HAAD Exam Questions

EMERGENCY NURSING
1. The client is brought to the emergency department due to drug poisoning.
Which of the following nursing interventions is most effective in the
management of the client’s condition?

a) Gastric lavage
b) Activated charcoal
c) Cathartic administration
d) Milk dilution

2. Health care providers were informed of the presence of biochemical terrorism

in the area. The nurse in the emergency department is helping in preparing and
administering antitoxins. Which of the following agents of bioterrorism is treated
with an antitoxin?

a) Botulism
b) Smallpox
c) Anthrax
d) Tularemia

3. A client is given Morphine 6 mg IV push after the surgery. Moments later, the
client is sleeping quietly and the vital signs are as follows: Pulse 69 bpm,
Respiration rate: 7 CPM, BP: 100/60 mmHg. Which of the following nursing
actions is the priority this time?

a) Let the client rest.

b) Administer oxygen.
c) Administer naloxone (Narcan) per physician’s order.
d) Place epinephrine at the bedside.

4. The nurse is assessing the fluid status of a client receiving IV fluids after
surgery. Which of the following symptoms indicate fluid volume overload?

a) Temperature: 38.9°C, BP 90/60, pulse 98, and thready.

b) Cool skin, respiratory crackles, pulse 84, and bounding.
c) Abdominal pain, headache, and lethargy.
d) CVP of 5, Urinary output: 700 cc/24 hours and nystagmus.
5. An unconscious client with multiple injuries arrives in the emergency
department. Which of the following nursing interventions receives the highest
priority?

a) Stopping bleeding from open wounds

b) Checking for neck fracture
c) Establishing an airway
d) Replacing blood loss

FUNDAMENTALS OF NURSING
6. A client is recovering from a total laryngectomy procedure. Which of the
following interventions should the nurse include in the instructions regarding
care for the stoma? Select all that apply.

a) Clean the stoma using diluted alcohol.

b) Keep water away from the stoma.
c) Avoid using soap near the stoma.
d) Wipe secretions draining around the stoma using a soft tissue.
e) Regularly wash the stoma using a washcloth.
f) Apply a thin layer of petroleum jelly into the skin surrounding the stoma.

7. A nurse is assessing a group of clients. The nurse knows that which of the
following clients is at risk for fluid volume deficit?

a) Client diagnosed with liver cirrhosis.

b) Client with diminished kidney function.
c) Client diagnosed with congestive heart failure.
d) Client attached to a colostomy bag.

8. A pediatric client is for discharge after a plaster cast is applied on the left
forearm. Which of the following should the nurse include in the home care
instructions to be provided to the client’s parent? Select all that apply.

a) To lift the cast while it is drying, use the fingertips.

b) Keep sharp objects and small toys far from the cast.
c) Use padded objects to scratch itchy parts under the cast.
d) Apply heated pad on the edge of the cast and over the fingers to alleviate
coldness.
e) Report numbness and tingling in the extremity immediately.
f) Elevate the affected side for 24-48 hours following the procedure to avoid
swelling.
9. The school nurse is conducting a health teaching to a group of parents about
poison prevention at home. A mother asks the nurse about the initial step in
case of poison ingestion. Which of the following responses if made by the nurse
is incorrect?

a) “Give a bottle if Ipecac to your child to induce vomiting.”

b) “Induce vomiting if your child swallows lighter fluid.”
c) “Give your child water or milk to dilute the poison.”
d) “Store harmful chemicals in hard to reach areas.”

