot formation b. Potenti
al for bleeding
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c. Presence of an antigen-antibody response d. Presence of cardiac enzymes 16. W
hich of the following white blood cell (WBC) counts clearly indicates leukocytos
is? a. 4,500/mm³ b. 7,000/mm³ c. 10,000/mm³ d. 25,000/mm³ 17. After 5 days of diuretic t
herapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigu
e, muscle cramping and muscle weakness. These symptoms probably indicate that th
e patient is experiencing: a. Hypokalemia b. Hyperkalemia c. Anorexia d. Dysphag
ia 18. Which of the following statements about chest X-ray is false? a. No contr
adictions exist for this test b. Before the procedure, the patient should remove
all jewelry, metallic objects, and buttons above the waist c. A signed consent
is not required d. Eating, drinking, and medications are allowed before this tes
t 19. The most appropriate time for the nurse to obtain a sputum specimen for cu
lture is: a. Early in the morning b. After the patient eats a light breakfast c.
After aerosol therapy d. After chest physiotherapy 20. A patient with no known
allergies is to receive penicillin every 6 hours. When administering the medicat
ion, the nurse observes a fine rash on the patient’s skin. The most appropriate nu
rsing action would be to: a. Withhold the moderation and notify the physician b.
Administer the medication and notify the physician c. Administer the medication
with an antihistamine d. Apply corn starch soaks to the rash 21. All of the fol
lowing nursing interventions are correct when using the Ztrack method of drug in
jection except: a. Prepare the injection site with alcohol b. Use a needle that’s
a least 1” long c. Aspirate for blood before injection d. Rub the site vigorously
after the injection to promote absorption 22. The correct method for determining
the vastus lateralis site for I.M. injection is to: a. Locate the upper aspect
of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crest
b. Palpate the lower edge of the acromion process and the midpoint lateral aspe
ct of the arm
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c. Palpate a 1” circular area anterior to the umbilicus d. Divide the area between
the greater femoral trochanter and the lateral femoral condyle into thirds, and
select the middle third on the anterior of the thigh 23. The mid-deltoid inject
ion site is seldom used for I.M. injections because it: a. Can accommodate only
1 ml or less of medication b. Bruises too easily c. Can be used only when the pa
tient is lying down d. Does not readily parenteral medication 24. The appropriat
e needle size for insulin injection is: a. 18G, 1 ½” long b. 22G, 1” long c. 22G, 1 ½” lon
g d. 25G, 5/8” long 25. The appropriate needle gauge for intradermal injection is:
a. 20G b. 22G c. 25G d. 26G 26. Parenteral penicillin can be administered as an
: a. IM injection or an IV solution b. IV or an intradermal injection c. Intrade
rmal or subcutaneous injection d. IM or a subcutaneous injection 27. The physici
an orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is:
a. 0.6 mg b. 10 mg c. 60 mg d. 600 mg 28. The physician orders an IV solution of
dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop fac
tor is 15 gtt = 1 ml? a. 5 gtt/minute b. 13 gtt/minute c. 25 gtt/minute d. 50 gt
t/minute 29. Which of the following is a sign or symptom of a hemolytic reaction
to blood transfusion? a. Hemoglobinuria b. Chest pain c. Urticaria d. Distended
neck veins 30. Which of the following conditions may require fluid restriction?
a. Fever b. Chronic Obstructive Pulmonary Disease c. Renal Failure
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d. Dehydration 31. All of the following are common signs and symptoms of phlebit
is 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 bl
eeding at the insertion site 32. The best way of determining whether a patient h
as learned to instill ear medication properly is for the nurse to: a. Ask the pa
tient if he/she has used ear drops before b. Have the patient repeat the nurse’s i
nstructions 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. W
hich of the following types of medications can be administered via gastrostomy t
ube? 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 d
esigned for oral use, except for extended-duration compounds 34. A patient who d
evelops hives after receiving an antibiotic is exhibiting drug: a. Tolerance b.
Idiosyncrasy c. Synergism d. Allergy 35. A patient has returned to his room afte
r femoral arteriography. All of the following are appropriate nursing interventi
ons 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 vita
l 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 p
rimarily a voluntary action c. Is induced by the administration of an antitussiv
e drug d. Can be inhibited by “splinting” the abdomen 37. An infected patient has ch
ills and begins shivering. The best nursing intervention is to: a. Apply iced al
cohol sponges b. Provide increased cool liquids c. Provide additional bedclothes
d. Provide increased ventilation
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38. A clinical nurse specialist is a nurse who has: a. Been certified by the Nat
ional League for Nursing b. Received credentials from the Philippine Nurses’ Assoc
iation c. Graduated from an associate degree program and is a registered profess
ional nurse d. Completed a master’s degree in the prescribed clinical area and is
a registered professional nurse. 39. The purpose of increasing urine acidity thr
ough dietary means is to: a. Decrease burning sensations b. Change the urine’s col
or c. Change the urine’s concentration d. Inhibit the growth of microorganisms 40.
Clay colored stools indicate: a. Upper GI bleeding b. Impending constipation c.
An effect of medication d. Bile obstruction 41. In which step of the nursing pr
ocess would the nurse ask a patient if the medication she administered relieved
his pain? a. Assessment b. Analysis c. Planning d. Evaluation 42. All of the fol
lowing are good sources of vitamin A except: a. White potatoes b. Carrots c. Apr
icots d. Egg yolks 43. Which of the following is a primary nursing intervention
necessary for all patients with a Foley Catheter in place? a. Maintain the drain
age tubing and collection bag level with the patient’s bladder b. Irrigate the pat
ient with 1% Neosporin solution three times a daily c. Clamp the catheter for 1
hour every 4 hours to maintain the bladder’s elasticity d. Maintain the drainage t
ubing and collection bag below bladder level to facilitate drainage by gravity 4
4. The ELISA test is used to: a. Screen blood donors for antibodies to human imm
unodeficiency virus (HIV) b. Test blood to be used for transfusion for HIV antib
odies c. Aid in diagnosing a patient with AIDS d. All of the above 45. The two b
lood vessels most commonly used for TPN infusion are the: a. Subclavian and jugu
lar veins b. Brachial and subclavian veins
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c. Femoral and subclavian veins d. Brachial and femoral veins 46. Effective skin
disinfection before a surgical procedure includes which of the following method
s? a. Shaving the site on the day before surgery b. Applying a topical antisepti
c to the skin on the evening before surgery c. Having the patient take a tub bat
h on the morning of surgery d. Having the patient shower with an antiseptic soap
on the evening v=before and the morning of surgery 47. When transferring a pati
ent from a bed to a chair, the nurse should use which muscles to avoid back inju
ry? a. Abdominal muscles b. Back muscles c. Leg muscles d. Upper arm muscles 48.
Thrombophlebitis typically develops in patients with which of the following con
ditions? a. Increases partial thromboplastin time b. Acute pulsus paradoxus c. A
n impaired or traumatized blood vessel wall d. Chronic Obstructive Pulmonary Dis
ease (COPD) 49. In a recumbent, immobilized patient, lung ventilation can become
altered, leading to such respiratory complications as: a. Respiratory acidosis,
ateclectasis, and hypostatic pneumonia b. Appneustic breathing, atypical pneumo
nia and respiratory alkalosis c. Cheyne-Strokes respirations and spontaneous pne
umothorax d. Kussmail’s respirations and hypoventilation 50. Immobility impairs bl
adder elimination, resulting in such disorders as a. Increased urine acidity and
relaxation of the perineal muscles, causing incontinence b. Urine retention, bl
adder distention, and infection c. Diuresis, natriuresis, and decreased urine sp
ecific gravity d. Decreased calcium and phosphate levels in the urine
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ANSWERS AND RATIONALE – FOUNDATION OF NURSING 1. D. In the circular chain of infec
tion, pathogens must be able to leave their reservoir and be transmitted to a su
sceptible host through a portal of entry, such as broken skin. 2. C. Respiratory
isolation, like strict isolation, requires that the door to the door patient’s ro
om remain closed. However, the patient’s room should be well ventilated, so openin
g the window or turning on the ventricular is desirable. The nurse does not need
to wear gloves for respiratory isolation, but good hand washing is important fo
r all types of isolation. 3. A. Leukopenia is a decreased number of leukocytes (
white blood cells), which are important in resisting infection. None of the othe
r situations would put the patient at risk for contracting an infection; taking
broadspectrum antibiotics might actually reduce the infection risk. 4. A. Soaps
and detergents are used to help remove bacteria because of their ability to lowe
r the surface tension of water and act as emulsifying agents. Hot water may lead
to skin irritation or burns. 5. A. Depending on the degree of exposure to patho
gens, hand washing may last from 10 seconds to 4 minutes. After routine patient
contact, hand washing for 30 seconds effectively minimizes the risk of pathogen
transmission. 6. B. The urinary system is normally free of microorganisms except
at the urinary meatus. Any procedure that involves entering this system must us
e surgically aseptic measures to maintain a bacteria-free state. 7. C. All invas
ive procedures, including surgery, catheter insertion, and administration of par
enteral therapy, require sterile technique to maintain a sterile environment. Al
l equipment must be sterile, and the nurse and the physician must wear sterile g
loves and maintain surgical asepsis. In the operating room, the nurse and physic
ian are required to wear sterile gowns, gloves, masks, hair covers, and shoe cov
ers for all invasive procedures. Strict isolation requires the use of clean glov
es, masks, gowns and equipment to prevent the transmission of highly communicabl
e diseases by contact or by airborne routes. Terminal disinfection is the disinf
ection of all contaminated supplies and equipment after a patient has been disch
arged to prepare them for reuse by another patient. The purpose of protective (r
everse) isolation is to prevent a person with seriously impaired resistance from
coming into contact who potentially pathogenic organisms. 8. C. The edges of a
sterile field are considered contaminated. When sterile items are allowed to com
e in contact with the edges of the field, the sterile items also become contamin
ated. 9. B. Hair on or within body areas, such as the nose, traps and holds part
icles that contain microorganisms. Yawning and hiccupping do not prevent microor
ganisms from entering or leaving the body. Rapid eye movement marks the stage of
sleep during which dreaming occurs. 10. D. The inside of the glove is always co
nsidered to be clean, but not sterile.
