1. Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions? A.

Providing a back massage B. Feeding a client C. Providing hair care D. Providing oral hygiene 2. The nurse is preparing to take vital sign in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best m ethod used to assess the client s temperature? A. Oral B. Axillary C. Radial D. Heat sensitive tape 3. A nurse obtained a client s pulse and found the rate to be above normal. The nu rse document this findings as: A. B. C. D. 4. rt Tachypnea Hyper pyrexia Arrythmia Tachycardia Which of the following actions should the nurse take to use a wide base suppo when assisting a client to get up in a chair?

A. Bend at the waist and place arms under the client s arms and lift B. Face the client, bend knees and place hands on client s forearm and lift C. Spread his or her feet apart D. Tighten his or her pelvic muscles 5. A client had oral surgery following a motor vehicle accident. The nurse asses sing the client finds the skin flushed and warm. Which of the following would be the best method to take the client s body temperature? A. Oral B. Axillary C. Arterial line D. Rectal 6. A client who is unconscious needs frequent mouth care. When performing a mout h care, the best position of a client is: A. Fowler s position B. Side lying C. Supine D. Trendelenburg 7. A client is hospitalized for the first time, which of the following actions e nsure the safety of the client? A. Keep unnecessary furniture out of the way B. Keep the lights on at all time C. Keep side rails up at all time D. Keep all equipment out of view 8. A walk-in client enters into the clinic with a chief complaint of abdominal p ain and diarrhea. The nurse takes the client s vital sign hereafter. What phrase o f nursing process is being implemented here by the nurse? A. B. C. D. 9. Assessment Diagnosis Planning Implementation It is best describe as a systematic, rational method of planning and providin

g nursing care for individual, families, group and community A. Assessment B. Nursing Process C. Diagnosis D. Implementation 10. Exchange of gases takes place in which of the following organ? A. Kidney B. Lungs C. Liver D. Heart 11. The Chamber of the heart that receives oxygenated blood from the lungs is th e? A. Left atrium B. Right atrium C. Left ventricle D. Right ventricle 12. A muscular enlarge pouch or sac that lies slightly to the left which is used for temporary storage of food A. Gallbladder B. Urinary bladder C. Stomach D. Lungs 13. The ability of the body to defend itself against scientific invading agent s uch as baceria, toxin, viruses and foreign body A. Hormones B. Secretion C. Immunity D. Glands 14. Hormones secreted by Islets of Langerhans A. Progesterone B. Testosterone C. Insulin D. Hemoglobin 15. It is a transparent membrane that focuses the light that enters the eyes to the retina. A. Lens B. Sclera C. Cornea D. Pupils 16. Which of the following is included in Orem s theory? A. Maintenance of a sufficient intake of air B. Self perception C. Love and belonging D. Physiologic needs 17. Which of the following cluster of data belong to Maslow s hierarchy of needs A. Love and belonging B. Physiologic needs C. Self actualization D. All of the above 18. This is characterized by severe symptoms relatively of short duration.

A. Chronic Illness B. Acute Illness C. Pain D. Syndrome 19. Which of the following is the nurse s role in the health promotion A. Health risk appraisal B. Teach client to be effective health consumer C. Worksite wellness D. None of the above 20. It is describe as a collection of people who share some attributes of their lives. A. Family B. Illness C. Community D. Nursing 21. Five teaspoon is equivalent to how many milliliters (ml)? A. 30 ml B. 25 ml C. 12 ml D. 22 ml 22. 1800 ml is equal to how many liters? A. 1.8 B. 18000 C. 180 D. 2800 23. Which of the following is the abbreviation of drops? A. Gtt. B. Gtts. C. Dp. D. Dr. 24. The abbreviation for micro drop is A. gtt B. gtt C. mdr D. mgts 25. Which of the following is the meaning of PRN? A. When advice B. Immediately C. When necessary D. Now 26. Which of the following is the appropriate meaning of CBR? A. Cardiac Board Room B. Complete Bathroom C. Complete Bed Rest D. Complete Board Room 27. 1 tsp is equals to how many drops? A. 15 B. 60 C. 10 D. 30 28. 20 cc is equal to how many ml?

A. 2 B. 20 C. 2000 D. 20000 29. 1 cup is equals to how many ounces? A. 8 B. 80 C. 800 D. 8000 30. The nurse must verify the client s identity before administration of medicatio n. Which of the following is the safest way to identify the client? A. Ask the client his name B. Check the client s identification band C. State the client s name aloud and have the client repeat it D. Check the room number 31. The nurse prepares to administer buccal medication. The medicine should be p laced A. On the client s skin B. Between the client s cheeks and gums C. Under the client s tongue D. On the client s conjuctiva 32. The nurse administers cleansing enema. The common position for this procedur e is A. Sims left lateral B. Dorsal Recumbent C. Supine D. Prone 33. A client complains of difficulty of swallowing, when the nurse try to admini ster capsule medication. Which of the following measures the nurse should do? A. Dissolve the capsule in a glass of water B. Break the capsule and give the content with an applesauce C. Check the availability of a liquid preparation D. Crash the capsule and place it under the tongue 34. Which of the following is the appropriate route of administration for insuli n? A. Intramuscular B. Intradermal C. Subcutaneous D. Intravenous 35. The nurse is ordered to administer ampicillin capsule TIP p.o. The nurse sho ud give the medication A. Three times a day orally B. Three times a day after meals C. Two time a day by mouth D. Two times a day before meals 36. Back Care is best describe as: A. Caring for the back by means of massage B. Washing of the back C. Application of cold compress at the back D. Application of hot compress at the back 37. It refers to the preparation of the bed with a new set of linens

A. Bed bath B. Bed making C. Bed shampoo D. Bed lining 38. Which of the following is the most important purpose of handwashing A. To promote hand circulation B. To prevent the transfer of microorganism C. To avoid touching the client with a dirty hand D. To provide comfort 39. What should be done in order to prevent contaminating of the environment in bed making? A. Avoid funning soiled linens B. Strip all linens at the same time C. Finished both sides at the time D. Embrace soiled linen 40. The most important purpose of cleansing bed bath is: A. To cleanse, refresh and give comfort to the client who must remain in bed B. To expose the necessary parts of the body C. To develop skills in bed bath D. To check the body temperature of the client in bed 41. Which of the following technique involves the sense of sight? A. Inspection B. Palpation C. Percussion D. Auscultation 42. The first techniques used examining the abdomen of a client is: A. Palpation B. Auscultation C. Percussion D. Inspection 43. A technique in physical examination that is use to assess the movement of ai r through the tracheobronchial tree: A. Palpation B. Auscultation C. Inspection D. Percussion 44. An instrument used for auscultation is: A. Percussion-hammer B. Audiometer C. Stethoscope D. Sphygmomanometer 45. Resonance is best describe as: A. Sounds created by air filled lungs B. Short, high pitch and thudding C. Moderately loud with musical quality D. Drum-like 46. The best position for examining the rectum is: A. Prone B. Sim s C. Knee-chest

D. Lithotomy 47. It refers to the manner of walking A. Gait B. Range of motion C. Flexion and extension D. Hopping 48. The nurse asked the client to read the Snellen chart. Which of the following is tested: A. Optic B. Olfactory C. Oculomotor D. Troclear 49. Another name for knee-chest position is: A. Genu-dorsal B. Genu-pectoral C. Lithotomy D. Sim s 50. The nurse prepare IM injection that is irritating to the subcutaneous tissue . Which of the following is the best action in order to prevent tracking of the medication A. B. C. D. Use a small gauge needle Apply ice on the injection site Administer at a 45 angle Use the Z-track technique

1. The most appropriate nursing order for a patient who develops dyspnea and sho rtness of breath would be A. B. C. D. Maintain the patient on strict bed rest at all times Maintain the patient in an orthopneic position as needed Administer oxygen by Venturi mask at 24%, as needed Allow a 1 hour rest period between activities

2. The nurse observes that Mr. Adams begins to have increased difficulty breathi ng. She elevates the head of the bed to the high Fowler position, which decrease s his respiratory distress. The nurse documents this breathing as: A. B. C. D. Tachypnea Eupnca Orthopnea Hyperventilation

3. The physician orders a platelet count to be performed on Mrs. Smith after bre akfast. The nurse is responsible for: A. B. C. D. Instructing the patient about this diagnostic test Writing the order for this test Giving the patient breakfast All of the above

4. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the food s allowed on a 500-mg low sodium diet. These include: A. A ham and Swiss cheese sandwich on whole wheat bread B. Mashed potatoes and broiled chicken

C. A tossed salad with oil and vinegar and olives D. Chicken bouillon 5. The physician orders a maintenance dose of 5,000 units of subcutaneous hepari n (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now inclu de: A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time. B. Reporting an APTT above 45 seconds to the physician C. Assessing the patient for signs and symptoms of frank and occult bleeding D. All of the above 6. The four main concepts common to nursing that appear in each of the current c onceptual models are: A. B. C. D. Person, Person, Person, Person, nursing, environment, medicine health, nursing, support systems health, psychology, nursing environment, health, nursing

7. In Maslow s hierarchy of physiologic needs, the human need of greatest priority is: A. B. C. D. Love Elimination Nutrition Oxygen

8. The family of an accident victim who has been declared brain-dead seems amena ble to organ donation. What should the nurse do? A. B. C. D. Discourage them from making a decision until their grief has eased Listen to their concerns and answer their questions honestly Encourage them to sign the consent form right away Tell them the body will not be available for a wake or funeral

9. A new head nurse on a unit is distressed about the poor staffing on the 11 p. m. to 7 a.m. shift. What should she do? A. B. C. D. Complain to her fellow nurses Wait until she knows more about the unit Discuss the problem with her supervisor Inform the staff that they must volunteer to rotate

10. Which of the following principles of primary nursing has proven the most sat isfying to the patient and nurse? A. Continuity of patient care promotes efficient, cost-effective nursing care B. Autonomy and authority for planning are best delegated to a nurse who knows t he patient well C. Accountability is clearest when one nurse is responsible for the overall plan and its implementation. D. The holistic approach provides for a therapeutic relationship, continuity, an d efficient nursing care. 11. If nurse administers an injection to a patient who refuses that injection, s he has committed: A. Assault and battery

B. Negligence C. Malpractice D. None of the above 12. If patient asks the nurse her opinion about a particular physicians and the nurse replies that the physician is incompetent, the nurse could be held liable for: A. B. C. D. Slander Libel Assault Respondent superior

13. A registered nurse reaches to answer the telephone on a busy pediatric unit, momentarily turning away from a 3 month-old infant she has been weighing. The i nfant falls off the scale, suffering a skull fracture. The nurse could be charge d with: A. B. C. D. Defamation Assault Battery Malpractice

14. Which of the following is an example of nursing malpractice? A. The nurse administers penicillin to a patient with a documented history of al lergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia. B. The nurse applies a hot water bottle or a heating pad to the abdomen of a pat ient with abdominal cramping. C. The nurse assists a patient out of bed with the bed locked in position; the p atient slips and fractures his right humerus. D. The nurse administers the wrong medication to a patient and the patient vomit s. This information is documented and reported to the physician and the nursing supervisor. 15. Which of the following signs and symptoms would the nurse expect to find whe n assessing an Asian patient for postoperative pain following abdominal surgery? A. B. C. D. Decreased blood pressure and heart rate and shallow respirations Quiet crying Immobility, diaphoresis, and avoidance of deep breathing or coughing Changing position every 2 hours

16. A patient is admitted to the hospital with complaints of nausea, vomiting, d iarrhea, and severe abdominal pain. Which of the following would immediately ale rt the nurse that the patient has bleeding from the GI tract? A. B. C. C. Complete blood count Guaiac test Vital signs Abdominal girth

17. The correct sequence for assessing the abdomen is: A. B. . C. D. Tympanic percussion, measurement of abdominal girth, and inspection Assessment for distention, tenderness, and discoloration around the umbilicus Percussions, palpation, and auscultation Auscultation, percussion, and palpation

18. High-pitched gurgles head over the right lower quadrant are: A. B. C. D. A sign A sign Normal A sign of increased bowel motility of decreased bowel motility bowel sounds of abdominal cramping

19. A patient about to undergo abdominal inspection is best placed in which of t he following positions? A. B. C. D. Prone Trendelenburg Supine Side-lying

20. For a rectal examination, the patient can be directed to assume which of the following positions? A. B. C. D. Genupecterol Sims Horizontal recumbent All of the above

21. During a Romberg test, the nurse asks the patient to assume which position? A. B. C. D. Sitting Standing Genupectoral Trendelenburg

22. If a patient s blood pressure is 150/96, his pulse pressure is: A. B. C. D. 54 96 150 246

23. A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indic ates: A. B. C. D. Infection Hypothermia Anxiety Dehydration

24. Which of the following parameters should be checked when assessing respirati ons? A. B. C. D. Rate Rhythm Symmetry All of the above

25. A 38-year old patient s vital signs at 8 a.m. are axillary temperature 99.6 F (37.6 C); pulse rate, 88; respiratory rate, 30. Which findings should be reporte d? A. Respiratory rate only

B. Temperature only C. Pulse rate and temperature D. Temperature and respiratory rate 26. All of the following can cause tachycardia except: A. B. C. D. Fever Exercise Sympathetic nervous system stimulation Parasympathetic nervous system stimulation

27. Palpating the midclavicular line is the correct technique for assessing A. B. C. D. Baseline vital signs Systolic blood pressure Respiratory rate Apical pulse

28. The absence of which pulse may not be a significant finding when a patient i s admitted to the hospital? A. B. C. D. Apical Radial Pedal Femoral

29. Which of the following patients is at greatest risk for developing pressure ulcers? A. An alert, chronic arthritic patient treated with steroids and aspirin B. An 88-year old incontinent patient with gastric cancer who is confined to his bed at home C. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula D. A confused 78-year old patient with congestive heart failure (CHF) who requir es assistance to get out of bed. 30. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler s position. After assessing Mrs. Pa ul, the nurse writes the following nursing diagnosis: Impaired gas exchange rela ted to increased secretions. Which of the following nursing interventions has th e greatest potential for improving this situation? A. B. C. D. Encourage the patient to increase her fluid intake to 200 ml every 2 hours Place a humidifier in the patient s room. Continue administering oxygen by high humidity face mask Perform chest physiotheraphy on a regular schedule

31. The most common deficiency seen in alcoholics is: A. B. C. D. Thiamine Riboflavin Pyridoxine Pantothenic acid

32. Which of the following statement is incorrect about a patient with dysphagia ? A. The patient will find pureed or soft foods, such as custards, easier to swall ow than water B. Fowler s or semi Fowler s position reduces the risk of aspiration during swallowi

ng C. The patient should always feed himself D. The nurse should perform oral hygiene before assisting with feeding. 33. To assess the kidney function of a patient with an indwelling urinary (Foley ) catheter, the nurse measures his hourly urine output. She should notify the ph ysician if the urine output is: A. B. C. D. Less than 30 ml/hour 64 ml in 2 hours 90 ml in 3 hours 125 ml in 4 hours

34. Certain substances increase the amount of urine produced. These include: A. B. C. D. Caffeine-containing drinks, such as coffee and cola. Beets Urinary analgesics Kaolin with pectin (Kaopectate)

35. A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Which o f the following nursing interventions would be appropriate? A. B. C. D. Encourage the patient to walk in the hall alone Discourage the patient from walking in the hall for a few more days Accompany the patient for his walk. Consuit a physical therapist before allowing the patient to ambulate

36. A patient has exacerbation of chronic obstructive pulmonary disease (COPD) m anifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. An appropriate nursing diagnosis would be: A. B. C. D. Ineffective airway clearance related to thick, tenacious secretions. Ineffective airway clearance related to dry, hacking cough. Ineffective individual coping to COPD. Pain related to immobilization of affected leg.