10. A patient underwent surgery where skin grafting was done and a drain was
placed temporarily. The nurse in charge after the operation should know how to
assess the skin graft. Which of the following assessments would suggest an
abnormal skin graft?

a) The graft is warm to touch

b) Brisk capillary refill is noted
c) Sanguinous fluid at the surgical drain
d) Graft has a different color from the patient’s skin

PSYCHIATRIC NURSING
11. The client is admitted to a psychiatric unit with a diagnosis of
undifferentiated schizophrenia. To cope up with anxiety, the nurse knows that
the client will probably use which of the following defense mechanism?

a) Projection
b) Rationalization
c) Regression
d) Repression

12. The client in the psychiatric unit is copying and imitating the movements of
the nurse. During recovery, the client verbalized thoughts that the nurse is like
a mirror and felt connected with the nurse. This behavior is known by which of
the following terms?

a) Echopraxia
b) Ego-syntonicity
c) Modeling
d) Ritualism
13. The nurse working in the psychiatric unit noticed that one of the clients is
scheduled for an ECT the next morning. Who among the following clients will
most likely undergo ECT?

a) A schizophrenic client hearing voices

b) Client with Antisocial personality disorder with a history of brawling
c) Client who exhibits 7 different personalities or persona
d) Client with major depression who is in antidepressants for 2 months

14. The nurse is to administer Lorazepam (Ativan) which is a benzodiazepine.

The nurse should understand that benzodiazepines enhance which
neurotransmitter?

a) Serotonin
b) GABA
c) Dopamine
d) Acetylcholine

15. Behavioral therapy is based on theories regarding learning. The nurse is

about to conduct behavioral therapy to an adolescent client with a psychiatric
condition. Which of the following is not a method or a strategy of behavioral
therapy?

a) Operant conditioning
b) Milieu therapy
c) Systematic desensitization
d) Aversion therapy

MATERNAL-NEWBORN
16. A primigravida at 31 weeks came in with the following signs and symptoms:
BP: 160/110 mmHg, proteinuria, and edema. She is diagnosed with pre-
eclampsia; Magnesium Sulfate was then administered to treat the condition.
Which of the following nursing assessments would indicate drug toxicity?

a) Patient is drowsy
b) Exaggerated deep tendon reflexes
c) Urinary output of 180 ml for 8 hours
d) Respiratory rate or 16/min

17. A G2P2 patient gave birth to a preterm baby boy. Twelve hours after
delivery, she noted yellowish discoloration on her baby’s skin and eyes. She is
worried and asked the nurse about the cause of her baby’s condition. What is
the most appropriate response for the nurse to give?

a) Early-onset breast milk jaundice is common in breastfed infants.

b) Don’t worry, jaundice is normal after birth.
c) Your baby was delivered preterm that is why he has jaundice.
d) Breastfeed your baby frequently while we further assess your baby’s
condition.

18. Prior to a vaginal examination, the nurse reviews the care of intrapartum
clients. Which one of the following statements is true about cervical changes in
a primipara client?

a) Effacement precedes dilatation

b) Effacement and dilatation occur simultaneously
c) Dilatation precedes effacement
d) Effacement is not necessary

19. The nurse is taking care of the client in the active phase of stage 1 labor.
The fetal position is LOA. When membranes rupture, which among the following
should the nurse expects to see:

a) A large amount of bloody fluid

b) A moderate amount of clear to straw-colored fluid
c) A small amount of greenish fluid
d) A small segment of the umbilical cord

20. The client in labor for the past 10 hours shows no change in cervical
dilatation and has stayed 5-6 cm for the past 2 hours. Uterine contractions
remain regular at 2-minute interval, lasting 40-45 seconds. Which is a priority
action of the nurse?

a) Assess for presence of a full bladder.

b) Suggest placement of an internal uterine pressure catheter to determine the
adequacy of contractions.
c) Encourage the woman to do deep breathing techniques.
d) Suggest to the physician that oxytocin augmentation be started to stimulate
labor.
MEDICAL-SURGICAL
21. The blood count of the client revealed a high number of RBC. What is the
reason why a high number of RBC is normal for clients residing on a higher
altitude?

a) Higher altitude changes the body’s absorption of essential nutrients.

b) A decrease in atmospheric oxygen stimulates erythropoiesis.
c) RBC sequestration of the spleen is impaired in higher altitudes.
d) Limited production of leukocytes and platelets in higher altitudes makes the
ratio of RBC higher.