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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 an
d 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 com
monly when a health care worker attempts to cap a used needle. Therefore, used n
eedles should never be recapped; instead they should be inserted in a specially
designed puncture resistant, labeled container. Wearing gloves is not always nec
essary when administering an I.M. injection. Enteric precautions prevent the tra
nsfer of pathogens via feces. 13. A. Nurses and other health care professionals
previously believed that massaging a reddened area with lotion would promote ven
ous return and reduce edema to the area. However, research has shown that massag
e only increases the likelihood of cellular ischemia and necrosis to the area. 1
4. B. Before a blood transfusion is performed, the blood of the donor and recipi
ent must be checked for compatibility. This is done by blood typing (a test that
determines a person’s blood type) and cross-matching (a procedure that determines
the compatibility of the donor’s and recipient’s blood after the blood types has be
en matched). If the blood specimens are incompatible, hemolysis and antigen-anti
body reactions will occur. 15. A. Platelets are disk-shaped cells that are essen
tial for blood coagulation. A platelet count determines the number of thrombocyt
es in blood available for promoting hemostasis and assisting with blood coagulat
ion after injury. It also is used to evaluate the patient’s 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 bleedi
ng; 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 (leu
kocytes) 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, a
nd muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level)
, which is a potential side effect of diuretic therapy. The physician usually or
ders supplemental potassium to prevent hypokalemia in patients receiving diureti
cs. Anorexia is another symptom of hypokalemia. Dysphagia means difficulty swall
owing. 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 le
ad 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 th
e waist. A signed consent is not required because a chest
202
X-ray is not an invasive examination. Eating, drinking and medications are allow
ed because the X-ray is of the chest, not the abdominal region. 19. A. Obtaining
a sputum specimen early in this morning ensures an adequate supply of bacteria
for culturing and decreases the risk of contamination from food or medication. 2
0. A. Initial sensitivity to penicillin is commonly manifested by a skin rash, e
ven in individuals who have not been allergic to it previously. Because of the d
anger of anaphylactic shock, he nurse should withhold the drug and notify the ph
ysician, who may choose to substitute another drug. Administering an antihistami
ne is a dependent nursing intervention that requires a written physician’s order.
Although applying corn starch to the rash may relieve discomfort, it is not the
nurse’s top priority in such a potentially life-threatening situation. 21. D. The
Z-track method is an I.M. injection technique in which the patient’s skin is pulle
d in such a way that the needle track is sealed off after the injection. This pr
ocedure seals medication deep into the muscle, thereby minimizing skin staining
and irritation. Rubbing the injection site is contraindicated because it may cau
se the medication to extravasate into the skin. 22. D. The vastus lateralis, a l
ong, thick muscle that extends the full length of the thigh, is viewed by many c
linicians as the site of choice for I.M. injections because it has relatively fe
w major nerves and blood vessels. The middle third of the muscle is recommended
as the injection site. The patient can be in a supine or sitting position for an
injection into this site. 23. A. The mid-deltoid injection site can accommodate
only 1 ml or less of medication because of its size and location (on the deltoi
d muscle of the arm, close to the brachial artery and radial nerve). 24. D. A 25
G, 5/8” needle is the recommended size for insulin injection because insulin is ad
ministered by the subcutaneous route. An 18G, 1 ½” needle is usually used for I.M. i
njections in children, typically in the vastus lateralis. A 22G, 1 ½” needle is usua
lly used for adult I.M. injections, which are typically administered in the vast
us lateralis or ventrogluteal site. 25. D. Because an intradermal injection does
not penetrate deeply into the skin, a small-bore 25G needle is recommended. Thi
s type of injection is used primarily to administer antigens to evaluate reactio
ns for allergy or sensitivity studies. A 20G needle is usually used for I.M. inj
ections of oilbased medications; a 22G needle for I.M. injections; and a 25G nee
dle, for I.M. injections; and a 25G needle, for subcutaneous insulin injections.
26. A. Parenteral penicillin can be administered I.M. or added to a solution an
d given I.V. It cannot be administered subcutaneously or intradermally. 27. D. g
r 10 x 60mg/gr 1 = 600 mg 28. C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute 29.
A. Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates
a hemolytic reaction (incompatibility of the donor’s and recipient’s blood). In this
reaction, antibodies in the recipient’s plasma combine rapidly with donor RBC’s; th
e cells are hemolyzed in either
203
circulatory or reticuloendothelial system. Hemolysis occurs more rapidly in ABO
incompatibilities than in Rh incompatibilities. Chest pain and urticaria may be
symptoms of impending anaphylaxis. Distended neck veins are an indication of hyp
ervolemia. 30. C. In real failure, the kidney loses their ability to effectively
eliminate wastes and fluids. Because of this, limiting the patient’s intake of or
al and I.V. fluids may be necessary. Fever, chronic obstructive pulmonary diseas
e, and dehydration are conditions for which fluids should be encouraged. 31. D.
Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V.
solutions or medications), mechanical irritants (the needle or catheter used du
ring venipuncture or cannulation), or a localized allergic reaction to the needl
e or catheter. Signs and symptoms of phlebitis include pain or discomfort, edema
and heat at the I.V. insertion site, and a red streak going up the arm or leg f
rom the I.V. insertion site. 32. D. Return demonstration provides the most certa
in evidence for evaluating the effectiveness of patient teaching. 33. D. Capsule
s, enteric-coated tablets, and most extended duration or sustained release produ
cts should not be dissolved for use in a gastrostomy tube. They are pharmaceutic
ally manufactured in these forms for valid reasons, and altering them destroys t
heir purpose. The nurse should seek an alternate physician’s order when an ordered
medication is inappropriate for delivery by tube. 34. D. A drug-allergy is an a
dverse reaction resulting from an immunologic response following a previous sens
itizing exposure to the drug. The reaction can range from a rash or hives to ana
phylactic shock. Tolerance to a drug means that the patient experiences a decrea
sing physiologic response to repeated administration of the drug in the same dos
age. Idiosyncrasy is an individual’s unique hypersensitivity to a drug, food, or o
ther substance; it appears to be genetically determined. Synergism, is a drug in
teraction in which the sum of the drug’s combined effects is greater than that of
their separate effects. 35. D. A hemoglobin and hematocrit count would be ordere
d by the physician if bleeding were suspected. The other answers are appropriate
nursing interventions for a patient who has undergone femoral arteriography. 36
. A. Coughing, a protective response that clears the respiratory tract of irrita
nts, usually is involuntary; however it can be voluntary, as when a patient is t
aught to perform coughing exercises. An antitussive drug inhibits coughing. Spli
nting the abdomen supports the abdominal muscles when a patient coughs. 37. C. I
n an infected patient, shivering results from the body’s attempt to increase heat
production and the production of neutrophils and phagocytotic action through inc
reased skeletal muscle tension and contractions. Initial vasoconstriction may ca
use skin to feel cold to the touch. Applying additional bed clothes helps to equ
alize the body
204
temperature and stop the chills. Attempts to cool the body result in further shi
vering, increased metabloism, and thus increased heat production. 38. D. A clini
cal nurse specialist must have completed a master’s degree in a clinical specialty
and be a registered professional nurse. The National League of Nursing accredit
s educational programs in nursing and provides a testing service to evaluate stu
dent nursing competence but it does not certify nurses. The American Nurses Asso
ciation identifies requirements for certification and offers examinations for ce
rtification in many areas of nursing., such as medical surgical nursing. These c
ertification (credentialing) demonstrates that the nurse has the knowledge and t
he 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 knowl
edge and skill. She must successfully complete the licensing examination to beco
me 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. Constip
ation is characterized by small, hard masses. Many medications and foods will di
scolor stool – for example, drugs containing iron turn stool black.; beets turn st
ool red. 41. D. In the evaluation step of the nursing process, the nurse must de
cide whether the patient has achieved the expected outcome that was identified i
n 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, br
occoli, and cabbage) and yellow fruits (such as apricots, and cantaloupe). Anima
l sources include liver, kidneys, cream, butter, and egg yolks. 43. D. Maintaing
the drainage tubing and collection bag level with the patient’s bladder could res
ult in reflux of urine into the kidney. Irrigating the bladder with Neosporin an
d clamping the catheter for 1 hour every 4 hours must be prescribed by a physici
an. 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 combin
ed with various signs and symptoms helps to diagnose acquired immunodeficiency s
yndrome (AIDS) 45. D. Tachypnea (an abnormally rapid rate of breathing) would in
dicate that the patient was still hypoxic (deficient in oxygen).The partial pres
sures of arterial oxygen and carbon dioxide listed are within the normal range.
Eupnea refers to normal respiration. 46. D. Studies have shown that showering wi
th an antiseptic soap before surgery is the most effective method of removing mi
croorganisms from the skin. Shaving the site of the intended surgery might cause
breaks in the skin, thereby increasing the risk of infection; however, if indic
ated, shaving, should be done immediately before surgery, not the day before.
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A topical antiseptic would not remove microorganisms and would be beneficial onl
y after proper cleaning and rinsing. Tub bathing might transfer organisms to ano
ther body site rather than rinse them away. 47. C. The leg muscles are the stron
gest muscles in the body and should bear the greatest stress when lifting. Muscl
es of the abdomen, back, and upper arms may be easily injured. 48. C. The factor
s, known as Virchow’s triad, collectively predispose a patient to thromboplebitis;
impaired venous return to the heart, blood hypercoagulability, and injury to a
blood vessel wall. Increased partial thromboplastin time indicates a prolonged b
leeding time during fibrin clot formation, commonly the result of anticoagulant
(heparin) therapy. Arterial blood disorders (such as pulsus paradoxus) and lung
diseases (such as COPD) do not necessarily impede venous return of injure vessel
walls. 49. A. Because of restricted respiratory movement, a recumbent, immobili
ze patient is at particular risk for respiratory acidosis from poor gas exchange
; atelectasis from reduced surfactant and accumulated mucus in the bronchioles,
and hypostatic pneumonia from bacterial growth caused by stasis of mucus secreti
ons. 50. B. The immobilized patient commonly suffers from urine retention caused
by decreased muscle tone in the perineum. This leads to bladder distention and
urine stagnation, which provide an excellent medium for bacterial growth leading
to infection. Immobility also results in more alkaline urine with excessive amo
unts of calcium, sodium and phosphate, a gradual decrease in urine production, a
nd an increased specific gravity.