37. Mrs. Lim begins to cry as the nurse discusses hair loss. The best response w ould be: A. Don t worry. It s only temporary B. Why are you crying? I didn t get to the bad news yet C. Your hair is really pretty D. I know this will be difficult for you, but your hair will grow back after the completion of chemotheraphy 38. An additional Vitamin C is required during all of the following periods exce pt: A. B. C. D. Infancy Young adulthood Childhood Pregnancy

39. A prescribed amount of oxygen s needed for a patient with COPD to prevent: A. Cardiac arrest related to increased partial pressure of carbon dioxide in art erial blood (PaCO2)

B. Circulatory overload due to hypervolemia C. Respiratory excitement D. Inhibition of the respiratory hypoxic stimulus 40. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most significant symptom of his disorder? A. B. C. D. Lethargy Increased pulse rate and blood pressure Muscle weakness Muscle irritability

41. Which of the following nursing interventions promotes patient safety? A. B. C. D. Asses the patient s ability to ambulate and transfer from a bed to a chair Demonstrate the signal system to the patient Check to see that the patient is wearing his identification band All of the above

42. Studies have shown that about 40% of patients fall out of bed despite the us e of side rails; this has led to which of the following conclusions? A. B. C. D. Side Side Side Side rails rails rails rails are ineffective should not be used are a deterrent that prevent a patient from falling out of bed. are a reminder to a patient not to get out of bed

43. Examples of patients suffering from impaired awareness include all of the fo llowing except: A. B. C. D. A A A A semiconscious or over fatigued patient disoriented or confused patient patient who cannot care for himself at home patient demonstrating symptoms of drugs or alcohol withdrawal

44. The most common injury among elderly persons is: A. B. C. D. Atheroscleotic changes in the blood vessels Increased incidence of gallbladder disease Urinary Tract Infection Hip fracture

45. The most common psychogenic disorder among elderly person is: A. B. C. D. Depression Sleep disturbances (such as bizarre dreams) Inability to concentrate Decreased appetite

46. Which of the following vascular system changes results from aging? A. B. C. D. Increased peripheral resistance of the blood vessels Decreased blood flow Increased work load of the left ventricle All of the above

47. Which of the following is the most common cause of dementia among elderly pe rsons? A. Parkinson s disease

B. Multiple sclerosis C. Amyotrophic lateral sclerosis (Lou Gerhig s disease) D. Alzheimer s disease 48. The nurse s most important legal responsibility after a patient s death in a hos pital is: A. B. C. D. Obtaining a consent of an autopsy Notifying the coroner or medical examiner Labeling the corpse appropriately Ensuring that the attending physician issues the death certification

49. Before rigor mortis occurs, the nurse is responsible for: A. B. C. D. Providing a complete bath and dressing change Placing one pillow under the body s head and shoulders Removing the body s clothing and wrapping the body in a shroud Allowing the body to relax normally

50. When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a major nursing priority is to: A. B. C. D. Protect the patient from injury Insert an airway Elevate the head of the bed Withdraw all pain medications

Here are the answers and rationale to the Fundamentals of Nursing (50 Questions) Part 2 B. When a patient develops dyspnea and shortness of breath, the orthopneic posit ion encourages maximum chest expansion and keeps the abdominal organs from press ing against the diaphragm, thus improving ventilation. Bed rest and oxygen by Ve nturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. Allowing for rest periods decreases the possibility of hypoxia. C. Orthopnea is difficulty of breathing except in the upright position. Tachypne a is rapid respiration characterized by quick, shallow breaths. Eupnea is normal respiration quiet, rhythmic, and without effort. C. A platelet count evaluates the number of platelets in the circulating blood v olume. The nurse is responsible for giving the patient breakfast at the schedule d time. The physician is responsible for instructing the patient about the test and for writing the order for the test. B. Mashed potatoes and broiled chicken are low in natural sodium chloride. Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindic ated on a low sodium diet. D. All of the identified nursing responsibilities are pertinent when a patient i s receiving heparin. The normal activated partial thromboplastin time is 16 to 2 5 seconds and the normal prothrombin time is 12 to 15 seconds; these levels must remain within two to two and one half the normal levels. All patients receiving anticoagulant therapy must be observed for signs and symptoms of frank and occu lt bleeding (including hemorrhage, hypotension, tachycardia, tachypnea, restless ness, pallor, cold and clammy skin, thirst and confusion); blood pressure should be measured every 4 hours and the patient should be instructed to report prompt ly any bleeding that occurs with tooth brushing, bowel movements, urination or h eavy prolonged menstruation. D. The focus concepts that have been accepted by all theorists as the focus of n ursing practice from the time of Florence Nightingale include the person receivi ng nursing care, his environment, his health on the health illness continuum, an

d the nursing actions necessary to meet his needs. D. Maslow, who defined a need as a satisfaction whose absence causes illness, co nsidered oxygen to be the most important physiologic need; without it, human lif e could not exist. According to this theory, other physiologic needs (including food, water, elimination, shelter, rest and sleep, activity and temperature regu lation) must be met before proceeding to the next hierarchical levels on psychos ocial needs. B. The brain-dead patient s family needs support and reassurance in making a decis ion about organ donation. Because transplants are done within hours of death, de cisions about organ donation must be made as soon as possible. However, the fami ly s concerns must be addressed before members are asked to sign a consent form. T he body of an organ donor is available for burial. C. Although a new head nurse should initially spend time observing the unit for its strengths and weakness, she should take action if a problem threatens patien t safety. In this case, the supervisor is the resource person to approach. D. Studies have shown that patients and nurses both respond well to primary nurs ing care units. Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. Nurses feel personal satisfaction, much of it related to positive feedback from the patients. They a lso seem to gain a greater sense of achievement and esprit de corps. A. Assault is the unjustifiable attempt or threat to touch or injure another per son. Battery is the unlawful touching of another person or the carrying out of t hreatened physical harm. Thus, any act that a nurse performs on the patient agai nst his will is considered assault and battery. A. Oral communication that injures an individual s reputation is considered slande r. Written communication that does the same is considered libel. D. Malpractice is defined as injurious or unprofessional actions that harm anoth er. It involves professional misconduct, such as omission or commission of an ac t that a reasonable and prudent nurse would or would not do. In this example, th e standard of care was breached; a 3-month-old infant should never be left unatt ended on a scale. A. The three elements necessary to establish a nursing malpractice are nursing e rror (administering penicillin to a patient with a documented allergy to the dru g), injury (cerebral damage), and proximal cause (administering the penicillin c aused the cerebral damage). Applying a hot water bottle or heating pad to a pati ent without a physician s order does not include the three required components. As sisting a patient out of bed with the bed locked in position is the correct nurs ing practice; therefore, the fracture was not the result of malpractice. Adminis tering an incorrect medication is a nursing error; however, if such action resul ted in a serious illness or chronic problem, the nurse could be sued for malprac tice. C. An Asian patient is likely to hide his pain. Consequently, the nurse must obs erve for objective signs. In an abdominal surgery patient, these might include i mmobility, diaphoresis, and avoidance of deep breathing or coughing, as well as increased heart rate, shallow respirations (stemming from pain upon moving the d iaphragm and respiratory muscles), and guarding or rigidity of the abdominal wal l. Such a patient is unlikely to display emotion, such as crying. B. To assess for GI tract bleeding when frank blood is absent, the nurse has two options: She can test for occult blood in vomitus, if present, or in stool thro ugh guaiac (Hemoccult) test. A complete blood count does not provide immediate r esults and does not always immediately reflect blood loss. Changes in vital sign s may be cause by factors other than blood loss. Abdominal girth is unrelated to blood loss. D. Because percussion and palpation can affect bowel motility and thus bowel sou nds, they should follow auscultation in abdominal assessment. Tympanic percussio n, measurement of abdominal girth, and inspection are methods of assessing the a bdomen. Assessing for distention, tenderness and discoloration around the umbili cus can indicate various bowel-related conditions, such as cholecystitis, append icitis and peritonitis. C. Hyperactive sounds indicate increased bowel motility; two or three sounds per

minute indicate decreased bowel motility. Abdominal cramping with hyperactive, high pitched tinkling bowel sounds can indicate a bowel obstruction. C. The supine position (also called the dorsal position), in which the patient l ies on his back with his face upward, allows for easy access to the abdomen. In the prone position, the patient lies on his abdomen with his face turned to the side. In the Trendelenburg position, the head of the bed is tilted downward to 3 0 to 40 degrees so that the upper body is lower than the legs. In the lateral po sition, the patient lies on his side. D. All of these positions are appropriate for a rectal examination. In the genup ectoral (knee-chest) position, the patient kneels and rests his chest on the tab le, forming a 90 degree angle between the torso and upper legs. In Sims position, the patient lies on his left side with the left arm behind the body and his rig ht leg flexed. In the horizontal recumbent position, the patient lies on his bac k with legs extended and hips rotated outward. B. During a Romberg test, which evaluates for sensory or cerebellar ataxia, the patient must stand with feet together and arms resting at the sides first with eye s open, then with eyes closed. The need to move the feet apart to maintain this stance is an abnormal finding. A. The pulse pressure is the difference between the systolic and diastolic blood pressure readings in this case, 54. D. A slightly elevated temperature in the immediate preoperative or post operati ve period may result from the lack of fluids before surgery rather than from inf ection. Anxiety will not cause an elevated temperature. Hypothermia is an abnorm ally low body temperature. D. The quality and efficiency of the respiratory process can be determined by ap praising the rate, rhythm, depth, ease, sound, and symmetry of respirations. D. Under normal conditions, a healthy adult breathes in a smooth uninterrupted p attern 12 to 20 times a minute. Thus, a respiratory rate of 30 would be abnormal . A normal adult body temperature, as measured on an oral thermometer, ranges be tween 97 and 100F (36.1 and 37.8C); an axillary temperature is approximately one deg ree lower and a rectal temperature, one degree higher. Thus, an axillary tempera ture of 99.6F (37.6C) would be considered abnormal. The resting pulse rate in an a dult ranges from 60 to 100 beats/minute, so a rate of 88 is normal. D. Parasympathetic nervous system stimulation of the heart decreases the heart r ate as well as the force of contraction, rate of impulse conduction and blood fl ow through the coronary vessels. Fever, exercise, and sympathetic stimulation al l increase the heart rate. D. The apical pulse (the pulse at the apex of the heart) is located on the midcl avicular line at the fourth, fifth, or sixth intercostal space. Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. Blo od pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expirati on. C. Because the pedal pulse cannot be detected in 10% to 20% of the population, i ts absence is not necessarily a significant finding. However, the presence or ab sence of the pedal pulse should be documented upon admission so that changes can be identified during the hospital stay. Absence of the apical, radial, or femor al pulse is abnormal and should be investigated. B. Pressure ulcers are most likely to develop in patients with impaired mental s tatus, mobility, activity level, nutrition, circulation and bladder or bowel con trol. Age is also a factor. Thus, the 88-year old incontinent patient who has im paired nutrition (from gastric cancer) and is confined to bed is at greater risk . A. Adequate hydration thins and loosens pulmonary secretions and also helps to r eplace fluids lost from elevated temperature, diaphoresis, dehydration and dyspn ea. High- humidity air and chest physiotherapy help liquefy and mobilize secreti ons. A. Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition. C. A patient with dysphagia (difficulty swallowing) requires assistance with fee

ding. Feeding himself is a long-range expected outcome. Soft foods, Fowler s or se mi-Fowler s position, and oral hygiene before eating should be part of the feeding regimen. A. A urine output of less than 30ml/hour indicates hypovolemia or oliguria, whic h is related to kidney function and inadequate fluid intake. A. Fluids containing caffeine have a diuretic effect. Beets and urinary analgesi cs, such as pyridium, can color urine red. Kaopectate is an anti diarrheal medic ation. C. A hospitalized surgical patient leaving his room for the first time fears rej ection and others staring at him, so he should not walk alone. Accompanying him will offer moral support, enabling him to face the rest of the world. Patients s hould begin ambulation as soon as possible after surgery to decrease complicatio ns and to regain strength and confidence. Waiting to consult a physical therapis t is unnecessary. A. Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness o f breath are signs of ineffective airway clearance. Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. Ineffective individual coping related to C OPD is wrong because the etiology for a nursing diagnosis should not be a medica l diagnosis (COPD) and because no data indicate that the patient is coping ineff ectively. Pain related to immobilization of affected leg would be an appropriate nursing diagnosis for a patient with a leg fracture. D. I know this will be difficult acknowledges the problem and suggests a resolutio n to it. Don t worry.. offers some relief but doesn t recognize the patient s feelings. ..I didn t get to the bad news yet would be inappropriate at any time. Your hair is really pretty offers no consolation or alternatives to the patient. B. Additional Vitamin C is needed in growth periods, such as infancy and childho od, and during pregnancy to supply demands for fetal growth and maternal tissues . Other conditions requiring extra vitamin C include wound healing, fever, infec tion and stress. D. Delivery of more than 2 liters of oxygen per minute to a patient with chronic obstructive pulmonary disease (COPD), who is usually in a state of compensated respiratory acidosis (retaining carbon dioxide (CO2)), can inhibit the hypoxic s timulus for respiration. An increased partial pressure of carbon dioxide in arte rial blood (PACO2) would not initially result in cardiac arrest. Circulatory ove rload and respiratory excitement have no relevance to the question. C. Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/li ter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias. The com bined effects of inadequate food intake and prolonged diarrhea can deplete the p otassium stores of a patient with GI problems. D. Assisting a patient with ambulation and transfer from a bed to a chair allows the nurse to evaluate the patient s ability to carry out these functions safely. Demonstrating the signal system and providing an opportunity for a return demons tration ensures that the patient knows how to operate the equipment and encourag es him to call for assistance when needed. Checking the patient s identification b and verifies the patient s identity and prevents identification mistakes in drug a dministration. D. Since about 40% of patients fall out of bed despite the use of side rails, si de rails cannot be said to prevent falls; however, they do serve as a reminder t hat the patient should not get out of bed. The other answers are incorrect inter pretations of the statistical data. C. A patient who cannot care for himself at home does not necessarily have impai red awareness; he may simply have some degree of immobility. D. Hip fracture, the most common injury among elderly persons, usually results f rom osteoporosis. The other answers are diseases that can occur in the elderly f rom physiologic changes. A. Sleep disturbances, inability to concentrate and decreased appetite are sympt oms of depression, the most common psychogenic disorder among elderly persons. O ther symptoms include diminished memory, apathy, disinterest in appearance, with drawal, and irritability. Depression typically begins before the onset of old ag