22. The nurse is assessing muscle coordination and mobility of the client with a
musculoskeletal disorder. The nurse noted impulsive and brief muscle twitching
of the face and the limbs. The finding would be noted as:

a) Tremor
b) Chorea
c) Athetosis
d) Dystonia

23. The nurse is assigned to render care to the client with altered mobility.
Which of the following statements is true regarding body mechanics when
moving clients?

a) Stand at arm’s length from the working area.

b) Elevate adjustable beds to the hip level.
c) Swivel the body when moving the client.
d) Move the client with a wide base and straight knees.

24. The nurse is assisting the client with a crutch in walking starting with the
four-point gait. Which of the following procedures is used for a four-point gait?

a) Move the left crutch and the right foot forward.

b) Move both crutches forward.
c) Advance the affected leg and crutches together.
d) Move the right crutch forward followed by the left foot.

25. The nurse is assisting the client and noted tenderness and focal pain at the
tailbone. Which of the following conditions would the nurse suspect?

a) Osteoporosis
b) Arthritis
c) Coccydynia
d) Muscular dystrophy

26. The nurse is caring for the client with Myasthenia Gravis. Which of the
following nursing interventions is appropriate for this condition?

a) Monitor the duration of stiffness and not the intensity to determine when to
perform ROM.
b) When swallowing is difficult, give semi-solid foods instead of liquids to lessen
the risk of choking.
c) Have the client sleep with a pillow between the trunk and arm to decrease
tension on the supraspinatus tendon and to prevent blood flow compromise in
its watershed region.
d) Position the client in a semi-fowler’s position to relieve dyspnea.

27. The client arrived in the clinic for a follow up visit regarding Tendonitis. The
client informed the physician that the pain was not relieved with rest, ice,
compression and elevation. Which of the following interventions might be the
next order of the physician for the client?

a) Surgery
b) Opioids
c) Alternative NSAID
d) Chiropractic treatment

28. The physician is assessing the client with symptoms of Rheumatoid Arthritis.
Which of the following laboratory tests would the nurse expect that the
physician would order?

a) Albumin
b) CPK-MB
c) RBS
d) RH-factor

29. The nurse is caring for the client who has intermittent claudication. If the
nurse is unable to palpate for any pedal pulses when examining the client,
which is a priority nursing intervention among the following?

a. Notify the physician immediately.

b. Schedule the client for emergency surgery.
c. Recheck pedal pulses with a Doppler.
d. Assess the apical and radial pulses for any irregularity.
30. The client asks the nurse about Raynaud’s disease. Which of the following
would be a suitable definition of Raynaud’s disease?

a. It is the constriction of the cutaneous vessels due to the vasospasm of the

arterioles and the arteries of the upper and lower extremities.
b. It is an occlusive disease of the median and small arteries and veins.
c. It is the abnormal dilation of the arterial wall caused by localized weakness
and stretching in the wall of the artery.
d. It is a chronic disorder in which partial or total arterial occlusion deprives the
lower extremity of oxygen and nutrients.

CARDIO
31. The nurse is assessing the ECG result of the client. The condition in which
the electrical conduction in the AV node is absent is known as:

a) First degree AV block

b) Second degree AV block
c) Third-degree AV block
d) Fourth degree AV block

32. The client presented with complaints of headache accompanied with mild
chest pain that is recurring every 5 hours for the last 2 weeks. Which of the
following nursing action should take priority?

a) A complete health history with an emphasis on preceding events.

b) Chest exam with auscultation
c) An electrocardiogram
d) Take the client’s vital signs.