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PRACTICE TEST II
Maternal and Child Health
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MATERNAL AND CHILD HEALTH 1. For the client who is using oral contraceptives, th
e nurse informs the client about the need to take the pill at the same time each
day to accomplish which of the following? a. Decrease the incidence of nausea b
. Maintain hormonal levels c. Reduce side effects d. Prevent drug interactions 2
. When teaching a client about contraception. Which of the following would the n
urse include as the most effective method for preventing sexually transmitted in
fections? a. Spermicides b. Diaphragm c. Condoms d. Vasectomy 3. When preparing
a woman who is 2 days postpartum for discharge, recommendations for which of the
following contraceptive methods would be avoided? a. Diaphragm b. Female condom
c. Oral contraceptives d. Rhythm method 4. For which of the following clients w
ould the nurse expect that an intrauterine device would not be recommended? a. W
oman over age 35 b. Nulliparous woman c. Promiscuous young adult d. Postpartum c
lient 5. A client in her third trimester tells the nurse, “I’m constipated all the t
ime!” Which of the following should the nurse recommend? a. Daily enemas b. Laxati
ves c. Increased fiber intake d. Decreased fluid intake 6. Which of the followin
g would the nurse use as the basis for the teaching plan when caring for a pregn
ant teenager concerned about gaining too much weight during pregnancy? a. 10 pou
nds per trimester b. 1 pound per week for 40 weeks c. ½ pound per week for 40 week
s d. A total gain of 25 to 30 pounds 7. The client tells the nurse that her last
menstrual period started on January 14 and ended on January 20. Using Nagele’s ru
le, the nurse determines her EDD to be which of the following? a. September 27
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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 daugh
ter born at 30 weeks gestation and I lost a baby at about 8 weeks,” the nurse shou
ld 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 midl
ine at the suprapubic region c. Fetoscope placed midway between the umbilicus an
d the xiphoid process d. External electronic fetal monitor placed at the umbilic
us 10. When developing a plan of care for a client newly diagnosed with gestatio
nal diabetes, which of the following instructions would be the priority? a. Diet
ary intake b. Medication c. Exercise d. Glucose monitoring 11. A client at 24 we
eks gestation has gained 6 pounds in 4 weeks. Which of the following would be th
e priority when assessing the client? a. Glucosuria b. Depression c. Hand/face e
dema d. Dietary intake 12. A client 12 weeks’ pregnant come to the emergency depar
tment with abdominal cramping and moderate vaginal bleeding. Speculum examinatio
n 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. Comple
te 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 client’s uterus for firmness and position in r
elation 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 wh
en a primipara who is lactating tells the nurse that she has sore nipples? a. Te
ll her to breast feed more frequently b. Administer a narcotic before breast fee
ding 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’ postpart
um that are as follows: BP 90/60; temperature 100.4 F; pulse 100 weak, thready; R
20 per minute. Which of the following should the nurse do first? a. Report the t
emperature to the physician b. Recheck the blood pressure with another cuff c. A
ssess the uterus for firmness and position d. Determine the amount of lochia 17.
The nurse assesses the postpartum vaginal discharge (lochia) on four clients. W
hich 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 discha
rge 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 deliv
ery 18. A postpartum client has a temperature of 101.4 F, with a uterus that is te
nder when palpated, remains unusually large, and not descending as normally expe
cted. 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. Facilit
ating 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 i
n maintaining a neutral thermal environment for the newborn? a. Placing infant u
nder radiant warmer after bathing b. Covering the scale with a warmed blanket pr
ior to weighing c. Placing crib close to nursery window for family viewing
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d. Covering the infant’s head with a knit stockinette 21. A newborn who has an asy
mmetrical Moro reflex response should be further assessed for which of the follo
wing? a. Talipes equinovarus b. Fractured clavicle c. Congenital hypothyroidism
d. Increased intracranial pressure 22. During the first 4 hours after a male cir
cumcision, assessing for which of the following is the priority? a. Infection b.
Hemorrhage c. Discomfort d. Dehydration 23. The mother asks the nurse. “What’s wron
g with my son’s breasts? Why are they so enlarged?” Whish of the following would be
the best response by the nurse? a. “The breast tissue is inflamed from the trauma
experienced with birth” b. “A decrease in material hormones present before birth cau
ses enlargement,” c. “You should discuss this with your doctor. It could be a malign
ancy” d. “The tissue has hypertrophied while the baby was in the uterus” 24. Immediate
ly after birth the nurse notes the following on a male newborn: respirations 78;
apical hearth rate 160 BPM, nostril flaring; mild intercostal retractions; and
grunting at the end of expiration. Which of the following should the nurse do? a
. Call the assessment data to the physician’s attention b. Start oxygen per nasal
cannula at 2 L/min. c. Suction the infant’s mouth and nares d. Recognize this as n
ormal first period of reactivity 25. The nurse hears a mother telling a friend o
n the telephone about umbilical cord care. Which of the following statements by
the mother indicates effective teaching? a. “Daily soap and water cleansing is bes
t” b. ‘Alcohol helps it dry and kills germs” c. “An antibiotic ointment applied daily pr
events infection” d. “He can have a tub bath each day” 26. A newborn weighing 3000 gra
ms and feeding every 4 hours needs 120 calories/kg of body weight every 24 hours
for proper growth and development. How many ounces of 20 cal/oz formula should
this newborn receive at each feeding to meet nutritional needs? a. 2 ounces b. 3
ounces c. 4 ounces d. 6 ounces
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27. The postterm neonate with meconium-stained amniotic fluid needs care designe
d to especially monitor for which of the following? a. Respiratory problems b. G
astrointestinal problems c. Integumentary problems d. Elimination problems 28. W
hen measuring a client’s 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
client’s plan of care? a. Daily weights b. Seizure precautions c. Right lateral p
ositioning d. Stress reduction 30. A postpartum primipara asks the nurse, “When ca
n we have sexual intercourse again?” Which of the following would be the nurse’s bes
t response? a. “Anytime you both want to.” b. “As soon as choose a contraceptive metho
d.” c. “When the discharge has stopped and the incision is healed.” d. “After your 6 wee
ks examination.” 31. When preparing to administer the vitamin K injection to a neo
nate, the nurse would select which of the following sites as appropriate for the
injection? a. Deltoid muscle b. Anterior femoris muscle c. Vastus lateralis mus
cle d. Gluteus maximus muscle 32. When performing a pelvic examination, the nurs
e observes a red swollen area on the right side of the vaginal orifice. The nurs
e would document this as enlargement of which of the following? a. Clitoris b. P
arotid gland c. Skene’s gland d. Bartholin’s gland 33. To differentiate as a female,
the hormonal stimulation of the embryo that must occur involves which of the fo
llowing? a. Increase in maternal estrogen secretion b. Decrease in maternal andr
ogen secretion c. Secretion of androgen by the fetal gonad d. Secretion of estro
gen by the fetal gonad
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34. A client at 8 weeks’ gestation calls complaining of slight nausea in the morni
ng hours. Which of the following client interventions should the nurse question?
a. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water b. Eat
ing a few low-sodium crackers before getting out of bed c. Avoiding the intake o
f liquids in the morning hours d. Eating six small meals a day instead of thee l
arge meals 35. The nurse documents positive ballottement in the client’s prenatal
record. The nurse understands that this indicates which of the following? a. Pal
pable contractions on the abdomen b. Passive movement of the unengaged fetus c.
Fetal kicking felt by the client d. Enlargement and softening of the uterus 36.
During a pelvic exam the nurse notes a purple-blue tinge of the cervix. The nurs
e documents this as which of the following? a. Braxton-Hicks sign b. Chadwick’s si
gn c. Goodell’s sign d. McDonald’s sign 37. During a prenatal class, the nurse expla
ins the rationale for breathing techniques during preparation for labor based on
the understanding that breathing techniques are most important in achieving whi
ch of the following? a. Eliminate pain and give the expectant parents something
to do b. Reduce the risk of fetal distress by increasing uteroplacental perfusio
n c. Facilitate relaxation, possibly reducing the perception of pain d. Eliminat
e pain so that less analgesia and anesthesia are needed 38. After 4 hours of act
ive labor, the nurse notes that the contractions of a primigravida client are no
t strong enough to dilate the cervix. Which of the following would the nurse ant
icipate doing? a. Obtaining an order to begin IV oxytocin infusion b. Administer
ing a light sedative to allow the patient to rest for several hour c. Preparing
for a cesarean section for failure to progress d. Increasing the encouragement t
o the patient when pushing begins 39. A multigravida at 38 weeks’ gestation is adm
itted with painless, bright red bleeding and mild contractions every 7 to 10 min
utes. Which of the following assessments should be avoided? a. Maternal vital si
gn b. Fetal heart rate c. Contraction monitoring d. Cervical dilation
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40. Which of the following would be the nurse’s most appropriate response to a cli
ent who asks why she must have a cesarean delivery if she has a complete placent
a previa? a. “You will have to ask your physician when he returns.” b. “You need a ces
arean 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 n
urse understands that the fetal head is in which of the following positions with
a face presentation? a. Completely flexed b. Completely extended c. Partially e
xtended d. Partially flexed 42. With a fetus in the left-anterior breech present
ation, the nurse would expect the fetal heart rate would be most audible in whic
h of the following areas? a. Above the maternal umbilicus and to the right of mi
dline b. In the lower-left maternal abdominal quadrant c. In the lower-right mat
ernal abdominal quadrant d. Above the maternal umbilicus and to the left of midl
ine 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. Meco
nium 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 th
e 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 its
elf 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 f
ollowing was an outgrowth of this concept? a. Labor, delivery, recovery, postpar
tum (LDRP) b. Nurse-midwifery c. Clinical nurse specialist d. Prepared childbirt
h 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 preve
nt 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 te
aching a group of adolescents about variations in the length of the menstrual cy
cle, the nurse understands that the underlying mechanism is due to variations in
which of the following phases? a. Menstrual phase b. Proliferative phase c. Sec
retory phase d. Ischemic phase 50. When teaching a group of adolescents about ma
le hormone production, which of the following would the nurse include as being p
roduced by the Leydig cells? a. Follicle-stimulating hormone b. Testosterone c.