e and usually is caused by psychosocial, genetic, or biochemical factors D. Aging decreases elasticity of the blood vessels, which leads to increased per ipheral resistance and decreased blood flow. These changes, in turn, increase th e work load of the left ventricle. D. Alzheimer;s disease, sometimes known as senile dementia of the Alzheimer s type or primary degenerative dementia, is an insidious; progressive, irreversible, a nd degenerative disease of the brain whose etiology is still unknown. Parkinson s disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphon ia. Multiple sclerosis, a progressive, degenerative disease involving demyelinat ion of the nerve fibers, usually begins in young adulthood and is marked by peri ods of remission and exacerbation. Amyotrophic lateral sclerosis, a disease mark ed by progressive degeneration of the neurons, eventually results in atrophy of all the muscles; including those necessary for respiration. C. The nurse is legally responsible for labeling the corpse when death occurs in the hospital. She may be involved in obtaining consent for an autopsy or notify ing the coroner or medical examiner of a patient s death; however, she is not lega lly responsible for performing these functions. The attending physician may need information from the nurse to complete the death certificate, but he is respons ible for issuing it. B. The nurse must place a pillow under the decreased person s head and shoulders t o prevent blood from settling in the face and discoloring it. She is required to bathe only soiled areas of the body since the mortician will wash the entire bo dy. Before wrapping the body in a shroud, the nurse places a clean gown on the b ody and closes the eyes and mouth. A. Ensuring the patient s safety is the most essential action at this time. The ot her nursing actions may be necessary but are not a major priority. 1. Which element in the circular chain of infection can be eliminated by preserv ing skin integrity? A. B. C. D. Host Reservoir Mode of transmission Portal of entry

2. Which of the following will probably result in a break in sterile technique f or respiratory isolation? A. B. C. D. Opening Turning Opening Failing the patient s window to the outside environment on the patient s room ventilator the door of the patient s room leading into the hospital corridor to wear gloves when administering a bed bath

3. Which of the following patients is at greater risk for contracting an infecti on? A. B. C. D. A A A A patient with leukopenia patient receiving broad-spectrum antibiotics postoperative patient who has undergone orthopedic surgery newly diagnosed diabetic patient

4. Effective hand washing requires the use of: A. B. C. D. Soap or detergent to promote emulsification Hot water to destroy bacteria A disinfectant to increase surface tension All of the above

5. After routine patient contact, hand washing should last at least: A. B. C. D. 30 seconds 1 minute 2 minute 3 minutes

6. Which of the following procedures always requires surgical asepsis? A. B. C. D. Vaginal instillation of conjugated estrogen Urinary catheterization Nasogastric tube insertion Colostomy irrigation

7. Sterile technique is used whenever: A. B. C. D. Strict isolation is required Terminal disinfection is performed Invasive procedures are performed Protective isolation is necessary

8. Which of the following constitutes a break in sterile technique while prepari ng a sterile field for a dressing change? A. Using sterile forceps, rather than sterile gloves, to handle a sterile item 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 small amount of solution (15 to 30 ml) before pouring the solut ion into a sterile container 9. A natural body defense that plays an active role in preventing infection is: A. B. C. D. Yawning Body hair Hiccupping Rapid eye movements

10. All of the following statement are true about donning sterile gloves except: A. The first glove should be picked up by grasping the inside of the cuff. B. The second glove should be picked up by inserting the gloved fingers under th e 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 be careful that the firs t thing she touches is the: A. B. C. D. Waist tie and neck tie at the back of the gown Waist tie in front of the gown Cuffs of the gown Inside of the gown

12. Which of the following nursing interventions is considered the most effectiv e form or universal precautions? A. Cap all used needles before removing them from their syringes B. Discard all used uncapped needles and syringes in an impenetrable protective container

C. Wear gloves when administering IM injections D. Follow enteric precautions 13. All of the following measures are recommended to prevent pressure ulcers exc ept: A. B. C. D. Massaging the reddened are with lotion Using a water or air mattress Adhering to a schedule for positioning and turning Providing meticulous skin care

14. Which of the following blood tests should be performed before a blood transf usion? A. B. C. D. Prothrombin and coagulation time Blood typing and cross-matching Bleeding and clotting time Complete blood count (CBC) and electrolyte levels.

15. The primary purpose of a platelet count is to evaluate the: A. B. C. D. Potential for clot formation Potential for bleeding Presence of an antigen-antibody response Presence of cardiac enzymes

16. Which of the following white blood cell (WBC) counts clearly indicates leuko cytosis? A. B. C. D. 4,500/mm 7,000/mm 10,000/mm 25,000/mm

17. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a pa tient begins to exhibit fatigue, muscle cramping and muscle weakness. These symp toms probably indicate that the patient is experiencing: A. B. C. D. Hypokalemia Hyperkalemia Anorexia Dysphagia

18. Which of the following statements about chest X-ray is false? A. No contradictions 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 test 19. The most appropriate time for the nurse to obtain a sputum specimen for cult ure is: A. B. C. D. Early After After After in the morning the patient eats a light breakfast aerosol therapy chest physiotherapy

20. A patient with no known allergies is to receive penicillin every 6 hours. Wh

en administering the medication, the nurse observes a fine rash on the patient s s kin. The most appropriate nursing action would be to: A. B. C. D. Withhold the moderation and notify the physician Administer the medication and notify the physician Administer the medication with an antihistamine Apply corn starch soaks to the rash

21. All of the following nursing interventions are correct when using the Z-trac k method of drug injection except: A. B. C. D. Prepare the injection site with alcohol Use a needle that s a least 1 long Aspirate for blood before injection Rub the site vigorously after the injection to promote absorption

22. The correct method for determining the vastus lateralis site for I.M. inject ion is to: A. Locate the upper aspect of the upper outer quadrant of 8 cm below the iliac crest B. Palpate the lower edge of the acromion process and the t of the arm C. Palpate a 1 circular area anterior to the umbilicus D. Divide the area between the greater femoral trochanter l condyle into thirds, and select the middle third on the the buttock about 5 to midpoint lateral aspec and the lateral femora anterior of the thigh

23. The mid-deltoid injection site is seldom used for I.M. injections because it : A. B. C. D. Can accommodate only 1 ml or less of medication Bruises too easily Can be used only when the patient is lying down Does not readily parenteral medication

24. The appropriate needle size for insulin injection is: A. B. C. D. 18G, 22G, 22G, 25G, 1 long 1 long 1 long 5/8 long

25. The appropriate needle gauge for intradermal injection is: A. B. C. D. 20G 22G 25G 26G

26. Parenteral penicillin can be administered as an: A. B. C. D. IM injection or an IV solution IV or an intradermal injection Intradermal or subcutaneous injection IM or a subcutaneous injection

27. The physician 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. W hat would the flow rate be if the drop factor is 15 gtt = 1 ml? A. B. C. D. 5 gtt/minute 13 gtt/minute 25 gtt/minute 50 gtt/minute

29. Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion? A. B. C. D. Hemoglobinuria Chest pain Urticaria Distended neck veins

30. Which of the following conditions may require fluid restriction? A. B. C. D. Fever Chronic Obstructive Pulmonary Disease Renal Failure Dehydration

31. All of the following are common signs and symptoms of phlebitis except: A. B. C. D. Pain or discomfort at the IV insertion site Edema and warmth at the IV insertion site A red streak exiting the IV insertion site Frank bleeding at the insertion site

32. The best way of determining whether a patient has learned to instill ear med ication properly is for the nurse to: A. B. C. D. Ask the patient if he/she has used ear drops before Have the patient repeat the nurse s instructions using her own words Demonstrate the procedure to the patient and encourage to ask questions Ask the patient to demonstrate the procedure

33. Which of the following types of medications can be administered via gastrost omy tube? A. B. C. D. Any oral medications Capsules whole contents are dissolve in water Enteric-coated tablets that are thoroughly dissolved in water Most tablets designed for oral use, except for extended-duration compounds

34. A patient who develops hives after receiving an antibiotic is exhibiting dru g: A. B. C. D. Tolerance Idiosyncrasy Synergism Allergy

35. A patient has returned to his room after femoral arteriography. All of the f ollowing are appropriate nursing interventions except:

A. B. C. D.

Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours Check the pressure dressing for sanguineous drainage Assess a vital signs every 15 minutes for 2 hours Order a hemoglobin and hematocrit count 1 hour after the arteriography

36. The nurse explains to a patient that a cough: A. B. C. D. Is a protective response to clear the respiratory tract of irritants Is primarily a voluntary action Is induced by the administration of an antitussive drug Can be inhibited by splinting the abdomen

37. An infected patient has chills and begins shivering. The best nursing interv ention is to: A. B. C. D. Apply iced alcohol sponges Provide increased cool liquids Provide additional bedclothes Provide increased ventilation

38. A clinical nurse specialist is a nurse who has: A. Been certified by the National League for Nursing B. Received credentials from the Philippine Nurses Association C. Graduated from an associate degree program and is a registered professional n urse D. Completed a master s degree in the prescribed clinical area and is a registered professional nurse. 39. The purpose of increasing urine acidity through dietary means is to: A. B. C. D. Decrease burning sensations Change the urine s color Change the urine s concentration Inhibit the growth of microorganisms

40. Clay colored stools indicate: A. B. C. D. Upper GI bleeding Impending constipation An effect of medication Bile obstruction

41. In which step of the nursing process would the nurse ask a patient if the me dication she administered relieved his pain? A. B. C. D. Assessment Analysis Planning Evaluation

42. All of the following are good sources of vitamin A except: A. B. C. D. White potatoes Carrots Apricots Egg yolks

43. Which of the following is a primary nursing intervention necessary for all p

atients with a Foley Catheter in place? A. Maintain the drainage tubing and collection bag level with the patient s bladde r B. Irrigate the patient with 1% Neosporin solution three times a daily C. Clamp the catheter for 1 hour every 4 hours to maintain the bladder s elasticit y D. Maintain the drainage tubing and collection bag below bladder level to facili tate drainage by gravity 44. The ELISA test is used to: A. B. C. D. Screen blood donors for antibodies to human immunodeficiency virus (HIV) Test blood to be used for transfusion for HIV antibodies Aid in diagnosing a patient with AIDS All of the above

45. The two blood vessels most commonly used for TPN infusion are the: A. B. C. D. Subclavian and jugular veins Brachial and subclavian veins Femoral and subclavian veins Brachial and femoral veins

46. Effective skin disinfection before a surgical procedure includes which of th e following methods? A. Shaving the site on the day before surgery B. Applying a topical antiseptic to the skin on the evening before surgery C. Having the patient take a tub bath 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 patient from a bed to a chair, the nurse should use whic h muscles to avoid back injury? A. B. C. D. Abdominal muscles Back muscles Leg muscles Upper arm muscles

48. Thrombophlebitis typically develops in patients with which of the following conditions? A. B. C. D. Increases partial thromboplastin time Acute pulsus paradoxus An impaired or traumatized blood vessel wall Chronic Obstructive Pulmonary Disease (COPD)

49. In a recumbent, immobilized patient, lung ventilation can become altered, le ading to such respiratory complications as: A. B. C. D. Respiratory acidosis, ateclectasis, and hypostatic pneumonia Appneustic breathing, atypical pneumonia and respiratory alkalosis Cheyne-Strokes respirations and spontaneous pneumothorax Kussmail s respirations and hypoventilation

50. Immobility impairs bladder elimination, resulting in such disorders as A. Increased urine acidity and relaxation of the perineal muscles, causing incon

tinence B. Urine retention, bladder distention, and infection C. Diuresis, natriuresis, and decreased urine specific gravity D. Decreased calcium and phosphate levels in the urine Here are the answers and rationale for Fundamentals of Nursing (50 Questions) Pa rt 3 D. In the circular chain of infection, pathogens must be able to leave their res ervoir and be transmitted to a susceptible host through a portal of entry, such as broken skin. C. Respiratory isolation, like strict isolation, requires that the door to the d oor patient s room remain closed. However, the patient s room should be well ventila ted, so opening the window or turning on the ventricular is desirable. The nurse does not need to wear gloves for respiratoryisolation, but good hand washing is important for all types of isolation. A. Leukopenia is a decreased number of leukocytes (white blood cells), which are important in resisting infection. None of the other situations would put the pa tient at risk for contracting an infection; taking broad-spectrum antibiotics mi ght actually reduce the infection risk. A. Soaps and detergents are used to help remove bacteria because of their abilit y to lower the surface tension of water and act as emulsifying agents. Hot water may lead to skin irritation or burns. A. Depending on the degree of exposure to pathogens, hand washing may last from 10 seconds to 4 minutes. After routine patient contact, hand washing for 30 seco nds effectively minimizes the risk of pathogen transmission. B. The urinary system is normally free of microorganisms except at the urinary m eatus. Any procedure that involves entering this system must use surgically asep tic measures to maintain a bacteria-free state. C. All invasive procedures, including surgery, catheter insertion, and administr ation of parenteral therapy, require sterile technique to maintain a sterile env ironment. All equipment must be sterile, and the nurse and the physician must we ar sterile gloves and maintain surgical asepsis. In the operating room, the nurs e and physician are required to wear sterile gowns, gloves, masks, hair covers, and shoe covers for all invasive procedures. Strictisolation requires the use of clean gloves, masks, gowns and equipment to prevent the transmission of highly communicable diseases by contact or by airborne routes. Terminal disinfection is the disinfection of all contaminated supplies and equipment after a patient has been discharged to prepare them for reuse by another patient. The purpose of pr otective (reverse)isolation is to prevent a person with seriously impaired resis tance from coming into contact who potentially pathogenic organisms. C. The edges of a sterile field are considered contaminated. When sterile items are allowed to come in contact with the edges of the field, the sterile items al so become contaminated. B. Hair on or within body areas, such as the nose, traps and holds particles tha t contain microorganisms. Yawning and hiccupping do not prevent microorganisms f rom entering or leaving the body. Rapid eye movement marks the stage of sleep du ring which dreaming occurs. D. The inside of the glove is always considered to be clean, but not sterile. A. The back of the gown is considered clean, the front is contaminated. So, afte r removing gloves and washing hands, the nurse should untie the back of the gown ; slowly move backward away from the gown, holding the inside of the gown and ke eping the edges off the floor; turn and fold the gown inside out; discard it in a contaminated linen container; then wash her hands again. B. According to the Centers for Disease Control (CDC), blood-to-blood contact oc curs most commonly when a health care worker attempts to cap a used needle. Ther efore, used needles should never be recapped; instead they should be inserted in a specially designed puncture resistant, labeled container. Wearing gloves is n ot always necessary when administering an I.M. injection. Enteric precautions pr event the transfer of pathogens via feces.