33. The pediatric client is diagnosed with a congenital heart disorder. Most
infants having this condition experience difficulty with feeding, failure to thrive
and bluish discoloration of the skin. This congenital condition is called:

a) Ventricular septal defect (VSD)

b) Atrioventricular septal defect (AVSD)
c) Tetralogy of Fallot (ToF)
d) Ebstein’s Anomaly

34. The client who recently suffered from a myocardial infarction is brought to
the emergency department for further assessment. The client will most likely
have elevated serum levels of:
a) Creatinine kinase
b) Amylase
c) Acid phosphatase
d) Alkaline phosphatase

35. The client with a history of CHF is experiencing a hypertensive crisis. Which
one of the following agents should be the drug of choice?

a) Diaxozide
b) Nitroprusside
c) Hydralazine
d) Trimethaphen

ANSWER WITH RATIONALE

1. Answer: B

a) Gastric lavage
Gastric lavage cannot be used as a general treatment for poisoning. It has
limited therapeutic effects and produces problems related to the procedure.

b) Activated charcoal
The administration of activated charcoal is the most effective in the
management of poisoning because it absorbs chemicals in the gastrointestinal
tract, thus reducing its toxicity.

c) Cathartic administration
The elimination of the poisonous substance could be aided by cathartic
administration. However, it is not the most effective intervention.

d) Milk dilution
Diluting the ingested poison with milk is not the most effective management for
ingested poison.

2. Answer: A

a) Botulism
Botulism is treated with antitoxins and induced vomiting or enema in the
emergency department. There is no vaccine available for the agent.
b) Smallpox
There is no exact treatment for smallpox, but antiviral medications and vaccines
can help improve the client’s condition.

c) Anthrax
Antibiotics are the preferred treatment for anthrax.

d) Tularemia
The treatment for tularemia does not involve the introduction of antitoxins.

3. Answer: C

Rationale:

a) Let the client rest.

The client is already experiencing respiratory depression so the nurse must
administer naloxone (Narcan).

b) Administer oxygen.
It may be given but is not the priority at this time.

c) Administer naloxone (Narcan) per physician’s order.

This is given to reverse respiratory depression.

d) Place epinephrine at the bedside.

This is unnecessary at the moment.

4. Answer: B

a) Temperature: 38.9°C, BP 90/60, pulse 98 and thready.

This indicates dehydration.

b) Cool skin, respiratory crackles, pulse 84 and bounding.

Symptoms present in fluid volume overload are elevated blood pressure,
bounding pulse, edema, distended neck veins, headache, diarrhea, polyuria and
hepatomegaly.

c) Abdominal pain, headache and lethargy.

This is not related to fluid volume overload.
d) CVP of 5, Urinary output: 700 cc/24 hours and nystagmus.
The CVP must be elevated (greater than 10 mm/H2O) and nystagmus is not
present.

5. Answer: C

a) Stopping bleeding from open wounds

Circulatory needs or interventions can be done immediately after client’s airway
is established and respirations have been stabilized.

b) Checking for neck fracture

Although this is also an important intervention this can be done after the
priority interventions were given to the client

c) Establishing an airway
This is the priority when caring for unconscious clients with multiple injuries.
The nurse should take note of ABC (airway, breathing and circulation) as a
priority.

d) Replacing blood loss

Circulatory needs or interventions can be done immediately after the client’s
airway is established and respirations have been stabilized.

6. Answers: B, C, E and F

Rationale: Clients with a stoma should be advised to regularly wash the stoma
using a washcloth, apply a thin layer of petroleum jelly into the skin
surrounding the stoma to avoid skin cracking, and to keep water away from the
stoma. Items such as soaps, cotton swabs, and tissues must not be used when
caring for the stoma as these can potentially enter the stoma and block the
airway. The use of alcohol should not be practiced as well as it can promote
irritation and drying.

7. Answer: D

Rationale:
Fluid volume deficit is related to various conditions such as diarrhea, vomiting,
increased urinary output, heightened rates of respiration, inadequate fluid
replacement, ileostomy, draining fistulas and colostomy. Fluid volume excess,
on the other hand, can be observed in clients with liver cirrhosis, diminished
kidney function and congestive heart failure.