Leuteinizing hormone d. Gonadotropin releasing hormone
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ANSWERS AND RATIONALE – MATERNAL AND CHILD HEALTH 1. B. Regular timely ingestion o
f oral contraceptives is necessary to maintain hormonal levels of the drugs to s
uppress the action of the hypothalamus and anterior pituitary leading to inappro
priate secretion of FSH and LH. Therefore, follicles do not mature, ovulation is
inhibited, and pregnancy is prevented. The estrogen content of the oral site co
ntraceptive may cause the nausea, regardless of when the pill is taken. Side eff
ects and drug interactions may occur with oral contraceptives regardless of the
time the pill is taken. 2. C. Condoms, when used correctly and consistently, are
the most effective contraceptive method or barrier against bacterial and viral
sexually transmitted infections. Although spermicides kill sperm, they do not pr
ovide reliable protection against the spread of sexually transmitted infections,
especially intracellular organisms such as HIV. Insertion and removal of the di
aphragm along with the use of the spermicides may cause vaginal irritations, whi
ch could place the client at risk for infection transmission. Male sterilization
eliminates spermatozoa from the ejaculate, but it does not eliminate bacterial
and/or viral microorganisms that can cause sexually transmitted infections. 3. A
. The diaphragm must be fitted individually to ensure effectiveness. Because of
the changes to the reproductive structures during pregnancy and following delive
ry, the diaphragm must be refitted, usually at the 6 weeks’ examination following
childbirth or after a weight loss of 15 lbs or more. In addition, for maximum ef
fectiveness, spermicidal jelly should be placed in the dome and around the rim.
However, spermicidal jelly should not be inserted into the vagina until involuti
on is completed at approximately 6 weeks. Use of a female condom protects the re
productive system from the introduction of semen or spermicides into the vagina
and may be used after childbirth. Oral contraceptives may be started within the
first postpartum week to ensure suppression of ovulation. For the couple who has
determined the female’s fertile period, using the rhythm method, avoidance of int
ercourse during this period, is safe and effective. 4. C. An IUD may increase th
e risk of pelvic inflammatory disease, especially in women with more than one se
xual partner, because of the increased risk of sexually transmitted infections.
An UID should not be used if the woman has an active or chronic pelvic infection
, postpartum infection, endometrial hyperplasia or carcinoma, or uterine abnorma
lities. Age is not a factor in determining the risks associated with IUD use. Mo
st IUD users are over the age of 30. Although there is a slightly higher risk fo
r infertility in women who have never been pregnant, the IUD is an acceptable op
tion as long as the risk-benefit ratio is discussed. IUDs may be inserted immedi
ately after delivery, but this is not recommended because of the increased risk
and rate of expulsion at this time.
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5. C. During the third trimester, the enlarging uterus places pressure on the in
testines. This coupled with the effect of hormones on smooth muscle relaxation c
auses decreased intestinal motility (peristalsis). Increasing fiber in the diet
will help fecal matter pass more quickly through the intestinal tract, thus decr
easing the amount of water that is absorbed. As a result, stool is softer and ea
sier 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 ca
n 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 essen
tial to maintain hydration and promote stool evacuation. 6. D. To ensure adequat
e fetal growth and development during the 40 weeks of a pregnancy, a total weigh
t gain 25 to 30 pounds is recommended: 1.5 pounds in the first 10 weeks; 9 pound
s 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 tri
mester, the client should only gain 1.5 pounds in the first 10 weeks, not 1 poun
d per week. A weight gain of ½ pound per week would be 20 pounds for the total pre
gnancy, less than the recommended amount. 7. B. To calculate the EDD by Nagele’s r
ule, add 7 days to the first day of the last menstrual period and count back 3 m
onths, 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 LM
P), 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 o
f 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 considere
d preterm (P). A spontaneous abortion occurred at 8 weeks (A). She has two livin
g 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 pe
lvis into the abdominal cavity and is not at the level of the umbilicus. The fet
al heart rate at this age is not audible with a stethoscope. The uterus at 12 we
eks is just above the symphysis pubis in the abdominal cavity, not midway betwee
n 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 w
ould project the FHR, the uterus has not risen to the umbilicus at 12 weeks.
217
10. A. Although all of the choices are important in the management of diabetes,
diet therapy is the mainstay of the treatment plan and should always be the prio
rity. Women diagnosed with gestational diabetes generally need only diet therapy
without medication to control their blood sugar levels. Exercise, is important
for all pregnant women and especially for diabetic women, because it burns up gl
ucose, thus decreasing blood sugar. However, dietary intake, not exercise, is th
e priority. All pregnant women with diabetes should have periodic monitoring of
serum glucose. However, those with gestational diabetes generally do not need da
ily glucose monitoring. The standard of care recommends a fasting and 2hour post
prandial blood sugar level every 2 weeks. 11. C. After 20 weeks’ gestation, when t
here is a rapid weight gain, preeclampsia should be suspected, which may be caus
ed by fluid retention manifested by edema, especially of the hands and face. The
three classic signs of preeclampsia are hypertension, edema, and proteinuria. A
lthough urine is checked for glucose at each clinic visit, this is not the prior
ity. Depression may cause either anorexia or excessive food intake, leading to e
xcessive weight gain or loss. This is not, however, the priority consideration a
t this time. Weight gain thought to be caused by excessive food intake would req
uire a 24-hour diet recall. However, excessive intake would not be the primary c
onsideration for this client at this time. 12. B. Cramping and vaginal bleeding
coupled with cervical dilation signifies that termination of the pregnancy is in
evitable and cannot be prevented. Thus, the nurse would document an imminent abo
rtion. In a threatened abortion, cramping and vaginal bleeding are present, but
there is no cervical dilation. The symptoms may subside or progress to abortion.
In a complete abortion all the products of conception are expelled. A missed ab
ortion is early fetal intrauterine death without expulsion of the products of co
nception. 13. B. For the client with an ectopic pregnancy, lower abdominal pain,
usually unilateral, is the primary symptom. Thus, pain is the priority. Althoug
h the potential for infection is always present, the risk is low in ectopic preg
nancy because pathogenic microorganisms have not been introduced from external s
ources. The client may have a limited knowledge of the pathology and treatment o
f the condition and will most likely experience grieving, but this is not the pr
iority at this time. 14. D. Before uterine assessment is performed, it is essent
ial that the woman empty her bladder. A full bladder will interfere with the acc
uracy of the assessment by elevating the uterus and displacing to the side of th
e midline. Vital sign assessment is not necessary unless an abnormality in uteri
ne assessment is identified. Uterine assessment should not cause acute pain that
requires administration of analgesia. Ambulating the client is an essential com
ponent of postpartum care, but is not necessary prior to assessment of the uteru
s.
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15. A. Feeding more frequently, about every 2 hours, will decrease the infant’s fr
antic, vigorous sucking from hunger and will decrease breast engorgement, soften
the breast, and promote ease of correct latching-on for feeding. Narcotics admi
nistered prior to breast feeding are passed through the breast milk to the infan
t, causing excessive sleepiness. Nipple soreness is not severe enough to warrant
narcotic analgesia. All postpartum clients, especially lactating mothers, shoul
d wear a supportive brassiere with wide cotton straps. This does not, however, p
revent or reduce nipple soreness. Soaps are drying to the skin of the nipples an
d should not be used on the breasts of lactating mothers. Dry nipple skin predis
poses 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 i
ncreased pulse is a compensatory mechanism of the body in response to decreased
fluid volume. Thus, the nurse should check the amount of lochia present. Tempera
tures up to 100.48F in the first 24 hours after birth are related to the dehydra
ting effects of labor and are considered normal. Although rechecking the blood p
ressure may be a correct choice of action, it is not the first action that shoul
d be implemented in light of the other data. The data indicate a potential impen
ding hemorrhage. Assessing the uterus for firmness and position in relation to t
he 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 dischar
ge 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 pre
sent for 2 to 3 days after delivery. Bright red vaginal bleeding at this time su
ggests late postpartum hemorrhage, which occurs after the first 24 hours followi
ng 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 occu
rring from 3 to 10 days after delivery that contains decidua, erythrocytes, leuk
ocytes, cervical mucus, and microorganisms. Lochia alba is an almost colorless t
o yellowish discharge occurring from 10 days to 3 weeks after delivery and conta
ining leukocytes, decidua, epithelial cells, fat, cervical mucus, cholesterol cr
ystals, and bacteria. 18. A. The data suggests an infection of the endometrial l
ining of the uterus. The lochia may be decreased or copious, dark brown in appea
rance, and foul smelling, providing further evidence of a possible infection. Al
l the client’s data indicate a uterine problem, not a breast problem. Typically, t
ransient fever, usually 101 F, may be present with breast engorgement. Symptoms of
mastitis include influenza-like manifestations. Localized infection of an episi
otomy or C-section incision rarely causes systemic symptoms, and uterine involut
ion would not be affected. The client data do
219
not include dysuria, frequency, or urgency, symptoms of urinary tract infections
, which would necessitate assessing the client’s urine. 19. C. Because of early po
stpartum discharge and limited time for teaching, the nurse’s priority is to facil
itate the safe and effective care of the client and newborn. Although promoting
comfort and restoration of health, exploring the family’s emotional status, and te
aching about family planning are important in postpartum/newborn nursing care, t
hey are not the priority focus in the limited time presented by early post-partu
m discharge. 20. C. Heat loss by radiation occurs when the infant’s crib is placed
too near cold walls or windows. Thus placing the newborn’s crib close to the view
ing window would be least effective. Body heat is lost through evaporation durin
g bathing. Placing the infant under the radiant warmer after bathing will assist
the infant to be rewarmed. Covering the scale with a warmed blanket prior to we
ighing prevents heat loss through conduction. A knit cap prevents heat loss from
the head a large head, a large body surface area of the newborn’s body. 21. B. A
fractured clavicle would prevent the normal Moro response of symmetrical sequent
ial extension and abduction of the arms followed by flexion and adduction. In ta
lipes equinovarus (clubfoot) the foot is turned medially, and in plantar flexion
, with the heel elevated. The feet are not involved with the Moro reflex. Hypoth
yroiddism has no effect on the primitive reflexes. Absence of the Moror reflex i
s the most significant single indicator of central nervous system status, but it
is not a sign of increased intracranial pressure. 22. B. Hemorrhage is a potent
ial risk following any surgical procedure. Although the infant has been given vi
tamin K to facilitate clotting, the prophylactic dose is often not sufficient to
prevent bleeding. Although infection is a possibility, signs will not appear wi
thin 4 hours after the surgical procedure. The primary discomfort of circumcisio
n occurs during the surgical procedure, not afterward. Although feedings are wit
hheld prior to the circumcision, the chances of dehydration are minimal. 23. B.