A. Nurses and other health care professionals previously believed that massaging a reddened area with lotion would promote venous return and reduce edema to the area. However, research has shown that massage only increases the likelihood of cellular ischemia and necrosis to the area. B. Before a blood transfusion is performed, the blood of the donor and recipient must be checked for compatibility. This is done by blood typing (a test that de termines a person s blood type) and cross-matching (a procedure that determines th e compatibility of the donor s and recipient s blood after the blood types has been matched). If the blood specimens are incompatible, hemolysis and antigen-antibod y reactions will occur. A. Platelets are disk-shaped cells that are essential for blood coagulation. A p latelet count determines the number of thrombocytes in blood available for promo ting hemostasis and assisting with blood coagulation after injury. It also is us ed to evaluate the patient s potential for bleeding; however, this is not its prim ary purpose. The normal count ranges from 150,000 to 350,000/mm3. A count of 100 ,000/mm3 or less indicates a potential for bleeding; count of less than 20,000/m m3 is associated with spontaneous bleeding. D. Leukocytosis is any transient increase in the number of white blood cells (le ukocytes) in the blood. Normal WBC counts range from 5,000 to 100,000/mm3. Thus, a count of 25,000/mm3 indicates leukocytosis. A. Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia ( an inadequate potassium level), which is a potential side effect of diuretic the rapy. The physician usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics. Anorexia is another symptom of hypokalemia. Dy sphagia means difficulty swallowing. A. Pregnancy or suspected pregnancy is the only contraindication for a chest X-r ay. However, if a chest X-ray is necessary, the patient can wear a lead apron to protect the pelvic region from radiation. Jewelry, metallic objects, and button s would interfere with the X-ray and thus should not be worn above the waist. A signed consent is not required because a chest X-ray is not an invasive examinat ion. Eating, drinking and medications are allowed because the X-ray is of the ch est, not the abdominal region. 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 m edication. A. Initial sensitivity to penicillin is commonly manifested by a skin rash, even in individuals who have not been allergic to it previously. Because of the dang er of anaphylactic shock, he nurse should withhold the drug and notify the physi cian, who may choose to substitute another drug. Administering an antihistamine is a dependent nursing intervention that requires a written physician s order. Alt hough applying corn starch to the rash may relieve discomfort, it is not the nur se s top priority in such a potentially life-threatening situation. D. The Z-track method is an I.M. injection technique in which the patient s skin i s pulled in such a way that the needle track is sealed off after the injection. This procedure seals medication deep into the muscle, thereby minimizing skin st aining and irritation. Rubbing the injection site is contraindicated because it may cause the medication to extravasate into the skin. D. The vastus lateralis, a long, thick muscle that extends the full length of th e thigh, is viewed by many clinicians as the site of choice for I.M. injections because it has relatively few major nerves and blood vessels. The middle third o f the muscle is recommended as the injection site. The patient can be in a supin e or sitting position for an injection into this site. A. The mid-deltoid injection site can accommodate only 1 ml or less of medicatio n because of its size and location (on the deltoid muscle of the arm, close to t he brachial artery and radial nerve). D. A 25G, 5/8 needle is the recommended size for insulin injection because insuli n is administered by the subcutaneous route. An 18G, 1 needle is usually used for I.M. injections in children, typically in the vastus lateralis. A 22G, 1 needle is usually used for adult I.M. injections, which are typically administered in t he vastus lateralis or ventrogluteal site.

D. Because an intradermal injection does not penetrate deeply into the skin, a s mall-bore 25G needle is recommended. This type of injection is used primarily to administer antigens to evaluate reactions for allergy or sensitivity studies. A 20G needle is usually used for I.M. injections of oil-based medications; a 22G needle for I.M. injections; and a 25G needle, for I.M. injections; and a 25G nee dle, for subcutaneous insulin injections. A. Parenteral penicillin can be administered I.M. or added to a solution and giv en I.V. It cannot be administered subcutaneously or intradermally. D. gr 10 x 60mg/gr 1 = 600 mg C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute 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; the cells are hemolyzed in either circulatory or reticuloendothelial system. Hemoly sis occurs more rapidly in ABO incompatibilities than in Rh incompatibilities. C hest pain and urticaria may be symptoms of impending anaphylaxis. Distended neck veins are an indication of hypervolemia. C. In real failure, the kidney loses their ability to effectively eliminate wast es and fluids. Because of this, limiting the patient s intake of oral and I.V. flu ids may be necessary. Fever, chronic obstructive pulmonary disease, and dehydrat ion are conditions for which fluids should be encouraged. 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 during venipuncture or cannulation), or a localized allergic reaction to the ne edle or catheter. Signs and symptoms of phlebitis include pain or discomfort, ed ema and heat at the I.V. insertion site, and a red streak going up the arm or le g from the I.V. insertion site. D. Return demonstration provides the most certain evidence for evaluating the ef fectiveness of patient teaching. D. Capsules, enteric-coated tablets, and most extended duration or sustained rel ease products should not be dissolved for use in a gastrostomy tube. They are ph armaceutically manufactured in these forms for valid reasons, and altering them destroys their purpose. The nurse should seek an alternate physician s order when an ordered medication is inappropriate for delivery by tube. D. A drug-allergy is an adverse reaction resulting from an immunologic response following a previous sensitizing exposure to the drug. The reaction can range fr om a rash or hives to anaphylactic shock. Tolerance to a drug means that the pat ient experiences a decreasing physiologic response to repeated administration of the drug in the same dosage. Idiosyncrasy is an individual s unique hypersensitiv ity to a drug, food, or other substance; it appears to be genetically determined . Synergism, is a drug interaction in which the sum of the drug s combined effects is greater than that of their separate effects. D. A hemoglobin and hematocrit count would be ordered by the physician if bleedi ng were suspected. The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography. A. Coughing, a protective response that clears the respiratory tract of irritant s, usually is involuntary; however it can be voluntary, as when a patient is tau ght to perform coughing exercises. An antitussive drug inhibits coughing. Splint ing the abdomen supports the abdominal muscles when a patient coughs. C. In an infected patient, shivering results from the body s attempt to increase h eat production and the production of neutrophils and phagocytotic action through increased skeletal muscle tension and contractions. Initial vasoconstriction ma y cause skin to feel cold to the touch. Applying additional bed clothes helps to equalize the body temperature and stop the chills. Attempts to cool the body re sult in further shivering, increased metabloism, and thus increased heat product ion. D. A clinical nurse specialist must have completed a master s degree in a clinical specialty and be a registered professional nurse. The National League of Nursin g accredits educational programs in nursing and provides a testing service to ev aluate student nursing competence but it does not certify nurses. The American N

urses Association identifies requirements for certification and offers examinati ons for certification in many areas of nursing., such as medical surgical nursin g. These certification (credentialing) demonstrates that the nurse has the knowl edge and the ability to provide high quality nursing care in the area of her cer tification. A graduate of an associate degree program is not a clinical nurse sp ecialist: however, she is prepared to provide bed side nursing with a high degre e of knowledge and skill. She must successfully complete the licensing examinati on to become a registered professional nurse. D. Microorganisms usually do not grow in an acidic environment. D. Bile colors the stool brown. Any inflammation or obstruction that impairs bil e flow will affect the stool pigment, yielding light, clay-colored stool. Upper GI bleeding results in black or tarry stool. Constipation is characterized by sm all, hard masses. Many medications and foods will discolor stool for example, dr ugs containing iron turn stool black.; beets turn stool red. D. In the evaluation step of the nursing process, the nurse must decide whether the patient has achieved the expected outcome that was identified in the plannin g phase. A. The main sources of vitamin A are yellow and green vegetables (such as carrot s, sweet potatoes, squash, spinach, collard greens, broccoli, and cabbage) and y ellow fruits (such as apricots, and cantaloupe). Animal sources include liver, k idneys, cream, butter, and egg yolks. D. Maintaing the drainage tubing and collection bag level with the patient s bladd er could result in reflux of urine into the kidney. Irrigating the bladder with Neosporin and clamping the catheter for 1 hour every 4 hours must be prescribed by a physician. D. The ELISA test of venous blood is used to assess blood and potential blood do nors to human immunodeficiency virus (HIV). A positive ELISA test combined with various signs and symptoms helps to diagnose acquired immunodeficiency syndrome (AIDS) A. Total Parenteral Nutrition (TPN) requires the use of a large vessel, such as the subclavian or jugular vein, to ensure rapid dilution of the solution and the reby prevent complications, such as hyperglycemia. The brachial and femoral vein s usually are contraindicated because they pose an increased risk of thrombophle bitis. D. Studies have shown that showering with an antiseptic soap before surgery is t he most effective method of removing microorganisms from the skin. Shaving the s ite of the intended surgery might cause breaks in the skin, thereby increasing t he risk of infection; however, if indicated, shaving, should be done immediately before surgery, not the day before. A topical antiseptic would not remove micro organisms and would be beneficial only after proper cleaning and rinsing. Tub ba thing might transfer organisms to another body site rather than rinse them away. C. The leg muscles are the strongest muscles in the body and should bear the gre atest stress when lifting. Muscles of the abdomen, back, and upper arms may be e asily injured. C. The factors, known as Virchow s triad, collectively predispose a patient to thr omboplebitis; impaired venous return to the heart, blood hypercoagulability, and injury to a blood vessel wall. Increased partial thromboplastin time indicates a prolonged bleeding time during fibrin clot formation, commonly the result of a nticoagulant (heparin) therapy. Arterial blood disorders (such as pulsus paradox us) and lung diseases (such as COPD) do not necessarily impede venous return of injure vessel walls. A. Because of restricted respiratory movement, a recumbent, immobilize patient i s at particular risk for respiratory acidosis from poor gas exchange; atelectasi s from reduced surfactant and accumulated mucus in the bronchioles, and hypostat ic pneumonia from bacterial growth caused by stasis of mucus secretions. B. The immobilized patient commonly suffers from urine retention caused by decre ased muscle tone in the perineum. This leads to bladder distention and urine sta gnation, which provide an excellent medium for bacterial growth leading to infec tion. Immobility also results in more alkaline urine with excessive amounts of c alcium, sodium and phosphate, a gradual decrease in urine production, and an inc

reased specific gravity.

1. The four major concepts in nursing theory are the A. B. C. D. Person, Environment, Nurse, Health Nurse, Person, Environment, Cure Promotive, Preventive, Curative, Rehabilitative Person, Environment, Nursing, Health

2. The act of utilizing the environment of the patient to assist him in his reco very is theorized by A. B. C. D. Nightingale Benner Swanson King

3. For her, Nursing is a theoretical system of knowledge that prescribes a proce ss of analysis and action related to care of the ill person A. B. C. D. King Henderson Roy Leininger

4. According to her, Nursing is a helping or assistive profession to persons who are wholly or partly dependent or when those who are supposedly caring for them are no longer able to give care. A. B. C. D. Henderson Orem Swanson Neuman

5. Nursing is a unique profession, Concerned with all the variables affecting an individual s response to stressors, which are intra, inter and extra personal in nature. A. B. C. D. Neuman Johnson Watson Parse

6. The unique function of the nurse is to assist the individual, sick or well, i n the performance of those activities contributing to health that he would perfo rm unaided if he has the necessary strength, will and knowledge, and do this in such a way as to help him gain independence as rapidly as possible. A. B. C. D. Henderson Abdellah Levin Peplau

7. Caring is the essence and central unifying, a dominant domain that distinguis hes nursing from other health disciplines. Care is an essential human need. A. Benner B. Watson

C. Leininger D. Swanson 8. Caring involves 5 processes, KNOWING, BEING WITH, DOING FOR, ENABLING and MAI NTAINING BELIEF. A. B. C. D. Benner Watson Leininger Swanson

9. Caring is healing, it is communicated through the consciousness of the nurse to the individual being cared for. It allows access to higher human spirit. A. B. C. D. Benner Watson Leininger Swanson

10. Caring means that person, events, projects and things matter to people. It r eveals stress and coping options. Caring creates responsibility. It is an inhere nt feature of nursing practice. It helps the nurse assist clients to recover in the face of the illness. A. B. C. D. Benner Watson Leininger Swanson

11. Which of the following is NOT TRUE about profession according to Marie Jahod a? A. A profession is an organization of an occupational group based on the applica tion of special knowledge B. It serves specific interest of a group C. It is altruistic D. Quality of work is of greater importance than the rewards 12. Which of the following is NOT an attribute of a professional? A. B. C. D. Concerned with quantity Self directed Committed to spirit of inquiry Independent

13. The most unique characteristic of nursing as a profession is A. B. C. D. Education Theory Caring Autonomy

14. This is the distinctive individual qualities that differentiate a person to another A. B. C. D. Philosophy Personality Charm Character

15. Refers to the moral values and beliefs that are used as guides to personal b ehavior and actions A. B. C. D. Philosophy Personality Charm Character

16. As a nurse manager, which of the following best describes this function? A. Initiate modification on client s lifestyle B. Protect client s right C. Coordinates the activities of other members of the health team in managing pa tient care D. Provide in service education programs, Use accurate nursing audit, formulate philosophy and vision of the institution 17. What best describes nurses as a care provider? A. B. C. D. Determine client s need Provide direct nursing care Help client recognize and cope with stressful psychological situation Works in combined effort with all those involved in patient s care

18. The nurse questions a doctors order of Morphine sulfate 50 mg, IM for a clie nt with pancreatitis. Which role best fit that statement? A. B. C. D. Change agent Client advocate Case manager Collaborator

19. These are nursing intervention that requires knowledge, skills and expertise of multiple health professionals. A. B. C. D. Dependent Independent Interdependent Intradependent

20. What type of patient care model is the most common for student nurses and pr ivate duty nurses? A. B. C. D. Total patient care Team nursing Primary Nursing Case management

21. This is the best patient care model when there are many nurses but few patie nts. A. B. C. D. Functional nursing Team nursing Primary nursing Total patient care

22. This patient care model works best when there are plenty of patient but few nurses A. Functional nursing

B. Team nursing C. Primary nursing D. Total patient care 23. RN assumes 24 hour responsibility for the client to maintain continuity of c are across shifts, days or visits. A. B. C. D. Functional nursing Team nursing Primary nursing Total patient care