8. Answers: B, E and F
Rationale:
Fingertips should not be used to handle casts while it is still drying since it
causes indentations in the cast and can produce continuous pressure into the
underlying skin. Instead of using the fingertips, the palms of the hand should be
used to lift the cast. Sharp objects and small toys must be kept away from the
cast, and padded objects should not be placed inside the cast as it can increase
the risk of altered skin integrity. Heating pads should not be applied into the
cast or fingers because the presence of cold fingers may signify the
development of neurovascular impairment and must be reported to the doctor
immediately. The affected side must also be elevated to prevent swelling. And
any signs of neurovascular impairment such as numbness and tingling in the
extremity should be reported right away to the health care provider.

9. Answer: B

Rationale:
a) “Give a bottle if Ipecac to your child to induce vomiting.”
Parents are advised to have Ipecac at home for each child. Doses range from 10
to 30 cc.

b) “Induce vomiting if your child swallows lighter fluid.”

Vomiting is contraindicated if hydrocarbons such as lighter fluid is ingested. This
increases the client’s risk for aspiration.

c) “Give your child water or milk to dilute the poison.”

These fluids may dilute toxins.

d) “Store harmful chemicals in hard to reach areas.”

Store harmful chemicals so that children cannot gain access to it.

10. Answer: D

a) The graft is warm to touch

A skin graft that is warm to touch indicates good circulation.

b) Brisk capillary refill is noted

Brisk capillary refill also indicates good circulation and skin perfusion.

c) Sanguinous fluid at the surgical drain

Sanguinous fluid noted at the surgical drain is normal after the surgical
procedure and would gradually turn into serosanguinous fluid then into a serous
fluid.
d) Graft has a different color from the patient’s skin
The skin graft should have the same color as with the patient’s skin.
Discoloration indicates poor perfusion to the skin graft.

11. Answer: C

Rationale:
Regression is characterized by a return to earlier behavior (such as in
childhood) to reduce anxiety is the basic defense mechanism in undifferentiated
schizophrenia. Projection involves blaming others and is related to paranoid
schizophrenia. Rationalization involves the justification of one’s actions.
Repression is the basic defense mechanism in neuroses.

12. Answer: A

Rationale:
Echopraxia is the copying and imitating of another’s behaviors and is related to
the loss of ego boundaries. Ego-syntonicity is behaviors that correspond with
the person’s sense of self. Modeling is the conscious copying or imitating of
someone’s behaviors. Ritualism refers to repetitive and compulsive behaviors.

13. Answer: D

a) A schizophrenic client hearing voices

ECT is not used in schizophrenia, tranquilizers are commonly prescribed.

b) Client with an Antisocial personality disorder with a history of brawling

ECT is not commonly used in treatment of personality disorders.

c) Client who exhibits 7 different personalities or persona

ECT is not the treatment of choice for clients with a split personalities.

d) Client with major depression who is in antidepressants for 2 months

ECT is commonly used for treatment of major depression in clients who have
not responded to antidepressants.

14. Answer: B

a) Serotonin
Benzodiazepines do not affect the regulation of serotonin in the body.
b) GABA
Benzodiazepines are able to attach the receptors of GABA. The drug potentiates
the ability of GABA in the body.

c) Dopamine
Benzodiazepine does not affect the regulation of dopamine in the body.

d) Acetylcholine
When Benzodiazepine is absorbed in the body it does not alter the levels of
acetylcholine.

15. Answer: B

a) Serotonin
Benzodiazepines do not affect the regulation of serotonin in the body.

b) GABA
Benzodiazepines are able to attach the receptors of GABA. The drug potentiates
the ability of GABA in the body.

c) Dopamine
Benzodiazepine does not affect the regulation of dopamine in the body.

d) Acetylcholine
When Benzodiazepine is absorbed in the body it does not alter the levels of
acetylcholine.

16. Answer: C

a) Patient is drowsy
Drowsiness and patient lethargy are therapeutic effects of drugs. Excessive
levels of magnesium would cause muscle weakness and unresponsiveness.

b) Exaggerated deep tendon reflexes

Below normal or absent deep tendon reflex is a sign of magnesium toxicity.

c) Urinary output of 180 ml for 8 hours

Magnesium is exclusively excreted by the kidneys. Urine output of <30ml/hour
suggests accumulation of toxic magnesium levels in the body.

d) Respiratory rate of 16/min

Magnesium sulfate toxicity would cause respiratory depression (RR is <12/min).
17. Answer: D

a) Early-onset breast milk jaundice is common in breastfed infants.