The presence of excessive estrogen and progesterone in the maternalfetal blood f
ollowed by prompt withdrawal at birth precipitates breast engorgement, which wil
l spontaneously resolve in 4 to 5 days after birth. The trauma of the birth proc
ess does not cause inflammation of the newborn’s breast tissue. Newborns do not ha
ve breast malignancy. This reply by the nurse would cause the mother to have und
ue anxiety. Breast tissue does not hypertrophy in the fetus or newborns. 24. D.
The first 15 minutes to 1 hour after birth is the first period of reactivity inv
olving respiratory and circulatory adaptation to extrauterine life. The data giv
en reflect the normal changes during this time period. The infant’s assessment dat
a reflect normal adaptation. Thus, the physician does not need to be notified an
d oxygen is not needed. The data do not indicate the presence of choking, gaggin
g or coughing, which are signs of excessive secretions. Suctioning is not necess
ary.
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25. B. Application of 70% isopropyl alcohol to the cord minimizes microorganisms
(germicidal) and promotes drying. The cord should be kept dry until it falls of
f and the stump has healed. Antibiotic ointment should only be used to treat an
infection, not as a prophylaxis. Infants should not be submerged in a tub of wat
er until the cord falls off and the stump has completely healed. 26. B. To deter
mine the amount of formula needed, do the following mathematical calculation. 3
kg x 120 cal/kg per day = 360 calories/day feeding q 4 hours = 6 feedings per da
y = 60 calories per feeding: 60 calories per feeding; 60 calories per feeding wi
th formula 20 cal/oz = 3 ounces per feeding. Based on the calculation. 2, 4 or 6
ounces are incorrect. 27. A. Intrauterine anoxia may cause relaxation of the an
al sphincter and emptying of meconium into the amniotic fluid. At birth some of
the meconium fluid may be aspirated, causing mechanical obstruction or chemical
pneumonitis. The infant is not at increased risk for gastrointestinal problems.
Even though the skin is stained with meconium, it is noninfectious (sterile) and
nonirritating. The postterm meconiumstained infant is not at additional risk fo
r bowel or urinary problems. 28. C. The nurse should use a nonelastic, flexible,
paper measuring tape, placing the zero point on the superior border of the symp
hysis pubis and stretching the tape across the abdomen at the midline to the top
of the fundus. The xiphoid and umbilicus are not appropriate landmarks to use w
hen measuring the height of the fundus (McDonald’s measurement). 29. B. Women hosp
italized with severe preeclampsia need decreased CNS stimulation to prevent a se
izure. Seizure precautions provide environmental safety should a seizure occur.
Because of edema, daily weight is important but not the priority. Preclampsia ca
uses vasospasm and therefore can reduce utero-placental perfusion. The client sh
ould be placed on her left side to maximize blood flow, reduce blood pressure, a
nd promote diuresis. Interventions to reduce stress and anxiety are very importa
nt to facilitate coping and a sense of control, but seizure precautions are the
priority. 30. C. Cessation of the lochial discharge signifies healing of the end
ometrium. Risk of hemorrhage and infection are minimal 3 weeks after a normal va
ginal delivery. Telling the client anytime is inappropriate because this respons
e does not provide the client with the specific information she is requesting. C
hoice of a contraceptive method is important, but not the specific criteria for
safe resumption of sexual activity. Culturally, the 6weeks’ examination has been u
sed as the time frame for resuming sexual activity, but it may be resumed earlie
r. 31. C. The middle third of the vastus lateralis is the preferred injection si
te for vitamin K administration because it is free of blood vessels and nerves a
nd is large enough to absorb the medication. The deltoid muscle of a newborn is
not large enough for a newborn IM injection. Injections into this muscle in a sm
all child might cause damage to the radial nerve. The
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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. Bartholin’s
glands are the glands on either side of the vaginal orifice. The clitoris is fem
ale erectile tissue found in the perineal area above the urethra. The parotid gl
ands are open into the mouth. Skene’s glands open into the posterior wall of the f
emale urinary meatus. 33. D. The fetal gonad must secrete estrogen for the embry
o 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 preg
nancy and does not effect differentiation. Secretion of androgen by the fetal go
nad would produce a male fetus. 34. A. Using bicarbonate would increase the amou
nt of sodium ingested, which can cause complications. Eating low-sodium crackers
would be appropriate. Since liquids can increase nausea avoiding them in the mo
rning hours when nausea is usually the strongest is appropriate. Eating six smal
l meals a day would keep the stomach full, which often decrease nausea. 35. B. B
allottement indicates passive movement of the unengaged fetus. Ballottement is n
ot a contraction. Fetal kicking felt by the client represents quickening. Enlarg
ement and softening of the uterus is known as Piskacek’s sign. 36. B. Chadwick’s sig
n refers to the purple-blue tinge of the cervix. Braxton Hicks contractions are
painless contractions beginning around the 4th month. Goodell’s sign indicates sof
tening of the cervix. Flexibility of the uterus against the cervix is known as M
cDonald’s sign. 37. C. Breathing techniques can raise the pain threshold and reduc
e the perception of pain. They also promote relaxation. Breathing techniques do
not eliminate pain, but they can reduce it. Positioning, not breathing, increase
s uteroplacental perfusion. 38. A. The client’s labor is hypotonic. The nurse shou
ld 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 inc
rease the uterine contractions and hopefully progress labor before a cesarean wo
uld be necessary. It is too early to anticipate client pushing with contractions
. 39. D. The signs indicate placenta previa and vaginal exam to determine cervic
al dilation would not be done because it could cause hemorrhage. Assessing mater
nal vital signs can help determine maternal physiologic status. Fetal heart rate
is important to assess fetal well-being and should be done. Monitoring the cont
ractions 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 w
hat a complete previa is and the reason the baby cannot come out except by cesar
ean delivery. Telling the client to ask the physician is a poor response and wou
ld increase the patient’s anxiety. Although a cesarean would help to prevent hemor
rhage, the statement does not explain why the hemorrhage could occur. With a com
plete 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 pres
entation, the head is completely or partially flexed. With a brow (forehead) pre
sentation, 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 l
eft of the middle. The other positions would be incorrect. 43. C. The greenish t
int is due to the presence of meconium. Lanugo is the soft, downy hair on the sh
oulders and back of the fetus. Hydramnios represents excessive amniotic fluid. V
ernix is the white, cheesy substance covering the fetus. 44. D. In a breech posi
tion, because of the space between the presenting part and the cervix, prolapse
of the umbilical cord is common. Quickening is the woman’s first perception of fet
al movement. Ophthalmia neonatorum usually results from maternal gonorrhea and i
s conjunctivitis. Pica refers to the oral intake of nonfood substances. 45. A. D
izygotic (fraternal) twins involve two ova fertilized by separate sperm. Monozyg
otic (identical) twins involve a common placenta, same genotype, and common chor
ion. 46. C. The zygote is the single cell that reproduces itself after conceptio
n. 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 1950’s 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 clini
cal nurse specialists did not develop from this challenge. 48. C. The ischial sp
ines are located in the mid-pelvic region and could be narrowed due to the previ
ous pelvic injury. The symphysis pubis, sacral promontory, and pubic arch are no
t 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 prod
uced by the Leyding cells in the seminiferous tubules. Follicle-stimulating horm
one and leuteinzing hormone are
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released by the anterior pituitary gland. The hypothalamus is responsible for re
leasing gonadotropin-releasing hormone.
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MEDICAL SURGICAL NURSING 1. Marco who was diagnosed with brain tumor was schedul
ed for craniotomy. In preventing the development of cerebral edema after surgery
, the nurse should expect the use of: a. Diuretics b. Antihypertensive c. Steroi
ds d. Anticonvulsants 2. Halfway through the administration of blood, the female
client complains of lumbar pain. After stopping the infusion Nurse Hazel should
: a. Increase the flow of normal saline b. Assess the pain further c. Notify the
blood bank d. Obtain vital signs. 3. Nurse Maureen knows that the positive diag
nosis for HIV infection is made based on which of the following: a. A history of
high risk sexual behaviors. b. Positive ELISA and western blot tests c. Identif
ication of an associated opportunistic infection d. Evidence of extreme weight l
oss and high fever 4. Nurse Maureen is aware that a client who has been diagnose
d with chronic renal failure recognizes an adequate amount of high-biologic-valu
e protein when the food the client selected from the menu was: a. Raw carrots b.
Apple juice c. Whole wheat bread d. Cottage cheese 5. Kenneth who has diagnosed
with uremic syndrome has the potential to develop complications. Which among th
e following complications should the nurse anticipates: a. Flapping hand tremors
b. An elevated hematocrit level c. Hypotension d. Hypokalemia 6. A client is ad
mitted to the hospital with benign prostatic hyperplasia, the nurse most relevan
t assessment would be: a. Flank pain radiating in the groin b. Distention of the
lower abdomen c. Perineal edema d. Urethral discharge 7. A client has undergone
with penile implant. After 24 hrs of surgery, the client’s scrotum was edematous
and painful. The nurse should: a. Assist the client with sitz bath b. Apply war
soaks in the scrotum c. Elevate the scrotum using a soft support
225
d. Prepare for a possible incision and drainage. 8. Nurse hazel receives emergen
cy laboratory results for a client with chest pain and immediately informs the p
hysician. An increased myoglobin level suggests which of the following? a. Liver
disease b. Myocardial damage c. Hypertension d. Cancer 9. Nurse Maureen would e
xpect the a client with mitral stenosis would demonstrate symptoms associated wi
th congestion in the: a. Right atrium b. Superior vena cava c. Aorta d. Pulmonar
y 10. A client has been diagnosed with hypertension. The nurse priority nursing
diagnosis would be: a. Ineffective health maintenance b. Impaired skin integrity
c. Deficient fluid volume d. Pain 11. Nurse Hazel teaches the client with angin
a about common expected side effects of nitroglycerin including: a. high blood p
ressure b. stomach cramps c. headache d. shortness of breath 12. The following a
re lipid abnormalities. Which of the following is a risk factor for the developm
ent of atherosclerosis and PVD? a. High levels of low density lipid (LDL) choles
terol b. High levels of high density lipid (HDL) cholesterol c. Low concentratio
n triglycerides d. Low levels of LDL cholesterol. 13. Which of the following rep
resents a significant risk immediately after surgery for repair of aortic aneury
sm? a. Potential wound infection b. Potential ineffective coping c. Potential el
ectrolyte balance d. Potential alteration in renal perfusion 14. Nurse Josie sho
uld instruct the client to eat which of the following foods to obtain the best s
upply of Vitamin B12? a. dairy products b. vegetables c. Grains d. Broccoli 15.
Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in
which of the following physiologic functions?
226
a. Bowel function b. Peripheral sensation c. Bleeding tendencies d. Intake and o
ut 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 acqu
iring acute lymphocytic leukemia (ALL)? a. 4 to 12 years. b. 20 to 30 years c. 4
0 to 50 years d. 60 60 70 years 18. Marie with acute lymphocytic leukemia suffer
s from nausea and headache. These clinical manifestations may indicate all of th
e following except a. effects of radiation b. chemotherapy side effects c. menin
geal irritation d. gastric distension 19. A client has been diagnosed with Disse
minated Intravascular Coagulation (DIC). Which of the following is contraindicat
ed with the client? a. Administering Heparin b. Administering Coumadin c. Treati
ng the underlying cause d. Replacing depleted blood products 20. Which of the fo
llowing findings is the best indication that fluid replacement for the client wi
th hypovolemic shock is adequate? a. Urine output greater than 30ml/hr b. Respir
atory 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 sig
ns and symptoms would Nurse Maureen include in teaching plan as an early manifes
tation of laryngeal cancer? a. Stomatitis b. Airway obstruction c. Hoarseness d.
Dysphagia 22. Karina a client with myasthenia gravis is to receive immunosuppre
ssive 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.
227
c. Decreases the production of autoantibodies that attack the acetylcholine rece
ptors. d. Inhibits the breakdown of acetylcholine at the neuromuscular junction.
23. A female client is receiving IV Mannitol. An assessment specific to safe ad
ministration of the said drug is: a. Vital signs q4h b. Weighing daily c. Urine
output hourly d. Level of consciousness q4h 24. Patricia a 20 year old college s
tudent with diabetes mellitus requests additional information about the advantag
es of using a pen like insulin delivery devices. The nurse explains that the adv
antages of these devices over syringes includes: a. Accurate dose delivery b. Sh
orter injection time c. Lower cost with reusable insulin cartridges d. Use of sm
aller gauge needle. 25. A male client’s left tibia is fractures in an automobile a
ccident, and a cast is applied. To assess for damage to major blood vessels from
the fracture tibia, the nurse in charge should monitor the client for: a. Swell
ing of the left thigh b. Increased skin temperature of the foot c. Prolonged rep
erfusion of the toes after blanching d. Increased blood pressure 26. After a lon
g leg cast is removed, the male client should: a. Cleanse the leg by scrubbing w
ith a brisk motion b. Put leg through full range of motion twice daily c. Report
any discomfort or stiffness to the physician d. Elevate the leg when sitting fo
r long periods of time. 27. While performing a physical assessment of a male cli
ent with gout of the great toe, NurseVivian should assess for additional tophi (
urate deposits) on the: a. Buttocks b. Ears c. Face d. Abdomen 28. Nurse Katrina
would recognize that the demonstration of crutch walking with tripod gait was u
nderstood when the client places weight on the: a. Palms of the hands and axilla
ry regions b. Palms of the hand c. Axillary regions d. Feet, which are set apart
29. Mang Jose with rheumatoid arthritis states, “the only time I am without pain
is when I lie in bed perfectly still”. During the convalescent stage, the nurse in
charge with Mang Jose should encourage: a. Active joint flexion and extension
228
b. Continued immobility until pain subsides c. Range of motion exercises twice d
aily d. Flexion exercises three times daily 30. A male client has undergone spin
al surgery, the nurse should: a. Observe the client’s bowel movement and voiding p
atterns b. Log-roll the client to prone position c. Assess the client’s feet for s
ensation and circulation d. Encourage client to drink plenty of fluids 31. Marin
a with acute renal failure moves into the diuretic phase after one week of thera
py. During this phase the client must be assessed for signs of developing: a. Hy
povolemia b. renal failure c. metabolic acidosis d. hyperkalemia 32. Nurse Judit
h obtains a specimen of clear nasal drainage from a client with a head injury. W
hich of the following tests differentiates mucus from cerebrospinal fluid (CSF)?
a. Protein b. Specific gravity c. Glucose d. Microorganism 33. A 22 year old cl
ient suffered from his first tonic-clonic seizure. Upon awakening the client ask
s the nurse, “What caused me to have a seizure? Which of the following would the n
urse include in the primary cause of tonic clonic seizures in adults more the 20
years? a. Electrolyte imbalance b. Head trauma c. Epilepsy d. Congenital defect
34. What is the priority nursing assessment in the first 24 hours after admissi
on of the client with thrombotic CVA? a. Pupil size and papillary response b. ch
olesterol level c. Echocardiogram d. Bowel sounds 35. Nurse Linda is preparing a
client with multiple sclerosis for discharge from the hospital to home. Which o
f the following instruction is most appropriate? a. “Practice using the mechanical
aids that you will need when future disabilities arise”. b. “Follow good health hab
its to change the course of the disease”. c. “Keep active, use stress reduction stra
tegies, and avoid fatigue. d. “You will need to accept the necessity for a quiet a
nd inactive lifestyle”. 36. The nurse is aware the early indicator of hypoxia in t
he unconscious client is: a. Cyanosis b. Increased respirations
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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 t
he carcinogen is irreversible? a. Progression stage b. Initiation stage c. Regre
ssion 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. Whi
ch of the client’s action could aggravate the cause of flare ups? a. Sleeping in c
ool and humidified environment b. Daily baths with fragrant soap c. Using clothe
s made from 100% cotton d. Increasing fluid intake 41. Atropine sulfate (Atropin
e) is contraindicated in all but one of the following client? a. A client with h
igh blood b. A client with bowel obstruction c. A client with glaucoma d. A clie
nt 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-yea
r-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 wo
uld the nurse assess next? a. Headache b. Bladder distension c. Dizziness d. Abi
lity 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 ex
cept: a. Antiemetics
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b. Diuretics c. Antihistamines d. Glucocorticoids 45. Which of the following com
plications associated with tracheostomy tube? a. Increased cardiac output b. Acu
te 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 w
hole 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 ecc
hymotic 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. s
elf inflicted injury d. elder abuse 48. Nurse Anna is aware that early adaptatio
n of client with renal carcinoma is: a. Nausea and vomiting b. flank pain c. wei
ght gain d. intermittent hematuria 49. A male client with tuberculosis asks Nurs
e Brian how long the chemotherapy must be continued. Nurse Brian’s 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 b
e: a. Keep trachea free of secretions b. Monitor for signs of infection c. Provi
de emotional support d. Promote means of communication
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ANSWERS AND RATIONALE – MEDICAL SURGICAL NURSING 1. C. Glucocorticoids (steroids)
are used for their anti-inflammatory action, which decreases the development of
edema. 2. A. The blood must be stopped at once, and then normal saline should be
infused to keep the line patent and maintain blood volume. 3. B. These tests co
nfirm the presence of HIV antibodies that occur in response to the presence of t
he human immunodeficiency virus (HIV). 4. D. One cup of cottage cheese contains
approximately 225 calories, 27 g of protein, 9 g of fat, 30 mg cholesterol, and
6 g of carbohydrate. Proteins of high biologic value (HBV) contain optimal level
s of amino acids essential for life. 5. A. Elevation of uremic waste products ca
uses irritation of the nerves, resulting in flapping hand tremors. 6. B. This in
dicates that the bladder is distended with urine, therefore palpable. 7. C. Elev
ation increases lymphatic drainage, reducing edema and pain. 8. B. Detection of
myoglobin is a diagnostic tool to determine whether myocardial damage has occurr
ed. 9. D. When mitral stenosis is present, the left atrium has difficulty emptyi
ng its contents into the left ventricle because there is no valve to prevent bac
k ward flow into the pulmonary vein, the pulmonary circulation is under pressure
. 10. A. Managing hypertension is the priority for the client with hypertension.
Clients with hypertension frequently do not experience pain, deficient volume,
or impaired skin integrity. It is the asymptomatic nature of hypertension that m
akes it so difficult to treat. 11. C. Because of its widespread vasodilating eff
ects, nitroglycerin often produces side effects such as headache, hypotension an
d dizziness. 12. A. An increased in LDL cholesterol concentration has been docum
ented at risk factor for the development of atherosclerosis. LDL cholesterol is
not broken down into the liver but is deposited into the wall of the blood vesse
ls. 13. D. There is a potential alteration in renal perfusion manifested by decr
eased urine output. The altered renal perfusion may be related to renal artery e
mbolism, prolonged hypotension, or prolonged aortic cross-clamping during the su
rgery. 14. A. Good source of vitamin B12 are dairy products and meats. 15. C. Ap
lastic anemia decreases the bone marrow production of RBC’s, white blood cells, an
d platelets. The client is at risk for bruising and bleeding tendencies. 16. B.
An elective procedure is scheduled in advance so that all preparations can be co
mpleted ahead of time. The vital signs are the final check that must be complete
d before the client leaves the room so that continuity of care and assessment is
provided for. 17. A. The peak incidence of Acute Lymphocytic Leukemia (ALL) is
4 years of age. It is uncommon after 15 years of age.
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18. D. Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It do
es invade the central nervous system, and clients experience headaches and vomit
ing from meningeal irritation. 19. B. Disseminated Intravascular Coagulation (DI
C) has not been found to respond to oral anticoagulants such as Coumadin. 20. A.