24. Who developed the first theory of nursing? A. B. C. D. Hammurabi Alexander Fabiola Nightingale

25. She introduces the NATURE OF NURSING MODEL. A. B. C. D. Henderson Nightingale Parse Orlando

26. She described the four conservation principle. A. B. C. D. Levin Leininger Orlando Parse

27. Proposed the HEALTH CARE SYSTEM MODEL. A. B. C. D. Henderson Orem Parse Neuman

28. Conceptualized the BEHAVIORAL SYSTEM MODEL A. B. C. D. Orem Johnson Henderson Parse A HELPING ART MODEL

29. Developed the CLINICAL NURSING A. B. C. D. Swanson Hall Weidenbach Zderad

30. Developed the ROLE MODELING and MODELING theory A. B. C. D. Erickson,Tomlin,Swain Neuman Newman Benner and Wrubel

31. Proposed the GRAND THEORY OF NURSING AS CARING A. B. C. D. Erickson, Tomlin, Swain Peterson,Zderad Bnner,Wrubel Boykin,Schoenhofer

32. Postulated the INTERPERSONAL ASPECT OF NURSING A. B. C. D. Travelbee Swanson Zderad Peplau

33. He proposed the theory of morality that is based on MUTUAL TRUST A. B. C. D. Freud Erikson Kohlberg Peters

34. He proposed the theory of morality based on PRINCIPLES A. B. C. D. Freud Erikson Kohlberg Peters

35. Freud postulated that child adopts parental standards and traits through A. B. C. D. Imitation Introjection Identification Regression

36. According to them, Morality is measured of how people treat human being and that a moral child strives to be kind and just A. B. C. D. Zderad and Peterson Benner and Wrubel Fowler and Westerhoff Schulman and Mekler

37. Postulated that FAITH is the way of behaving. He developed four theories of faith and development based on his experience. A. B. C. D. Giligan Westerhoff Fowler Freud

38. He described the development of faith. He suggested that faith is a spiritua l dimension that gives meaning to a persons life. Faith according to him, is a r elational phenomenon. A. B. C. D. Giligan Westerhoff Fowler Freud

39. Established in 1906 by the Baptist foreign mission society of America. Miss rose nicolet, was it s first superintendent. A. B. C. D. St. Paul Hospital School of nursing Iloilo Mission Hospital School of nursing Philippine General Hospital School of nursing St. Luke s Hospital School of nursing

40. Anastacia Giron-Tupas was the first Filipino nurse to occupy the position of chief nurse in this hospital. A. B. C. D. St. Paul Hospital Iloilo Mission Hospital Philippine General Hospital St. Luke s Hospital

41. She was the daughter of Hungarian kings, who feed 300-900 people everyday in their gate, builds hospitals, and care of the poor and sick herself. A. B. C. D. Elizabeth Catherine Nightingale Sairey Gamp

42. She dies of yellow fever in her search for truth to prove that yellow fever is carried by a mosquitoes. A. B. C. D. Clara louise Maas Pearl Tucker Isabel Hampton Robb Caroline Hampton Robb

43. He was called the father of sanitation. A. B. C. D. Abraham Hippocrates Moses Willam Halstead

44. The country where SHUSHURUTU originated A. B. C. D. China Egypt India Babylonia

45. They put girls clothes on male infants to drive evil forces away A. B. C. D. Chinese Egyptian Indian Babylonian

46. In what period of nursing does people believe in TREPHINING to drive evil fo rces away? A. Dark period B. Intuitive period C. Contemporary period

D. Educative period 47. This period ended when Pastor Fliedner, build Kaiserwerth institute for the training of Deaconesses A. B. C. D. Apprentice period Dark period Contemporary period Educative period

48. Period of nursing where religious Christian orders emerged to take care of t he sick A. B. C. D. Apprentice period Dark period Contemporary period Educative period

49. Founded the second order of St. Francis of Assisi A. B. C. D. St. St. St. St. Catherine Anne Clare Elizabeth

50. This period marked the religious upheaval of Luther, Who questions the Chris tian faith. A. B. C. D. Apprentice period Dark period Contemporary period Educative period

51. According to the Biopsychosocial and spiritual theory of Sister Callista Roy , Man, As a SOCIAL being is A. B. C. D. Like Like Like Like all other men some other men no other men men

52. She conceptualized that man, as an Open system is in constant interaction an d transaction with a changing environment. A. B. C. D. Roy Levin Neuman Newman

53. In a CLOSED system, which of the following is true? A. B. C. D. Affected by matter A sole island in vast ocean Allows input Constantly affected by matter, energy, information

54. Who postulated the WHOLISTIC concept that the totality is greater than sum o f its parts? A. Roy

B. Rogers C. Henderson D. Johnson 55. She theorized that man is composed of sub and supra systems. Subsystems are cells, tissues, organs and systems while the suprasystems are family, society an d community. A. B. C. D. Roy Rogers Henderson Johnson

56. Which of the following is not true about the human needs? A. B. C. D. Certain needs are common to all people Needs should be followed exactly in accordance with their hierarchy Needs are stimulated by internal factors Needs are stimulated by external factors

57. Which of the following is TRUE about the human needs? A. B. C. D. May not be deferred Are not interrelated Met in exact and rigid way Priorities are alterable

58. According to Maslow, which of the following is NOT TRUE about a self actuali zed person? A. B. C. D. Understands poetry, music, philosophy, science etc. Desires privacy, autonomous Follows the decision of the majority, uphold justice and truth Problem centered

59. According to Maslow, which of the following is TRUE about a self actualized person? A. B. C. D. Makes decision contrary to public opinion Do not predict events Self centered Maximum degree of self conflict

60. This is the essence of mental health A. B. C. D. Self Self Self Self awareness actualization esteem worth

61. Florence nightingale is born in A. B. C. D. Germany Britain France Italy

62. Which is unlikely of Florence Nightingale? A. Born May 12, 1840

B. Built St. Thomas school of nursing when she was 40 years old C. Notes in nursing D. Notes in hospital 63. What country did Florence Nightingale train in nursing? A. B. C. D. Belgium US Germany England

64. Which of the following is recognized for developing the concept of HIGH LEVE L WELLNESS? A. B. C. D. Erikson Madaw Peplau Dunn

65. One of the expectations is for nurses to join professional association prima rily because of A. B. C. D. Promotes advancement and professional growth among its members Works for raising funds for nurse s benefit Facilitate and establishes acquaintances Assist them and securing jobs abroad

66. Founder of the PNA A. B. C. D. Julita Sotejo Anastacia Giron Tupas Eufemia Octaviano Anesia Dionisio

67. Which of the following provides that nurses must be a member of a national n urse organization? A. B. C. D. R.A 877 1981 Code of ethics approved by the house of delegates and the PNA Board resolution No. 1955 Promulgated by the BON RA 7164

68. Which of the following best describes the action of a nurse who documents he r nursing diagnosis? A. B. C. D. She She She She documents it and charts it whenever necessary can be accused of malpractice does it regularly as an important responsibility charts it only when the patient is acutely ill

69. Which of the following does not govern nursing practice? A. B. C. D. RA 7164 RA 9173 BON Res. Code Of Ethics BON Res. Scope of Nursing Practice

70. A nurse who is maintaining a private clinic in the community renders service on maternal and child health among the neighborhood for a fee is:

A. B. C. D.

Primary care nurse Independent nurse practitioner Nurse-Midwife Nurse specialist

71. When was the PNA founded? A. B. C. D. September 22, 1922 September 02, 1920 October 21, 1922 September 02, 1922

72. Who was the first president of the PNA ? A. B. C. D. Anastacia Giron-Tupas Loreto Tupas Rosario Montenegro Ricarda Mendoza

73. Defines health as the ability to maintain internal milieu. Illness according to him/her/them is the failure to maintain internal environment. A. B. C. D. Cannon Bernard Leddy and Pepper Roy

74. Postulated that health is a state and process of being and becoming an integ rated and whole person. A. B. C. D. Cannon Bernard Dunn Roy

75. What regulates HOMEOSTASIS according to the theory of Walter Cannon? A. B. C. D. Positive feedback Negative feedback Buffer system Various mechanisms

76. Stated that health is WELLNESS. A termed define by the culture or an individ ual. A. B. C. D. Roy Henderson Rogers King

77. Defined health as a dynamic state in the life cycle, and Illness as interfer ence in the life cycle. A. B. C. D. Roy Henderson Rogers King

78. She defined health as the soundness and wholness of developed human structur e and bodily mental functioning.

A. B. C. D.

Orem Henderson Neuman Clark

79. According to her, Wellness is a condition in which all parts and subparts of an individual are in harmony with the whole system. A. B. C. D. Orem Henderson Neuman Johnson

80. Postulated that health is reflected by the organization, interaction, interd ependence and integration of the subsystem of the behavioral system. A. B. C. D. Orem Henderson Neuman Johnson

81. According to them, Well being is a subjective perception of BALANCE, HARMONY and VITALITY A. B. C. D. Leavell and Clark Peterson and Zderad Benner and Wruber Leddy and Pepper

82. He describes the WELLNESS-ILLNESS Continuum as interaction of the environmen t with well being and illness. A. B. C. D. Cannon Bernard Dunn Clark

83. An integrated method of functioning that is oriented towards maximizing one s potential within the limitation of the environment. A. B. C. D. Well being Health Low level Wellness High level Wellness

84. What kind of illness precursor, according to DUNN is cigarette smoking? A. B. C. D. Heredity Social Behavioral Environmental

85. According to DUNN, Overcrowding is what type of illness precursor? A. B. C. D. Heredity Social Behavioral Environmental

86. Health belief model was formulated in 1975 by who? A. B. C. D. Becker Smith Dunn Leavell and Clark

87. In health belief model, Individual perception matters. Which of the followin g is highly UNLIKELY to influence preventive behavior? A. B. C. D. Perceived Perceived Perceived Perceived susceptibility to an illness seriousness of an illness threat of an illness curability of an illness

88. Which of the following is not a PERCEIVED BARRIER in preventive action? A. B. C. D. Difficulty adhering to the lifestyle Economic factors Accessibility of health care facilities Increase adherence to medical therapies

89. Conceptualizes that health is a condition of actualization or realization of person s potential. Avers that the highest aspiration of people is fulfillment an d complete development actualization. A. B. C. D. Clinical Model Role performance Model Adaptive Model Eudaemonistic Model

90. Views people as physiologic system and Absence of sign and symptoms equates health. A. B. C. D. Clinical Model Role performance Model Adaptive Model Eudaemonistic Model

91. Knowledge about the disease and prior contact with it is what type of VARIAB LE according to the health belief model? A. B. C. D. Demographic Sociopsychologic Structural Cues to action

92. It includes internal and external factors that leads the individual to seek help A. B. C. D. Demographic Sociopsychologic Structural Cues to action

93. Influence from peers and social pressure is included in what variable of HBM ? A. Demographic B. Sociopsychologic

C. Structural D. Cues to action 94. Age, Sex, Race etc. is included in what variable of HBM? A. B. C. D. Demographic Sociopsychologic Structural Cues to action

95. According to Leavell and Clark s ecologic model, All of this are factors that affects health and illness except A. B. C. D. Reservoir Agent Environment Host

96. Is a multi dimensional model developed by PENDER that describes the nature o f persons as they interact within the environment to pursue health A. B. C. D. Ecologic Model Health Belief Model Health Promotion Model Health Prevention Model

97. Defined by Pender as all activities directed toward increasing the level of well being and self actualization. A. B. C. D. Health prevention Health promotion Health teaching Self actualization

98. Defined as an alteration in normal function resulting in reduction of capaci ties and shortening of life span. A. B. C. D. Illness Disease Health Wellness

99. Personal state in which a person feels unhealthy A. B. C. D. Illness Disease Health Wellness

100. According to her, Caring is defined as a nurturant way of responding to a v alued client towards whom the nurse feels a sense of commitment and responsibili ty. A. B. C. D. Benner Watson Leininger Swanson

Answers and Rationale 1. The four major concepts in nursing theory are the

A. Person, Environment, Nurse, Health B. Nurse, Person, Environment, Cure C. Promotive, Preventive, Curative, Rehabilitative D. Person, Environment, Nursing, Health Rationale:This is an actual board exam question and is a common board question. Theorist always describes The nursing profession by first defining what is NURSI NG, followed by the PERSON, ENVIRONMENT and HEALTH CONCEPT. The most popular the ory was perhaps Nightingale s. She defined nursing as the utilization of the perso ns environment to assist him towards recovery. She defined the person as somebod y who has a reparative capabilities mediated and enhanced by factors in his envi ronment. She describes the environment as something that would facilitate the pe rson s reparative process and identified different factors like sanitation, noise, etc. that affects a person s reparative state. 2. The act of utilizing the environment of the patient to assist him in his reco very is theorized by A. Nightingale B. Benner C. Swanson D. King Rationale: Florence nightingale do not believe in the germ theory, and perhaps t his was her biggest mistake. Yet, her theory was the first in nursing. She belie ved that manipulation of environment that includes appropriate noise, nutrition, hygiene, light, comfort, sanitation etc. could provide the client s body the nurt urance it needs for repair and recovery. 3. For her, Nursing is a theoretical system of knowledge that prescribes a proce ss of analysis and action related to care of the ill person A. King B. Henderson C. Roy D. Leininger Rationale:Remember the word THEOROYTICAL For Callista Roy, Nursing is a theoreti cal body of knowledge that prescribes analysis and action to care for an ill per son. She introduced the ADAPTATION MODEL and viewed person as a BIOSPSYCHOSOCIAL BEING. She believed that by adaptation, Man can maintain homeostasis. 4. According to her, Nursing is a helping or assistive profession to persons who are wholly or partly dependent or when those who are supposedly caring for them are no longer able to give care. A. Henderson B. Orem C. Swanson D. Neuman Rationale: In self care deficit theory, Nursing is defined as A helping or assis tive profession to person who are wholly or partly dependent or when people who are to give care to them are no longer available. Self care, are the activities that a person do for himself to maintain health, life and well being. 5. Nursing is a unique profession, Concerned with all the variables affecting an individual s response to stressors, which are intra, inter and extra personal in nature. A. Neuman B. Johnson C. Watson

D. Parse Rationale: Neuman divided stressors as either intra, inter and extra personal in nature. She said that NURSING is concerned with eliminating these stressors to obtain a maximum level of wellness. The nurse helps the client through PRIMARY, SECONDARY AND TERTIARY prevention modes. Please do not confuse this with LEAVELL and CLARK S level of prevention. 6. The unique function of the nurse is to assist the individual, sick or well, i n the performance of those activities contributing to health that he would perfo rm unaided if he has the necessary strength, will and knowledge, and do this in such a way as to help him gain independence as rapidly as possible A. Henderson B. Abdellah C. Levin D. Peplau Rationale: This was an actual board question. Remember this definition and assoc iate it with Virginia Henderson. Henderson also describes the NATURE OF NURSING theory. She identified 14 basic needs of the client. She describes nursing roles as SUBSTITUTIVE : Doing everything for the client, SUPPLEMENTARY : Helping the client and COMPLEMENTARY : Working with the client. Breathing normally, Eliminat ing waste, Eating and drinking adquately, Worship and Play are some of the basic needs according to her. 7. Caring is the essence and central unifying, a dominant domain that distinguis hes nursing from other health disciplines. Care is an essential human need. A. Benner B. Watson C. Leininger D. Swanson Rationale: There are many theorist that describes nursing as CARE. The most popu lar was JEAN WATSON S Human Caring Model. But this question pertains to Leininger s definition of caring. CUD I LIE IN GER? [ Could I Lie In There ] Is the Mnemonic s I am using not to get confused. C stands for CENTRAL , U stands for UNIFYING, D stands for DOMINANT DOMAIN. I emphasize on this matter due to feedback on the last June 2006 batch about a question about CARING. 8. Caring involves 5 processes, KNOWING, BEING WITH, DOING FOR, ENABLING and MAI NTAINING BELIEF. A. Benner B. Watson C. Leininger D. Swanson Rationale: Caring according to Swanson involves 5 processes. Knowing means under standing the client. Being with emphasizes the Physical presence of the nurse fo r the patient. Doing for means doing things for the patient when he is incapable of doing it for himself. Enabling means helping client transcend maturational a nd developmental stressors in life while Maintaining belief is the ability of th e Nurse to inculcate meaning to these events. 9. Caring is healing, it is communicated through the consciousness of the nurse to the individual being cared for. It allows access to higher human spirit. A. Benner B. Watson C. Leininger D. Swanson Rationale: The deepest and spiritual definition of Caring came from Jean watson.