This occurs in the first week of life due to insufficient breastfeeding.

b) Don’t worry, jaundice is normal after birth.

Yellowish discoloration of the eyes and the skin is not normal if it occurs within
the first 24 hours after birth.

c) Your baby was delivered preterm that is why he has jaundice.

Preterm and low birth weight infants will have physiologic jaundice that appears
on the second or third day after birth.

d) Breastfeed your baby frequently while we further assess your baby’s

condition.
Jaundice occurred twelve hours after birth, which needs further investigation
and management. Frequent breastfeeding will provide nutrient needs and
enhances bilirubin excretion.

18. Answer: A

a) Effacement precedes dilatation

In a primipara, effacement usually occurs before dilatation begins.

b) Effacement and dilatation occur simultaneously

In a multipara, effacement and dilatation progress together.

c) Dilatation precedes effacement

Effacement precedes dilatation or it can happen simultaneously with dilatation.

d) Effacement is not necessary

Effacement is always necessary in the labor process of the client.

19. Answer: B

a) A large amount of bloody fluid

This can be a sign when the client is experiencing vaginal bleeding and is a
danger sign during pregnancy.

b) A moderate amount of clear to straw-colored fluid

With the fetus in a vertex LOA presentation and no other indicators of distress,
the amniotic fluid should have a clear to straw-colored appearance.
c) A small amount of greenish fluid
This is noted when there is meconium passed before or during labor.

d) A small segment of the umbilical cord

This happens in a prolapsed umbilical cord.

20. Answer: A

a) Assess for presence of a full bladder.

Encourage the client in labor to void as necessary. Inform the client that a full
bladder can hinder efficient uterine contractions. An empty bladder allows more
space for the presenting part to pass through for delivery.

b) Suggest placement of an internal uterine pressure catheter to determine the

adequacy of contractions.
This is a device placed into the amniotic space to measure the strength of
uterine contractions during labor. This is not a priority to use this time.

c) Encourage the woman to do deep breathing techniques.

Breathing techniques can help to handle discomfort during contractions but is
not a priority this time.

d) Suggest to a physician that oxytocin augmentation be started to stimulate

labor.
Induction of labor may be done when the labor process is not progressing
normally. For this time, assessment for a full bladder is the priority.

21. Answer: B

a) Higher altitude changes the body’s absorption of essential nutrients.

Nutrition has nothing to do with the high number of RBC in higher altitudes.

b) Decrease in atmospheric oxygen stimulates erythropoiesis.

Clients residing at a higher altitude have less atmospheric oxygen available that
is why RBC production is stimulated and enhanced to cope up with the
environment.

c) RBC sequestration of the spleen is impaired in higher altitudes.

The function of the spleen is not altered in high altitudes.

d) Limited production of leukocytes and platelets in higher altitudes makes the

ratio of RBC higher.
Platelet and leukocyte production are not altered in high altitudes.
22. Answer: B

a) Tremor
Tremor is clinically defined as rhythmic and repetitive muscle movement.

b) Chorea
Chorea is clinically defined as brief and involuntary muscle twitching of the face
or limbs which hinders the client’s mobility.

c) Athetosis
Athetosis is clinically defined as the presence of irregular and slow twisting
motions.

d) Dystonia
Dystonia is similar to the definition of Athetosis but involves larger muscle
areas.

23. Answer: C

a) Stand at arm’s length from the working area.

Standing close to the working area is a proper body mechanics to prevent
muscle fatigue.

b) Elevate adjustable beds to the hip level.

The nurse should adjust the bed to waist level in order to prevent stretching
and muscle strain.

c) Swivel the body when moving the client.

Proper body mechanic includes turning the body as a whole unit when moving
the client to avoid twisting the back.

d) Move the client with a wide base and straight knees.