Urine output provides the most sensitive indication of the client’s response to t
herapy for hypovolemic shock. Urine output should be consistently greater than 3
0 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 body’s immune
response thus decreasing the production of antibodies that attack the acetylchol
ine receptors at the neuromuscular junction 23. C. The osmotic diuretic mannitol
is contraindicated in the presence of inadequate renal function or heart failur
e because it increases the intravascular volume that must be filtered and excret
ed 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 m
ay 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 t
hat usually occurs. 27. B. Uric acid has a low solubility, it tends to precipita
te and form deposits at various sites where blood flow is least active, includin
g cartilaginous tissue such as the ears. 28. B. The palms should bear the client’s
weight to avoid damage to the nerves in the axilla. 29. A. Active exercises, al
ternating extension, flexion, abduction, and adduction, mobilize exudates in the
joints relieves stiffness and pain. 30. C. Alteration in sensation and circulat
ion indicates damage to the spinal cord, if these occurs notify physician immedi
ately. 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 sho
uld be replaced. 32. C. The constituents of CSF are similar to those of blood pl
asma. An examination for glucose content is done to determine whether a body flu
id 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 an
d 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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36. D. Restlessness is an early indicator of hypoxia. The nurse should suspect h
ypoxia in unconscious client who suddenly becomes restless. 37. B. In spinal sho
ck, the bladder becomes completely atonic and will continue to fill unless the c
lient is catheterized. 38. A. Progression stage is the change of tumor from the
preneoplastic state or low degree of malignancy to a fast growing tumor that can
not be reversed. 39. D. Intensity is the major indicative of severity of pain an
d it is important for the evaluation of the treatment. 40. B. The use of fragran
t soap is very drying to skin hence causing the pruritus. 41. C. Atropine sulfat
e is contraindicated with glaucoma patients because it increases intraocular pre
ssure. 42. A. A 67 year old client is greater risk because the older adult clien
t is more likely to have a less-effective immune system. 43. B. The last area to
return sensation is in the perineal area, and the nurse in charge should monito
r the client for distended bladder. 44. D. Glucocorticoids play no significant r
ole in disease treatment. 45. D. Tracheostomy tube has several potential complic
ations including bleeding, infection and laryngeal nerve damage. 46. C. In burn,
the capillaries and small vessels dilate, and cell damage cause the release of
a histamine-like substance. The substance causes the capillary walls to become m
ore permeable and significant quantities of fluid are lost. 47. A. Aging process
involves increased capillary fragility and permeability. Older adults have a de
creased amount of subcutaneous fat and cause an increased incidence of bruise li
ke lesions caused by collection of extravascular blood in loosely structured der
mis. 48. D. Intermittent pain is the classic sign of renal carcinoma. It is prim
arily due to capillary erosion by the cancerous growth. 49. B. Tubercle bacillus
is a drug resistant organism and takes a long time to be eradicated. Usually a
combination of three drugs is used for minimum of 6 months and at least six mont
hs beyond culture conversion. 50. A. Patent airway is the most priority; therefo
re removal of secretions is necessary.
234
1.
2.
3.
4.
5.
6.
7.
8.
PSYCHIATRIC NURSING Marco approached Nurse Trish asking for advice on how to dea
l with his alcohol addiction. Nurse Trish should tell the client that the only e
ffective treatment for alcoholism is: a. Psychotherapy b. Alcoholics anonymous (
A.A.) c. Total abstinence d. Aversion Therapy Nurse Hazel is caring for a male c
lient who experience false sensory perceptions with no basis in reality. This pe
rception is known as: a. Hallucinations b. Delusions c. Loose associations d. Ne
ologisms Nurse Monet is caring for a female client who has suicidal tendency. Wh
en accompanying the client to the restroom, Nurse Monet should… a. Give her privac
y 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 w
ith anorexia nervosa. Which action should the nurse include in the plan? a. Prov
ide privacy during meals b. Set-up a strict eating plan for the client c. Encour
age client to exercise to reduce anxiety d. Restrict visits with the family A cl
ient is experiencing anxiety attack. The most appropriate nursing intervention s
hould include? a. Turning on the television b. Leaving the client alone c. Stayi
ng with the client and speaking in short sentences d. Ask the client to play wit
h other clients A female client is admitted with a diagnosis of delusions of GRA
NDEUR. This diagnosis reflects a belief that one is: a. Being Killed b. Highly f
amous and important c. Responsible for evil world d. Connected to client unrelat
ed to oneself A 20 year old client was diagnosed with dependent personality diso
rder. Which behavior is not likely to be evidence of ineffective individual copi
ng? a. Recurrent self-destructive behavior b. Avoiding relationship c. Showing i
nterest 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 beha
vior 9. Nurse Claire is caring for a client diagnosed with bulimia. The most app
ropriate initial goal for a client diagnosed with bulimia is? a. Encourage to av
oid 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 developme
nt? a. Generates new levels of awareness b. Assumes responsibility for her actio
ns c. Has maximum ability to solve problems and learn new skills d. Her percepti
on 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 Alzheimer’s type and depression. The symptom that is unrelated to depression
would be? a. Apathetic response to the environment b. “I don’t know” answer to questio
ns 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 fo
r a newly admitted client with bulimia nervosa would be to? a. Teach client to m
easure I & O b. Involve client in planning daily meal c. Observe client during m
eals d. Monitor client continuously 14. Nurse Patricia is aware that the major h
ealth complication associated with intractable anorexia nervosa would be? a. Car
diac dysrhythmias resulting to cardiac arrest b. Glucose intolerance resulting i
n protracted hypoglycemia c. Endocrine imbalance causing cold amenorrhea d. Decr
eased metabolism causing cold intolerance 15. Nurse Anna can minimize agitation
in a disturbed client by? a. Increasing stimulation b. limiting unnecessary inte
raction c. increasing appropriate sensory perception d. ensuring constant client
and staff contact
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16. A 39 year old mother with obsessive-compulsive disorder has become immobiliz
ed by her elaborate hand washing and walking rituals. Nurse Trish recognizes tha
t the basis of O.C. disorder is often: a. Problems with being too conscientious
b. Problems with anger and remorse c. Feelings of guilt and inadequacy d. Feelin
g of unworthiness and hopelessness 17. Mario is complaining to other clients abo
ut not being allowed by staff to keep food in his room. Which of the following i
nterventions would be most appropriate? a. Allowing a snack to be kept in his ro
om b. Reprimanding the client c. Ignoring the clients behavior d. Setting limits
on the behavior 18. Conney with borderline personality disorder who is to be di
scharge soon threatens to “do something” to herself if discharged. Which of the foll
owing actions by the nurse would be most important? a. Ask a family member to st
ay with the client at home temporarily b. Discuss the meaning of the client’s stat
ement with her c. Request an immediate extension for the client d. Ignore the cl
ients statement because it’s a sign of manipulation 19. Joey a client with antisoc
ial personality disorder belches loudly. A staff member asks Joey, “Do you know wh
y people find you repulsive?” this statement most likely would elicit which of the
following client reaction? a. Depensiveness b. Embarrassment c. Shame d. Remors
efulness 20. Which of the following approaches would be most appropriate to use
with a client suffering from narcissistic personality disorder when discrepancie
s exist between what the client states and what actually exist? a. Rationalizati
on b. Supportive confrontation c. Limit setting d. Consistency 21. Cely is exper
iencing alcohol withdrawal exhibits tremors, diaphoresis and hyperactivity. Bloo
d pressure is 190/87 mmhg and pulse is 92 bpm. Which of the medications would th
e nurse expect to administer? a. Naloxone (Narcan) b. Benzlropine (Cogentin) c.
Lorazepam (Ativan) d. Haloperidol (Haldol) 22. Which of the following foods woul
d the nurse Trish eliminate from the diet of a client in alcohol withdrawal? a.
Milk b. Orange Juice
237
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. Yawni
ng & diaphoresis b. Restlessness & Irritability c. Constipation & steatorrhea d.
Vomiting and Diarrhea 24. To establish open and trusting relationship with a fe
male client who has been hospitalized with severe anxiety, the nurse in charge s
hould? a. Encourage the staff to have frequent interaction with the client b. Sh
are an activity with the client c. Give client feedback about behavior d. Respec
t client’s need for personal space 25. Nurse Monette recognizes that the focus of
environmental (MILIEU) therapy is to: a. Manipulate the environment to bring abo
ut positive changes in behavior b. Allow the client’s freedom to determine whether
or not they will be involved in activities c. Role play life events to meet ind
ividual needs d. Use natural remedies rather than drugs to control behavior 26.
Nurse Trish would expect a child with a diagnosis of reactive attachment disorde
r 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 childh
ood depression Nurse Trina should say? a. It may appear acting out behavior b. D
oes not respond to conventional treatment c. Is short in duration & resolves eas
ily d. Looks almost identical to adult depression 28. Nurse Perry is aware that
language development in autistic child resembles: a. Scanning speech b. Speech l
ag c. Shuttering d. Echolalia 29. A 60 year old female client who lives alone te
lls the nurse at the community health center “I really don’t need anyone to talk to”.
The TV is my best friend. The nurse recognizes that the client is using the defe
nse mechanism known as? a. Displacement b. Projection
238
c. Sublimation d. Denial 30. When working with a male client suffering phobia ab
out black cats, Nurse Trish should anticipate that a problem for this client wou
ld be? a. Anxiety when discussing phobia b. Anger toward the feared object c. De
nying that the phobia exist d. Distortion of reality when completing daily routi
nes 31. Linda is pacing the floor and appears extremely anxious. The duty nurse
approaches in an attempt to alleviate Linda’s anxiety. The most therapeutic questi
on 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 Pen
ny is aware that the symptoms that distinguish post traumatic stress disorder fr
om other anxiety disorder would be: a. Avoidance of situation & certain activiti
es that resemble the stress b. Depression and a blunted affect when discussing t
he 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 f
acts and fills in the gaps with imaginary information. Nurse Benjie is aware tha
t this is typical of? a. Flight of ideas b. Associative looseness c. Confabulati
on 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 b
ehavior, excessive fears & nausea d. Excessive activity, memory lapses & an incr
eased pulse 35. A characteristic that would suggest to Nurse Anne that an adoles
cent may have bulimia would be: a. Frequent regurgitation & re-swallowing of foo
d 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 d
ecision making
239
d. Varied Activities 37. To further assess a client’s suicidal potential. Nurse Ka
trina should be especially alert to the client expression of: a. Frustration & f
ear of death b. Anger & resentment c. Anxiety & loneliness d. Helplessness & hop
elessness 38. A nursing care plan for a male client with bipolar I disorder shou
ld include: a. Providing a structured environment b. Designing activities that w
ill require the client to maintain contact with reality c. Engaging the client i
n conversing about current affairs d. Touching the client provide assurance 39.