For her, Caring expands the limits of openess and allows access to higher human spirit. 10. Caring means that person, events, projects and things matter to people. It r eveals stress and coping options. Caring creates responsibility. It is an inhere nt feature of nursing practice. It helps the nurse assist clients to recover in the face of the illness. A. Benner B. Watson C. Leininger D. Swanson Rationale: I think of CARE BEAR to facilitate retainment of BENNER. As in, Care Benner. For her, Caring means being CONNECTED or making things matter to people. Caring according to Benner give meaning to illness and re establish connection. 11. Which of the following is NOT TRUE about profession according to Marie Jahod a? A. A profession is an organization of an occupational group based on the applica tion of special knowledge B. It serves specific interest of a group C. It is altruistic D. Quality of work is of greater importance than the rewards Rationale: Believe it or not, you should know the definition of profession accor ding to Jahoda because it is asked in the Local boards. A profession should serv e the WHOLE COMMUNITY and not just a specific intrest of a group. Everything els e, are correct. 12. Which of the following is NOT an attribute of a professional? A. Concerned with quantity B. Self directed C. Committed to spirit of inquiry D. Independent Rationale: A professional is concerned with QUALITY and not QUANTITY. In nursing , We have methods of quality assurance and control to evaluate the effectiveness of nursing care. Nurses, are never concerned with QUANTITY of care provided. 13. The most unique characteristic of nursing as a profession is A. Education B. Theory C. Caring D. Autonomy Rationale: Caring and caring alone, is the most unique quality of the Nursing Pr ofession. It is the one the delineate Nursing from other professions. 14. This is the distinctive individual qualities that differentiate a person to another A. Philosophy B. Personality C. Charm D. Character Rationale: Personality are qualities that make us different from each other. The se are impressions that we made, or the footprints that we leave behind. This is the result of the integration of one s talents, behavior, appearance, mood, chara cter, morals and impulses into one harmonious whole. Philosophy is the basic tru th that fuel our soul and give our life a purpose, it shapes the facets of a per

son s character. Charm is to attract other people to be a change agent. Character is our moral values and belief that guides our actions in life. 15. Refers to the moral values and beliefs that are used as guides to personal b ehavior and actions A. Philosophy B. Personality C. Charm D. Character Rationale: Refer to number 14 16. As a nurse manager, which of the following best describes this function? A. Initiate modification on client s lifestyle B. Protect client s right C. Coordinates the activities of other members of the health team in managing pa tient care D. Provide in service education programs, Use accurate nursing audit, formulate philosophy and vision of the institution Rationale: A refers to being a change agent. B is a role of a patient advocate. C is a case manager while D basically summarized functions of a nurse manager. I f you haven t read Lydia Venzon s Book : NURSING MANAGEMENT TOWARDS QUALITY CARE, I suggest reading it in advance for your management subjects in the graduate schoo l. Formulating philosophy and vision is in PLANNING. Nursing Audit is in CONTROL LING, In service education programs are included in DIRECTING. These are the pro cesses of Nursing Management, I just forgot to add ORGANIZING which includes for mulating an organizational structure and plans, Staffing and developing qualific ations and job descriptions. 17. What best describes nurses as a care provider? A. Determine client s need B. Provide direct nursing care C. Help client recognize and cope with stressful psychological situation D. Works in combined effort with all those involved in patient s care Rationale: You can never provide nursing care if you don t know what are the needs of the client. How can you provide an effective postural drainage if you do not know where is the bulk of the client s secretion. Therefore, the best description of a care provider is the accurate and prompt determination of the client s need to be able to render an appropriate nursing care. 18. The nurse questions a doctors order of Morphine sulfate 50 mg, IM for a clie nt with pancreatitis. Which role best fit that statement? A. Change agent B. Client advocate C. Case manager D. Collaborator Rationale: As a client s advocate, Nurses are to protect the client s right and prom otes what is best for the client. Knowing that Morphine causes spasm of the sphi ncter of Oddi and will lead to further increase in the client s pain, The nurse kn ew that the best treatment option for the client was not provided and intervene to provide the best possible care. 19. These are nursing intervention that requires knowledge, skills and expertise of multiple health professionals. A. Dependent B. Independent

C. Interdependent D. Intradependent Rationale: Interdependent functions are those that needs expertise and skills of multiple health professionals. Example is when A child was diagnosed with nephr otic syndrome and the doctor ordered a high protein diet, Budek then work togeth er with the dietician about the age appropriate high protein foods that can be g iven to the child, Including the preparation to entice the child into eating the food. NOTE : It is still debated if the diet in NS is low, moderate or high pro tein, In the U.S, Protein is never restricted and can be taken in moderate amoun t. As far as the local examination is concerned, answer LOW PROTEIN HIGH CALORIC DIET. 20. What type of patient care model is the most common for student nurses and pr ivate duty nurses? A. Total patient care B. Team nursing C. Primary Nursing D. Case management Rationale: This is also known as case nursing. It is a method of nursing care wh erein, one nurse is assigned to one patient for the delivery of total care. Thes e are the method use by Nursing students, Private duty nurses and those in criti cal or isolation units. 21. This is the best patient care model when there are many nurses but few patie nts. A. Functional nursing B. Team nursing C. Primary nursing D. Total patient care Rationale: Total patient care works best if there are many nurses but few patien ts. 22. This patient care model works best when there are plenty of patient but few nurses A. Functional nursing B. Team nursing C. Primary nursing D. Total patient care Rationale: Functional nursing is task oriented, One nurse is assigned on a parti cular task leading to task expertise and efficiency. The nurse will work fast be cause the procedures are repetitive leading to task mastery. This care is not re commended as this leads fragmented nursing care. 23. RN assumes 24 hour responsibility for the client to maintain continuity of c are across shifts, days or visits. A. B. C. D. Functional nursing Team nursing Primary nursing Total patient care

Rationale: Your keyword in Primary nursing is the 24 hours. This does not necess arily means the nurse is awake for 24 hours, She can have a SECONDARY NURSES tha t will take care of the patient in shifts where she is not arround. 24. Who developed the first theory of nursing?

A. Hammurabi B. Alexander C. Fabiola D. Nightingale Rationale: Refer to question # 2. Hammurabi is the king of babylon that introduc es the LEX TALIONES law, If you kill me, you should be killed If you rob me, You should be robbed, An eye for an eye and a tooth for a tooth. Alexander the great was the son of King Philip II and is from macedonia but he ruled Greece includi ng Persia and Egypt. He is known to use a hammer to pierce a dying soldier s medul la towards speedy death when he thinks that the soldier will die anyway, just to relieve their suffering. Fabiola was a beautiful roman matron who converted her house into a hospital. 25. She introduces the NATURE OF NURSING MODEL. A. Henderson B. Nightingale C. Parse D. Orlando Rationale: Refer to question # 6. 26. She described the four conservation principle. A. Levin B. Leininger C. Orlando D. Parse Rationale: Myra Levin described the 4 Conservation principles which are concerne d with the Unity and Integrity of an individual. These are ENERGY : Our output t o facilitate meeting of our needs. STRUCTURAL INTEGRITY : We mus maintain the in tegrity of our organs, tissues and systems to be able to function and prevent ha rmful agents entering our body. PERSONAL INTEGRITY : These refers to our self es teem, self worth, self concept, identify and personality. SOCIAL INTEGRITY : Ref lects our societal roles to our society, community, family, friends and fellow i ndividuals. 27. Proposed the HEALTH CARE SYSTEM MODEL. A. Henderson B. Orem C. Parse D. Neuman Rationale: Betty Neuman asserted that nursing is a unique profession and is conc erned with all the variables affecting the individual s response to stressors. The se are INTRA or within ourselves, EXTRA or outside the individual, INTER means b etween two or more people. She proposed the HEALTH CARE SYSTEM MODEL which state s that by PRIMARY, SECONDARY and TERTIARY prevention, The nurse can help the cli ent maintain stability against these stressors. 28. Conceptualized the BEHAVIORAL SYSTEM MODEL A. B. C. D. Orem Johnson Henderson Parse

Rationale: According to Dorothy Johnson, Each person is a behavioral system that is composed of 7 subsystems. Man adjust or adapt to stressors by a using a LEAR NED PATTERN OF RESPONSE. Man uses his behavior to meet the demands of the enviro nment, and is able to modified his behavior to support these demands.

29. Developed the CLINICAL NURSING A. B. C. D. Swanson Hall Weidenbach Zderad

A HELPING ART MODEL

Rationale: Just remember ERNESTINE WEIDENBACHLINICAL. 30. Developed the ROLE MODELING and MODELING theory A. Erickson,Tomlin,Swain B. Neuman C. Newman D. Benner and Wrubel 31. Proposed the GRAND THEORY OF NURSING AS CARING A. Erickson, Tomlin, Swain B. Peterson,Zderad C. Bnner,Wrubel D. Boykin,Schoenhofer Rationale: This theory was called GRAND THEORY because boykin and schoenofer thi nks that ALL MAN ARE CARING, And that nursing is a response to this unique call. According to them, CARING IS A MORAL IMPERATIVE, meaning, ALL PEOPLE will tend to help a man who fell down the stairs even if he is not trained to do so. 32. Postulated the INTERPERSONAL ASPECT OF NURSING A. Travelbee B. Swanson C. Zderad D. Peplau Rationale: Travelbee s theory was referred to as INTERPERSONAL theory because she postulated that NURSING is to assist the individual and all people that affects this individual to cope with illness, recover and FIND MEANING to this experienc e. For her, Nursing is a HUMAN TO HUMAN relationship that is formed during illne ss. To her, an individual is a UNIQUE and irreplaceable being in continuous proc ess of becoming, evolving and changing. PLEASE do remember, that it is PARSE who postulated the theory of HUMAN BECOMING and not TRAVELBEE, for I read books tha t say it was TRAVELBEE and not PARSE. 33. He proposed the theory of morality that is based on MUTUAL TRUST A. Freud B. Erikson C. Kohlberg D. Peters Rationale: Kohlber states that relationships are based on mutual trust. He postu lated the levels of morality development. At the first stage called the PREMORAL or preconventional, A child do things and label them as BAD or GOOD depending o n the PUNISHMENT or REWARD they get. They have no concept of justice, fairness a nd equity, for them, If I punch this kid and mom gets mad, thats WRONG. But if I dance and sing, mama smiles and give me a new toy, then I am doing something go od. In the Conventional level, The individual actuates his act based on the resp onse of the people around him. He will follow the rules, regulations, laws and m orality the society upholds. If the law states that I should not resuscitate thi s man with a DNR order, then I would not. However, in the Post conventional leve l or the AUTONOMOUS level, the individual still follows the rules but can make a rule or bend part of these rules according to his own MORALITY. He can change t

he rules if he thinks that it is needed to be changed. Example is that, A nurse still continue resuscitating the client even if the client has a DNR order becau se he believes that the client can still recover and his mission is to save live s, not watch patients die. 34. He proposed the theory of morality based on PRINCIPLES A. B. C. D. Freud Erikson Kohlberg Peters

Rationale: Remember PETERS for PRINCIPLES. P is to P. He believes that morality has 3 components : EMOTION or how one feels, JUDGEMENT or how one reason and BEH AVIOR or how one actuates his EMOTION and JUDGEMENT. He believes that MORALITY e volves with the development of PRINCPLES or the person s vitrue and traits. He als o believes in AUTOMATICITY of virtues or he calls HABIT, like kindness, charity, honesty, sincerity and thirft which are innate to a person and therfore, will b e performed automatically. 35. Freud postulated that child adopts parental standards and traits through A. Imitation B. Introjection C. Identification D. Regression Rationale: A child, according to Freud adopts parental standards, traits, habits and norms through identication. A good example is the corned beef commercial WA LK LIKE A MAN, TALK LIKE A MAN Where the child identifies with his father by wea ring the same clothes and doing the same thing. 36. According to them, Morality is measured of how people treat human being and that a moral child strives to be kind and just A. Zderad and Peterson B. Benner and Wrubel C. Fowler and Westerhoff D. Schulman and Mekler Rationale: According to Schulman and Mekler, there are 2 components that makes a n action MORAL : The intention should be good and the Act must be just. A good e xample is ROBIN HOOD, His intention is GOOD but the act is UNJUST, which makes h is action IMMORAL. 37. Postulated that FAITH is the way of behaving. He developed four theories of faith and development based on his experience. A. Giligan B. Westerhoff C. Fowler D. Freud Rationale: There are only 2 theorist of FAITH that might be asked in the board e xaminations. Fowler and Westerhoff. What differs them is that, FAITH of fowler i s defined abstractly, Fowler defines faith as a FORCE that gives a meaning to a person s life while Westerhoff defines faith as a behavior that continuously devel ops through time. 38. He described the development of faith. He suggested that faith is a spiritua l dimension that gives meaning to a persons life. Faith according to him, is a r elational phenomenon.