The knees are bent to support the body’s center of gravity and maintain body
balance. Bending the knees will provide a wider base of support for effective
leverage and use of energy.

24. Answer: D

a) Move the left crutch and the right foot forward.

The two-point gait is applied when moving the left crutch and right foot at the
same time.
b) Move both crutches forward.
The swing-to or swing-through gait starts by placing both crutches forward.

c) Advance the affected leg and crutches together.

The three-point gait is applied when both crutches and the affected leg are
moved together.

d) Move the right crutch forward followed by the left foot

The four-point gait is applied by moving the right clutch forward followed by the
left foot. Then the left crutch will be moved forward followed by the right foot.

25. Answer: C

a) Osteoporosis
When too much calcium is dissolved from the bones, they lose density and are
easily fractured.

b) Arthritis
As we age, our joint tissues become less resilient to wear and tear and start to
degenerate manifesting swelling, pain, and oftentimes, loss of mobility of joints.
This is called arthritis.

c) Coccydynia
This is an Inflammation of the tailbone. Coccydynia is associated with pain and
tenderness at the tip of the tailbone between the buttocks. The condition is
worsened by sitting.

d) Muscular dystrophy
A muscular dystrophy is a group of inherited diseases in which the muscles that
control movement progressively weaken.

26. Answer: B

a) Monitor duration of stiffness and not the intensity to determine when to

perform ROM
This intervention is for arthritis.

b) When swallowing is difficult, give semi-solid foods instead of liquids to lessen

the risk of choking
This is a nursing intervention for Myasthenia Gravis due to difficulty swallowing.

c) Have the client sleep with a pillow between the trunk and arm to decrease
tension on the supraspinatus tendon and to prevent blood flow compromise in
its watershed region
This is for a Rotator cuff tear condition. This is to provide comfort for the client.

d) Position the client in a semi-fowler’s position to relieve dyspnea

This is for respiratory disorders such as Pneumonia. We place the client in this
position to relieve the difficulty of breathing.

27. Answer: B

a) Surgery
As much as possible, surgery should be the last resort for musculoskeletal pain.

b) Opioids
When the pain was not relieved by NSAIDs, opioids will be the next choice of
treatment most especially for moderate to severe pain rated 9/10.

c) Alternative NSAID
Since previous NSAID seems to be ineffective, there is no reason to prescribe
another brand. They have the same content.

d) Chiropractic treatment
This treatment involves spinal adjustment, but since physical therapy did not
produce a beneficial outcomes, this is no longer advisable.

28. Answer: D

a) Albumin
Albumin is a protein made by the liver. A serum albumin test measures the
amount of this protein in the clear liquid portion of the blood.

b) CPK-MB
The CPK-MB test is a cardiac marker used to assist diagnoses of acute
myocardial infarction.

c) RBS
A random glucose test or random blood glucose (RBG) is taken from a non-
fasting subject.

d) RH-factor
This is the correct answer. The rheumatoid factor (RF) test is primarily used to
help diagnose rheumatoid arthritis (RA) and to help distinguish RA from other
forms of arthritis or other conditions that cause similar symptoms.
29. Answer: C

a) Notify the physician immediately.

The nurse must check the peripheral pulses before notifying the physician.

b) Schedule the client for emergency surgery.

This is not a priority intervention for a client with arterial insufficiency.

c) Recheck pedal pulses with a Doppler.

For 15% of the normal population, the dorsalis pedis is not palpable. Also, the
pulses may disappear after exercise, so reassessing the peripheral pulse would
be an appropriate intervention.

d) Assess the apical and radial pulses for any irregularity.

The pulses to be assessed are the distal and peripheral pulse.