When planning care for a female client using ritualistic behavior, Nurse Gina mu
st 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 client’s con
scious control d. Is used by the client primarily for secondary gains 40. A 32 y
ear old male graduate student, who has become increasingly withdrawn and neglect
ful 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 th
inking c. Effective self boundaries d. Weak ego 41. A 23 year old client has bee
n admitted with a diagnosis of schizophrenia says to the nurse “Yes, its march, Ma
rch is little woman”. That’s literal you know”. These statement illustrate: a. Neologi
sms 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 wif
e 43. A male client who is experiencing disordered thinking about food being poi
soned 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
240
b. Using open ended question and silence c. Offering opinion about the need to e
at d. Verbalizing reasons that the client may not choose to eat 44. Nurse Nina i
s assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina
enters the client’s room, the client is found lying on the bed with a body pulled
into a fetal position. Nurse Nina should? a. Ask the client direct questions to
encourage talking b. Rake the client into the dayroom to be with other clients
c. Sit beside the client in silence and occasionally ask open-ended question d.
Leave the client alone and continue with providing care to the other clients 45.
Nurse Tina is caring for a client with delirium and states that “look at the spid
ers on the wall”. What should the nurse respond to the client? a. “You’re having hallu
cination, there are no spiders in this room at all” b. “I can see the spiders on the
wall, but they are not going to hurt you” c. “Would you like me to kill the spiders”
d. “I know you are frightened, but I do not see spiders on the wall” 46. Nurse Jonel
is providing information to a community group about violence in the family. Whi
ch statement by a group member would indicate a need to provide additional infor
mation? a. “Abuse occurs more in low-income families” b. “Abuser Are often jealous or
self-centered” c. “Abuser use fear and intimidation” d. “Abuser usually have poor self-e
steem” 47. During electroconvulsive therapy (ECT) the client receives oxygen by ma
sk via positive pressure ventilation. The nurse assisting with this procedure kn
ows that positive pressure ventilation is necessary because? a. Anesthesia is ad
ministered during the procedure b. Decrease oxygen to the brain increases confus
ion and disorientation c. Grand mal seizure activity depresses respirations d. M
uscle relaxations given to prevent injury during seizure activity depress respir
ations. 48. When planning the discharge of a client with chronic anxiety, Nurse
Chris evaluates achievement of the discharge maintenance goals. Which goal would
be most appropriately having been included in the plan of care requiring evalua
tion? a. The client eliminates all anxiety from daily situations b. The client i
gnores feelings of anxiety c. The client identifies anxiety producing situations
d. The client maintains contact with a crisis counselor 49. Nurse Tina is carin
g for a client with depression who has not responded to antidepressant medicatio
n. The nurse anticipates that what treatment procedure may be prescribed.
241
a. Neuroleptic medication b. Short term seclusion c. Psychosurgery d. Electrocon
vulsive therapy 50. Mario is admitted to the emergency room with drug-included a
nxiety related to over ingestion of prescribed antipsychotic medication. The mos
t 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 amou
nt ingested c. Reason for the suicide attempt d. Name of the nearest relative &
their phone number
242
ANSWERS AND RATIONALE – PSYCHIATRIC NURSING 1. C. Total abstinence is the only eff
ective treatment for alcoholism 2. A. Hallucinations are visual, auditory, gusta
tory, tactile or olfactory perceptions that have no basis in reality. 3. D. The
Nurse has a responsibility to observe continuously the acutely suicidal client.
The Nurse should watch for clues, such as communicating suicidal thoughts, and m
essages; hoarding medications and talking about death. 4. B. Establishing a cons
istent eating plan and monitoring client’s weight are important to this disorder.
5. C. Appropriate nursing interventions for an anxiety attack include using shor
t sentences, staying with the client, decreasing stimuli, remaining calm and med
icating as needed. 6. B. Delusion of grandeur is a false belief that one is high
ly famous and important. 7. D. Individual with dependent personality disorder ty
pically shows indecisiveness submissiveness and clinging behavior so that others
will make decisions with them. 8. A. Clients with schizotypal personality disor
der experience excessive social anxiety that can lead to paranoid thoughts 9. B.
Bulimia disorder generally is a maladaptive coping response to stress and under
lying issues. The client should identify anxiety causing situation that stimulat
e the bulimic behavior and then learn new ways of coping with the anxiety. 10. A
. An adult age 31 to 45 generates new level of awareness. 11. A. Neuromuscular B
locker, such as SUCCINYLCHOLINE (Anectine) produces respiratory depression becau
se it inhibits contractions of respiratory muscles. 12. C. With depression, ther
e is little or no emotional involvement therefore little alteration in affect. 1
3. D. These clients often hide food or force vomiting; therefore they must be ca
refully monitored. 14. A. These clients have severely depleted levels of sodium
and potassium because of their starvation diet and energy expenditure, these ele
ctrolytes are necessary for cardiac functioning. 15. B. Limiting unnecessary int
eraction will decrease stimulation and agitation. 16. C. Ritualistic behavior se
en in this disorder is aimed at controlling guilt and inadequacy by maintaining
an absolute set pattern of behavior. 17. D. The nurse needs to set limits in the
client’s manipulative behavior to help the client control dysfunctional behavior.
A consistent approach by the staff is necessary to decrease manipulation. 18. B
. Any suicidal statement must be assessed by the nurse. The nurse should discuss
the client’s statement with her to determine its meaning in terms of suicide. 19.
A. When the staff member ask the client if he wonders why others find him repul
sive, the client is likely to feel defensive because the question is belittling.
The natural tendency is to counterattack the threat to self image.
243
20. B. The nurse would specifically use supportive confrontation with the client
to point out discrepancies between what the client states and what actually exi
sts to increase responsibility for self. 21. C. The nurse would most likely admi
nister benzodiazepine, such as lorazepan (ativan) to the client who is experienc
ing symptom: The client’s experiences symptoms of withdrawal because of the reboun
d phenomenon when the sedation of the CNS from alcohol begins to decrease. 22. D
. Regular coffee contains caffeine which acts as psychomotor stimulants and lead
s 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, abdom
inal cramps and backache. 24. D. Moving to a client’s personal space increases the
feeling of threat, which increases anxiety. 25. A. Environmental (MILIEU) thera
py aims at having everything in the client’s surrounding area toward helping the c
lient. 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 behavi
or, such as temper tantrums, may indicate underlying depression. 28. D. The auti
stic 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 cli
ent with support & feeling of control. 32. D. Experiencing the actual trauma in
dreams or flashback is the major symptom that distinguishes post traumatic stres
s disorder from other anxiety disorder. 33. C. Confabulation or the filling in o
f memory gaps with imaginary facts is a defense mechanism used by people experie
ncing memory deficits. 34. A. These are the major signs of anorexia nervosa. Wei
ght loss is excessive (15% of expected weight) 35. C. Dental enamel erosion occu
rs from repeated self-induced vomiting. 36. B. Depression usually is both emotio
nal & physical. A simple daily routine is the best, least stressful and least an
xiety producing. 37. D. The expression of these feeling may indicate that this c
lient is unable to continue the struggle of life. 38. A. Structure tends to decr
ease agitation and anxiety and to increase the client’s feeling of security. 39. B
. The rituals used by a client with obsessive compulsive disorder help control t
he anxiety level by maintaining a set pattern of action. 40. C. A person with th
is disorder would not have adequate self-boundaries
244
41. D. Loose associations are thoughts that are presented without the logical co
nnections usually necessary for the listening to interpret the message. 42. C. H
elping the client to develop feeling of self worth would reduce the client’s need
to use pathologic defenses. 43. B. Open ended questions and silence are strategi
es 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 patie
nce from the nurse. The nurse facilitates communication with the client by sitti
ng in silence, asking open-ended question and pausing to provide opportunities f
or the client to respond. 45. D. When hallucination is present, the nurse should
reinforce reality with the client. 46. A. Personal characteristics of abuser in
clude low self-esteem, immaturity, dependence, insecurity and jealousy. 47. D. A
short acting skeletal muscle relaxant such as succinylcholine (Anectine) is adm
inistered during this procedure to prevent injuries during seizure. 48. C. Recog
nizing situations that produce anxiety allows the client to prepare to cope with
anxiety or avoid specific stimulus. 49. D. Electroconvulsive therapy is an effe
ctive 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 me
dication ingested are of outmost important in treating this potentially life thr
eatening situation.
245
References • • • • • • • • • • • • • • • • • • • • • • • • • Maternal and Child Nursing by
nfants and Children 8th Edition MS Manuals of Nursing Practice by Lippincott Psy
chiatric Mental Health Nursing 4th Edition by Fortinash Management and Leadershi
p for Nurse Administrators 5th Edition by Linda Roussel Essentials of Gerontolog
ical Nursing by Patricia Tabloski Fundamentals of Nursing 2nd Edition by Josie Q
uiambao-Udan RN, MAN Nursing Practice in the Community 4th Edition by Araceli Ma
glaya Community Health Nursing Services in the Philippines 9th Edition- DOH Fund
amentals of Nursing 7th Edition by Barbara Kozier Et al. Modules for Basic Nursi
ng Skills 6th Edition by Janice Rider Ellis Kaplan NCLEX-RN 2008-2009 Edition by
Barbara Irwin Saunders Q &A Review for the NCLEX-RN Examination 3rd Edition by
Linda Anne Silvestre Sia s Nursing Questions and Answers 2005 Edition by Maria L
oreto Evangelista-Sia NCLEX-RN Made Incredibly Easy by Lippincott and Williams L
ippincott’s Review Series Pediatric Nursing 2nd Edition Mosby s Review Questions f
or the NCLEX-RN Examination 5th Edition Saunders NCLEX-RN Examination 3rd editio
n Lippincott’s Review for NCLEX-RN 8th edition Davis NCLEX-RN Success 2nd edition
Lippincott’s Review Series – Maternal Newborn Nursing 2nd Edition Brunner and Suddar
t Review for NCLEX-RN Springhouse Made Incredibly Easy Jaypee s Comprehensive Re
view of CGFNS Lippincott’s Review Series – Medical Surgical Nursing 2nd Edition
246

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