A. Giligan B. Westerhoff C. Fowler D. Freud Rationale: Refer to # 37 39. Established in 1906 by the Baptist foreign mission society of America. Miss rose nicolet, was it s first superintendent. A. St. Paul Hospital School of nursing B. Iloilo Mission Hospital School of nursing C. Philippine General Hospital School of nursing D. St. Luke s Hospital School of nursing 40. Anastacia Giron-Tupas was the first Filipino nurse to occupy the position of chief nurse in this hospital. A. St. Paul Hospital B. Iloilo Mission Hospital C. Philippine General Hospital D. St. Luke s Hospital 41. She was the daughter of Hungarian kings, who feed 300-900 people everyday in their gate, builds hospitals, and care of the poor and sick herself. A. Elizabeth B. Catherine C. Nightingale D. Sairey Gamp Rationale:Saint Elizabeth of Hungary was a daughter of a King and is the patron saint of nurses. She build hospitals and feed hungry people everyday using the k ingdom s money. She is a princess, but devoted her life in feeding the hungry and serving the sick. 42. She dies of yellow fever in her search for truth to prove that yellow fever is carried by a mosquitoes. A. B. C. D. Clara louise Maas Pearl Tucker Isabel Hampton Robb Caroline Hampton Robb

Rationale: Clara Louise Maas sacrificed her life in research of YELLOW FEVER. Pe ople during her time do not believe that yellow fever was brought by mosquitoes. To prove that they are wrong, She allowed herself to be bitten by the vector an d after days, She died. 43. He was called the father of sanitation. A. Abraham B. Hippocrates C. Moses D. Willam Halstead 44. The country where SHUSHURUTU originated A. China B. Egypt C. India D. Babylonia 45. They put girls clothes on male infants to drive evil forces away A. Chinese

B. Egyptian C. Indian D. Babylonian Rationale: Chinese believes that male newborns are demon magnets. To fool those demons, they put female clothes to their male newborn. 46. In what period of nursing does people believe in TREPHINING to drive evil fo rces away? A. Dark period B. Intuitive period C. Contemporary period D. Educative period Rationale: Egyptians believe that a sick person is someone with an evil force or demon that is inside their heads. To release these evil spirits, They would ten d to drill holes on the patient s skull and it is called TREPHINING. 47. This period ended when Pastor Fliedner, build Kaiserwerth institute for the training of Deaconesses A. Apprentice period B. Dark period C. Contemporary period D. Educative period Rationale: What dilineates apprentice period among others is that, it ENDED when formal schools were established. During the apprentice period, There is no form al educational institution for nurses. Most of them receive training inside the convent or church. Some of them are trained just for the purpose of nursing the wounded soldiers. But almost all of them are influenced by the christian faith t o serve and nurse the sick. When Fliedner build the first formal school for nurs es, It marked the end of the APPRENTICESHIP period. 48. Period of nursing where religious Christian orders emerged to take care of t he sick A. Apprentice period B. Dark period C. Contemporary period D. Educative period Rationale: Apprentice period is marked by the emergence of religious orders the are devoted to religious life and the practice of nursing. 49. Founded the second order of St. Francis of Assisi A. St. Catherine B. St. Anne C. St. Clare D. St. Elizabeth Rationale: The poor clares, is the second order of St. Francis of assisi. The fi rst order was founded by St. Francis himself. St. Catherine of Siena was the fir st lady with the lamp. St. Anne is the mother of mama mary. St. Elizabeth is the patron saint of Nursing. 50. This period marked the religious upheaval of Luther, Who questions the Chris tian faith. A. B. C. D. Apprentice period Dark period Contemporary period Educative period

Rationale: Protestantism emerged with Martin Luther questions the Pope and Chris tianity. This started the Dark period of nursing when the christian faith was sm eared by controversies. These leads to closure of some hospital and schools run by the church. Nursing became the work of prostitutes, slaves, mother and least desirable of women. 51. According to the Biopsychosocial and spiritual theory of Sister Callista Roy , Man, As a SOCIAL being is A. Like all other men B. Like some other men C. Like no other men D. Like men Rationale: According to ROY, Man as a social being is like some other man. As a spiritual being and Biologic being, Man are all alike. As a psychologic being, N o man thinks alike. This basically summarized her BIOPSYHOSOCIAL theory which is included in our licensure exam coverage. 52. She conceptualized that man, as an Open system is in constant interaction an d transaction with a changing environment. A. Roy B. Levin C. Neuman D. Newman Rationale: OPEN system theory is ROY. As an open system, man continuously allows input from the environment. Example is when you tell me Im good looking, I will be happy the entire day, Because I am an open system and continuously interact and transact with my environment. A close system is best exemplified by a CANDLE . When you cover the candle with a glass, it will die because it will eventually use all the oxygen it needs inside the glass for combustion. A closed system do not allow inputs and output in its environment. 53. In a CLOSED system, which of the following is true? A. Affected by matter B. A sole island in vast ocean C. Allows input D. Constantly affected by matter, energy, information 54. Who postulated the WHOLISTIC concept that the totality is greater than sum o f its parts? A. Roy B. Rogers C. Henderson D. Johnson Rationale: The wholistic theory by Martha Rogers states that MAN is greater than the sum of all its parts and that his dignity and worth will not be lessen even if one of this part is missing. A good example is ANNE BOLEYN, The mother of Qu een Elizabeth and the wife of King Henry VIII. She was beheaded because Henry wa nts to mary another wife and that his divorce was not approved by the pope. Outr aged, He insisted on the separation of the Church and State and divorce Anne him self by making everyone believe that Anne is having an affair to another man. An ne was beheaded while her lips is still saying a prayer. Even without her head, People still gave respect to her diseased body and a separate head. She was stil l remembered as Anne boleyn, Mother of Elizabeth who lead england to their GOLDE N AGE. 55. She theorized that man is composed of sub and supra systems. Subsystems are cells, tissues, organs and systems while the suprasystems are family, society an

d community. A. Roy B. Rogers C. Henderson D. Johnson Rationale: According to Martha Rogers, Man is composed of 2 systems : SUB which includes cells, tissues, organs and system and SUPRA which includes our famly, c ommunity and society. She stated that when any of these systems are affected, it will affect the entire individual. 56. Which of the following is not true about the human needs? A. Certain needs are common to all people B. Needs should be followed exactly in accordance with their hierarchy C. Needs are stimulated by internal factors D. Needs are stimulated by external factors Rationale:Needs can be deferred. I can urinate later as not to miss the part of the movie s climax. I can save my money that are supposedly for my lunch to watch my idols in concert. The physiologic needs can be meet later for some other need s and need not be strictly followed according to their hierarchy. 57. Which of the following is TRUE about the human needs? A. May not be deferred B. Are not interrelated C. Met in exact and rigid way D. Priorities are alterable Rationale:Refer to question # 56. 58. According to Maslow, which of the following is NOT TRUE about a self actuali zed person? A. Understands poetry, music, philosophy, science etc. B. Desires privacy, autonomous C. Follows the decision of the majority, uphold justice and truth D. Problem centered Rationale: A,B and D are all qualities of a self actualized person. A self actua lized person do not follow the decision of majority but is self directed and can make decisions contrary to a popular opinion. 59. According to Maslow, which of the following is TRUE about a self actualized person? A. Makes decision contrary to public opinion B. Do not predict events C. Self centered D. Maximum degree of self conflict Rationale: Refer to question # 58. 60. This is the essence of mental health A. Self awareness B. Self actualization C. Self esteem D. Self worth Rationale: The peak of maslow s hierarchy is the essence of mental health. 61. Florence nightingale is born in

A. Germany B. Britain C. France D. Italy Rationale: Florence Nightingale was born in Florence, Italy, May 12, 1820. Studi ed in Germany and Practiced in England. 62. Which is unlikely of Florence Nightingale? A. Born May 12, 1840 B. Built St. Thomas school of nursing when she was 40 years old C. Notes in nursing D. Notes in hospital 63. What country did Florence Nightingale train in nursing? A. Belgium B. US C. Germany D. England 64. Which of the following is recognized for developing the concept of HIGH LEVE L WELLNESS? A. Erikson B. Madaw C. Peplau D. Dunn Rationale: According to Dunn, High level wellness is the ability of an individua l to maximize his full potential with the limitations imposed by his environment . According to him, An individual can be healthy or ill in both favorable and un favorable environment. 65. One of the expectations is for nurses to join professional association prima rily because of A. Promotes advancement and professional growth among its members B. Works for raising funds for nurse s benefit C. Facilitate and establishes acquaintances D. Assist them and securing jobs abroad 66. Founder of the PNA A. Julita Sotejo B. Anastacia Giron Tupas C. Eufemia Octaviano D. Anesia Dionisio 67. Which of the following provides that nurses must be a member of a national n urse organization? A. R.A 877 B. 1981 Code of ethics approved by the house of delegates and the PNA C. Board resolution No. 1955 Promulgated by the BON D. RA 7164 Rationale: This is an old board resolution. The new Board resolution is No. 220 series of 2004 also known as the Nursing Code Of ethics which states that [ SECT ION 17, A ] A nurse should be a member of an accredited professional organizatio n which is the PNA. 68. Which of the following best describes the action of a nurse who documents he r nursing diagnosis? A. She documents it and charts it whenever necessary

B. She can be accused of malpractice C. She does it regularly as an important responsibility D. She charts it only when the patient is acutely ill 69. Which of the following does not govern nursing practice? A. RA 7164 B. RA 9173 C. BON Res. Code Of Ethics D. BON Res. Scope of Nursing Practice Rationale:7164 is an old law. This is the 1991 Nursing Law which was repealed by the newer 9173. 70. A nurse who is maintaining a private clinic in the community renders service on maternal and child health among the neighborhood for a fee is: A. Primary care nurse B. Independent nurse practitioner C. Nurse-Midwife D. Nurse specialist 71. When was the PNA founded? A. September 22, 1922 B. September 02, 1920 C. October 21, 1922 D. September 02, 1922 Rationale: According to the official PNA website, they are founded September 02, 1922. 72. Who was the first president of the PNA ? A. Anastacia Giron-Tupas B. Loreto Tupas C. Rosario Montenegro D. Ricarda Mendoza Rationale: Anastacia Giron Tupas founded the FNA, the former name of the PNA but the first President was Rosario Montenegro. 73. Defines health as the ability to maintain internal milieu. Illness according to him/her/them is the failure to maintain internal environment. A. Cannon B. Bernard C. Leddy and Pepper D. Roy Rationale: According to Bernard, Health is the ability to maintain and Internal Milieu and Illness is the failure to maintain the internal environment. 74. Postulated that health is a state and process of being and becoming an integ rated and whole person. A. Cannon B. Bernard C. Dunn D. Roy Rationale:According to ROY, Health is a state and process of becoming a WHOLE AN D INTEGRATED Person. 75. What regulates HOMEOSTASIS according to the theory of Walter Cannon? A. Positive feedback

B. Negative feedback C. Buffer system D. Various mechanisms Rationale: The theory of Health as the ability to maintain homeostasis was postu lated by Walter Cannon. According to him, There are certain FEEDBACK Mechanism t hat regulates our Homeostasis. A good example is that when we overuse our arm, i t will produce pain. PAIN is a negative feedback that signals us that our arm ne eds a rest. 76. Stated that health is WELLNESS. A termed define by the culture or an individ ual. A. Roy B. Henderson C. Rogers D. King Rationale: Martha Rogers states that HEALTH is synonymous with WELLNESS and that HEALTH and WELLNESS is subjective depending on the definition of one s culture. 77. Defined health as a dynamic state in the life cycle, and Illness as interfer ence in the life cycle. A. Roy B. Henderson C. Rogers D. King Rationale: Emogene King states that health is a state in the life cycle and Illn ess is any interference on this cycle. I enjoyed the Movie LION KING and like wh at Mufasa said that they are all part of the CIRCLE OF LIFE, or the Life cycle. 78. She defined health as the soundness and wholness of developed human structur e and bodily mental functioning. A. Orem B. Henderson C. Neuman D. Clark Rationale: Orem defined health as the SOUNDNESS and WHOLENESS of developed human structure and of bodily and mental functioning. 79. According to her, Wellness is a condition in which all parts and subparts of an individual are in harmony with the whole system. A. Orem B. Henderson C. Neuman D. Johnson Rationale: Neuman believe that man is composed of subparts and when this subpart s are in harmony with the whole system, Wellness results. Please do not confuse this with the SUB and SUPRA systems of martha rogers. 80. Postulated that health is reflected by the organization, interaction, interd ependence and integration of the subsystem of the behavioral system. A. Orem B. Henderson C. Neuman D. Johnson Rationale: Once you see the phrase BEHAVIORAL SYSTEM, answer Dorothy Johnson.

81. According to them, Well being is a subjective perception of BALANCE, HARMONY and VITALITY A. Leavell and Clark B. Peterson and Zderad C. Benner and Wruber D. Leddy and Pepper Rationale: According to Leddy and Pepper, Wellness is subjective and depends on an individuals perception of balance, harmony and vitality. Leavell and Clark po stulared the ecologic model of health and illness or the AGENT-HOST-ENVIRONMENT model. Peterson and Zderad developed the HUMANISTIC NURSING PRACTICE theory whil e Benner and Wruber postulate the PRIMACY OF CARING MODEL. 82. He describes the WELLNESS-ILLNESS Continuum as interaction of the environmen t with well being and illness. A. Cannon B. Bernard C. Dunn D. Clark 83. An integrated method of functioning that is oriented towards maximizing one s potential within the limitation of the environment. A. Well being B. Health C. Low level Wellness D. High level Wellness 84. What kind of illness precursor, according to DUNN is cigarette smoking? A. Heredity B. Social C. Behavioral D. Environmental Rationale: Behavioral precursors includes smoking, alcoholism, high fat intake a nd other lifestyle choices. Environmental factors involved poor sanitation and o ver crowding. Heridity includes congenital and diseases acquired through the gen es. There are no social precursors according to DUNN. 85. According to DUNN, Overcrowding is what type of illness precursor? A. Heredity B. Social C. Behavioral D. Environmental 86. Health belief model was formulated in 1975 by who? A. Becker B. Smith C. Dunn D. Leavell and Clark Rationale: According to Becker, The belief of an individual greatly affects his behavior. If a man believes that he is susceptible to an illness, He will alter his behavior in order to prevent its occurence. For example, If a man thinks tha t diabetes is acquired through high intake of sugar and simple carbohydrates, th en he will limit the intake of foods rich in these components. 87. In health belief model, Individual perception matters. Which of the followin g is highly UNLIKELY to influence preventive behavior? A. Perceived susceptibility to an illness