30. Answer: A

a) It is the constriction of the cutaneous vessels due to the vasospasm of the

arterioles and the arteries of the upper and lower extremities. Raynaud’s
disease affects primarily the fingers, toes, ears and cheeks due to the
vasospasm of the arterioles and the arteries of the upper and lower extremities.
It, therefore, causes numbness, tingling, sweating and coldness of the affected
body part.

b) It is an occlusive disease of the median and small arteries and veins. This is
a description of Buerger’s disease.

c) It is the abnormal dilation of the arterial wall caused by localized weakness

and stretching in the wall of the artery. This is what happens in an aortic
aneurysm.

d) It is a chronic disorder in which partial or total arterial occlusion deprives the

lower extremity of oxygen and nutrients. This is a description suitable for
explaining peripheral arterial disease.

31. Answer: C

a) First degree AV block

In this type of AV block, the interval between the PR node increases.
b) Second degree AV block
In this type of AV block, electrical conduction between the atria and ventricle is
blocked.

c) Third-degree AV block
In this type of AV block, there is no conduction of impulses through the AV
node. It is also known as complete heart block.

d) Fourth degree AV block

This type of AV block does not exist.

32. Answer: D

a) A complete health history with an emphasis on preceding events.

It may provide vital information but is not the priority this time.

b) Chest exam with auscultation

It may also provide vital information but is not the priority this time.

c) An electrocardiogram
It may provide information about the electrical activity of the heart but is not
the priority this time.

d) Take the client’s vital signs.

This action provides a baseline wherein further interventions can be based.

33. Answer: C

a) Ventricular septal defect (VSD)

It is a defect in the ventricular septum, which is the wall dividing the left and
right ventricles of the heart. Infants having this kind of condition show signs of
pansystolic murmur along the lower left of sternal border

b) Atrioventricular septal defect (AVSD)

It is characterized by an abnormal or inadequate fusion of the superior and
inferior endocardial cushion with the mid-portion of the atrial septum and the
muscular portion of the ventricular septum. Upon cardiac auscultation, atypical
murmur and loud heart tones can be heard.

c) Tetralogy of Fallot (ToF)

Tetralogy of Fallot is one of the most common congenital heart disorders.
Infants with ToF disorder often display difficulty with feeding, failure to thrive,
episodes of bluish pale skin during crying or feeding and exertional dyspnea,
usually worsening with age.

d) Ebstein’s Anomaly
It is a rare heart defect that’s present at birth (congenital). In Einstein’s
anomaly, the tricuspid valve doesn’t work properly and blood leaks back
through the valve. This condition may also lead to enlargement of the heart or
heart failure.

34. Answer: A

a) Creatinine kinase
Creatinine kinase levels are used primarily to aid in the diagnosis of acute MI or
skeletal muscle damage. However, vigorous exercise, a fall, or
deep intramuscular injections can cause a significant increase in CK levels.

b) Amylase
Amylase is the enzyme produced by the pancreas that helps digest
carbohydrates. When the pancreas is inflamed, amylase is released into the
blood. An increase in the blood amylase levels may occur due to acute
pancreatitis, cancer of the pancreas, ovaries or lungs, cholecystitis, or
gastroenteritis.

c) Acid phosphatase
Acid phosphatase is an enzyme found in the kidneys, serum, semen, and
prostate gland. An increase in this enzyme can cause prostate cancer or
infarction, Paget’s disease, Gaucher’s disease, and multiple myeloma.

d) Alkaline phosphatase
Alkaline phosphatase is found primarily in the liver and bone. The importance of
measuring alkaline phosphatase is to check the possibility of bone disease or
liver disease. An increase in serum alkaline phosphatase may be due to liver
congestion or cholestasis and osteoblastic bone conditions.

35. Answer: B

a) Diaxozide
This drug is used in the treatment of hypoglycemia.

b) Nitroprusside
Sodium Nitroprusside is the drug of choice for hypertensive emergencies
because it has the most reliable antihypertensive activity. It takes effect
immediately upon administration.
c) Hydralazine
It was considered as the drug of choice for hypertensive emergencies but it is
replaced by Sodium Nitroprusside because of its unpredictable therapeutic
profile.

d) Trimethaphen
It is a short-acting ganglionic blocking agent, used to produce controlled
hypotension during surgery.