B. Perceived seriousness of an illness C. Perceived threat of an illness D. Perceived curability of an illness Rationale: If a man think he is susceptibe to a certain disease, thinks that the disease is serious and it is a threat to his life and functions, he will use pr eventive behaviors to avoid the occurence of this threat. 88. Which of the following is not a PERCEIVED BARRIER in preventive action? A. Difficulty adhering to the lifestyle B. Economic factors C. Accessibility of health care facilities D. Increase adherence to medical therapies Rationale:Perceived barriers are those factors that affects the individual s healt h preventive actions. Both A and B can affect the individual s ability to prevent the occurence of diseases. C and D are called Preventive Health Behaviors which enhances the individual s preventive capabilities. 89. Conceptualizes that health is a condition of actualization or realization of person s potential. Avers that the highest aspiration of people is fulfillment an d complete development actualization. A. Clinical Model B. Role performance Model C. Adaptive Model D. Eudaemonistic Model Rationale: Smith formulated 5 models of health. Clinical model simply states tha t when people experience sign and symptoms, they would think that they are unhea lthy therefore, Health is the absence of clinical sign and symptoms of a disease . Role performance model states that when a person does his role and activities without deficits, he is healthy and the inability to perform usual roles means t hat the person is ill. Adaptive Model states that if a person adapts well with h is environment, he is healthy and maladaptation equates illness. Eudaemonistic M odel of health according to smith is the actualization of a person s fullest poten tial. If a person functions optimally and develop self actualization, then, no d oubt that person is healthy. 90. Views people as physiologic system and Absence of sign and symptoms equates health. A. Clinical Model B. Role performance Model C. Adaptive Model D. Eudaemonistic Model Rationale: Refer to question # 89. 91. Knowledge about the disease and prior contact with it is what type of VARIAB LE according to the health belief model? A. Demographic B. Sociopsychologic C. Structural D. Cues to action Rationale:Modifying variables in Becker s health belief model includes DEMOGRAPHIC : Age, sex, race etc. SOCIOPSYCHOLOGIC : Social and Peer influence. STRUCTURAL : Knowledge about the disease and prior contact with it and CUES TO ACTION : Whi ch are the sign and symptoms of the disease or advice from friends, mass media a nd others that forces or makes the individual seek help. 92. It includes internal and external factors that leads the individual to seek

help A. Demographic B. Sociopsychologic C. Structural D. Cues to action Rationale: Refer to question # 91. 93. Influence from peers and social pressure is included in what variable of HBM ? A. Demographic B. Sociopsychologic C. Structural D. Cues to action Rationale: Refer to question # 91. 94. Age, Sex, Race etc. is included in what variable of HBM? A. Demographic B. Sociopsychologic C. Structural D. Cues to action Rationale: Refer to question # 91. 95. According to Leavell and Clark s ecologic model, All of this are factors that affects health and illness except A. Reservoir B. Agent C. Environment D. Host Rationale: According to L&C s Ecologic model, there are 3 factors that affect heal th and illness. These are the AGENT or the factor the leads to illness, either a bacteria or an event in life. HOST are persons that may or may not be affected by these agents. ENVIRONMENT are factors external to the host that may or may no t predispose him to the AGENT. 96. Is a multi dimensional model developed by PENDER that describes the nature o f persons as they interact within the environment to pursue health A. Ecologic Model B. Health Belief Model C. Health Promotion Model D. Health Prevention Model Rationale: Pender developed the concept of HEALTH PROMOTION MODEL which postulat ed that an individual engages in health promotion activities to increase well be ing and attain self actualization. These includes exercise, immunization, health y lifestyle, good food, self responsibility and all other factors that minimize if not totally eradicate risks and threats of health. 97. Defined by Pender as all activities directed toward increasing the level of well being and self actualization. A. Health prevention B. Health promotion C. Health teaching D. Self actualization Rationale: Refer to question # 96.

98. Defined as an alteration in normal function resulting in reduction of capaci ties and shortening of life span. A. Illness B. Disease C. Health D. Wellness Rationale: Disease are alteration in body functions resulting in reduction of ca pabilities or shortening of life span. 99. Personal state in which a person feels unhealthy A. Illness B. Disease C. Health D. Wellness Rationale: Illness is something PERSONAL. Unlike disease, Illness are personal s tate in which person feels unhealthy. An old person might think he is ILL but in fact, he is not due, to diminishing functions and capabilities, people might th ink they are ILL. Disease however, is something with tangible basis like lab res ults, X ray films or clinical sign and symptoms. 100. According to her, Caring is defined as a nurturant way of responding to a v alued client towards whom the nurse feels a sense of commitment and responsibili ty. A. Benner B. Watson C. Leininger D. Swanson Rationale: This is Jean Watson s definition of Nursing as caring. This was asked w ord per word last June 06' NLE. Benner defines caring as something that matters to people. She postulated the responsibility created by Caring in nursing. She w as also responsible for the PRIMACY OF CARING MODEL. Leininger defind the 4 cons ervation principle while Swanson introduced the 5 processes of caring. 1. When the General adaptation syndrome is activated, FLIGHT OR FIGHT response s ets in. Sympathetic nervous system releases norepinephrine while the adrenal med ulla secretes epinephrine. Which of the following is true with regards to that s tatement? A. B. C. D. Pupils will constrict Client will be lethargic Lungs will bronchodilate Gastric motility will increase

2. Which of the following response is not expected to a person whose GAS is acti vated and the FIGHT OR FLIGHT response sets in? A. The client B. The client C. Clients BP D. There will ion will not urinate due to relaxation of the detrusor muscle will be restless and alert will increase, there will be vasodilation be increase glycogenolysis, Pancrease will decrease insulin secret

3. State in which a person s physical, emotional, intellectual and social developm ent or spiritual functioning is diminished or impaired compared with a previous experience. A. Illness

B. Disease C. Health D. Wellness 4. This is the first stage of illness wherein, the person starts to believe that something is wrong. Also known as the transition phase from wellness to illness . A. B. C. D. Symptom Experience Assumption of sick role Medical care contact Dependent patient role

5. In this stage of illness, the person accepts or rejects a professionals sugge stion. The person also becomes passive and may regress to an earlier stage. A. B. C. D. Symptom Experience Assumption of sick role Medical care contact Dependent patient role

6. In this stage of illness, The person learns to accept the illness. A. B. C. D. Symptom Experience Assumption of sick role Medical care contact Dependent patient role

7. In this stage, the person tries to find answers for his illness. He wants his illness to be validated, his symptoms explained and the outcome reassured or pr edicted A. B. C. D. Symptom Experience Assumption of sick role Medical care contact Dependent patient role

8. The following are true with regards to aspect of the sick role except A. B. C. D. One One One One should be held responsible for his condition is excused from his societal role is obliged to get well as soon as possible is obliged to seek competent help

9. Refers to conditions that increases vulnerability of individual or group to i llness or accident A. B. C. D. Predisposing factor Etiology Risk factor Modifiable Risks

10. Refers to the degree of resistance the potential host has against a certain pathogen A. B. C. D. Susceptibility Immunity Virulence Etiology

11. A group of symptoms that sums up or constitute a disease A. B. C. D. Syndrome Symptoms Signs Etiology

12. A woman undergoing radiation therapy developed redness and burning of the sk in around the best. This is best classified as what type of disease? A. B. C. D. Neoplastic Traumatic Nosocomial Iatrogenic

13. The classification of CANCER according to its etiology Is best described as: 1. 2. 3. 4. 5. 6. A. B. C. D. Nosocomial Idiopathic Neoplastic Traumatic Congenital Degenrative 5 2 3 3 and and and and 2 3 4 5

14. Term to describe the reactiviation and recurrence of pronounced symptoms of a disease A. B. C. D. Remission Emission Exacerbation Sub acute

15. A type of illness characterized by periods of remission and exacerbation A. B. C. D. Chronic Acute Sub acute Sub chronic

16. Diseases that results from changes in the normal structure, from recognizabl e anatomical changes in an organ or body tissue is termed as A. B. C. D. Functional Occupational Inorganic Organic

17. It is the science of organism as affected by factors in their environment. I t deals with the relationship between disease and geographical environment. A. B. C. D. Epidemiology Ecology Statistics Geography

18. This is the study of the patterns of health and disease. Its occurrence and distribution in man, for the purpose of control and prevention of disease. A. B. C. D. Epidemiology Ecology Statistics Geography

19. Refers to diseases that produced no anatomic changes but as a result from ab normal response to a stimuli. A. B. C. D. Functional Occupational Inorganic Organic

20. In what level of prevention according to Leavell and Clark does the nurse su pport the client in obtaining OPTIMAL HEALTH STATUS after a disease or injury? A. B. C. D. Primary Secondary Tertiary None of the above

21. In what level of prevention does the nurse encourage optimal health and incr eases person s susceptibility to illness? A. B. C. D. Primary Secondary Tertiary None of the above

22. Also known as HEALTH MAINTENANCE prevention. A. B. C. D. Primary Secondary Tertiary None of the above

23. PPD In occupational health nursing is what type of prevention? A. B. C. D. Primary Secondary Tertiary None of the above

24. BCG in community health nursing is what type of prevention? A. B. C. D. Primary Secondary Tertiary None of the above

25. A regular pap smear for woman every 3 years after establishing normal pap sm ear for 3 consecutive years Is advocated. What level of prevention does this bel ongs? A. Primary B. Secondary C. Tertiary

D. None of the above 26. Self monitoring of blood glucose for diabetic clients is on what level of pr evention? A. B. C. D. Primary Secondary Tertiary None of the above

27. Which is the best way to disseminate information to the public? A. B. C. D. Newspaper School bulletins Community bill boards Radio and Television

28. Who conceptualized health as integration of parts and subparts of an individ ual? A. B. C. D. Newman Neuman Watson Rogers

29. The following are concept of health: 1. Health is a state of complete physical, mental and social wellbeing and not m erely an absence of disease or infirmity. 2. Health is the ability to maintain balance 3. Health is the ability to maintain internal milieu 4. Health is integration of all parts and subparts of an individual A. B. C. D. 1,2,3 1,3,4 2,3,4 1,2,3,4

30. The theorist the advocated that health is the ability to maintain dynamic eq uilibrium is A. B. C. D. Bernard Selye Cannon Rogers

31. Excessive alcohol intake is what type of risk factor? A. B. C. D. Genetics Age Environment Lifestyle

32. Osteoporosis and degenerative diseases like Osteoarthritis belongs to what t ype of risk factor? A. B. C. D. Genetics Age Environment Lifestyle

33. Also known as STERILE TECHNIQUE A. B. C. D. Surgical Asepsis Medical Asepsis Sepsis Asepsis

34. This is a person or animal, who is without signs of illness but harbors path ogen within his body and can be transferred to another A. B. C. D. Host Agent Environment Carrier

35. Refers to a person or animal, known or believed to have been exposed to a di sease. A. B. C. D. Carrier Contact Agent Host

36. A substance usually intended for use on inanimate objects, that destroys pat hogens but not the spores. A. B. C. D. Sterilization Disinfectant Antiseptic Autoclave

37. This is a process of removing pathogens but not their spores A. B. C. D. Sterilization Auto claving Disinfection Medical asepsis

38. The third period of infectious processes characterized by development of spe cific signs and symptoms A. B. C. D. Incubation period Prodromal period Illness period Convalescent period

39. A child with measles developed fever and general weakness after being expose d to another child with rubella. In what stage of infectious process does this c hild belongs? A. B. C. D. Incubation period Prodromal period Illness period Convalescent period

40. A 50 year old mailman carried a mail with anthrax powder in it. A minute aft er exposure, he still hasn t developed any signs and symptoms of anthrax. In what stage of infectious process does this man belongs?

A. B. C. D.

Incubation period Prodromal period Illness period Convalescent period

41. Considered as the WEAKEST LINK in the chain of infection that nurses can man ipulate to prevent spread of infection and diseases A. B. C. D. Etiologic/Infectious agent Portal of Entry Susceptible host Mode of transmission

42. Which of the following is the exact order of the infection chain? 1. 2. 3. 4. 5. 6. A. B. C. D. Susceptible host Portal of entry Portal of exit Etiologic agent Reservoir Mode of transmission 1,2,3,4,5,6 5,4,2,3,6,1 4,5,3,6,2,1 6,5,4,3,2,1

43. Markee, A 15 year old high school student asked you. What is the mode of tra nsmission of Lyme disease. You correctly answered him that Lyme disease is trans mitted via A. B. C. D. Direct contact transmission Vehicle borne transmission Air borne transmission Vector borne transmission

44. The ability of the infectious agent to cause a disease primarily depends on all of the following except A. B. C. D. Pathogenicity Virulence Invasiveness Non Specificity

45. Contact transmission of infectious organism in the hospital is usually cause by A. B. C. D. Urinary catheterization Spread from patient to patient Spread by cross contamination via hands of caregiver Cause by unclean instruments used by doctors and nurses

46. Transmission occurs when an infected person sneezes, coughs or laugh that is usually projected at a distance of 3 feet. A. B. C. D. Droplet transmission Airborne transmission Vehicle transmission Vector borne transmission

47. Considered as the first line of defense of the body against infection A. B. C. D. Skin WBC Leukocytes Immunization

48. All of the following contributes to host susceptibility except A. B. C. D. Creed Immunization Current medication being taken Color of the skin

49. Graciel has been injected TT5, her last dosed for tetanus toxoid immunizatio n. Graciel asked you, what type of immunity is TT Injections? You correctly answ er her by saying Tetanus toxoid immunization is a/an A. B. C. D. Natural active immunity Natural passive immunity Artificial active immunity Artificial passive immunity

50. Agatha, was hacked and slashed by a psychotic man while she was crossing the railway. She suffered multiple injuries and was injected Tetanus toxoid Immunog lobulin. Agatha asked you, What immunity does TTIg provides? You best answered h er by saying TTIg provides A. B. C. D. Natural active immunity Natural passive immunity Artificial active immunity Artificial passive immunity

51. This is the single most important procedure that prevents cross contaminatio n and infection A. B. C. D. Cleaning Disinfecting Sterilizing Handwashing

52. This is considered as the most important aspect of handwashing A. B. C. D. Time Friction Water Soap

53. In handwashing by medical asepsis, Hands are held . A. B. C. D. Above Above Below Below the the the the elbow, elbow, elbow, elbow, The hands must always be above the waist The hands are cleaner than the elbow Medical asepsis do not require hands to be above the waist Hands are dirtier than the lower arms

54. The suggested time per hand on handwashing using the time method is A. 5 to 10 seconds each hand B. 10 to 15 seconds each hand C. 15 to 30 seconds each hand

D. 30 to 60 seconds each hand 55. The minimum time in washing each hand should never be below A. B. C. D. 5 seconds 10 seconds 15 seconds 30 seconds

56. How many ml of liquid soap is recommended for handwashing procedure? A. B. C. D. 1-2 ml 2-3 ml 2-4 ml 5-10 ml

57. Which of the following is not true about sterilization, cleaning and disinfe ction? A. Equipment with small lumen are easier to clean B. Sterilization is the complete destruction of all viable microorganism includi ng spores C. Some organism are easily destroyed, while other, with coagulated protein requ ires longer time D. The number of organism is directly proportional to the length of time require d for sterilization 58. Karlita asked you, How long should she boil her glass baby bottle in water? You correctly answered her by saying A. The minimum time for boiling articles is 5 minutes B. Boil the glass baby bottler and other articles for atleast 10 minutes C. For boiling to be effective, a minimum of 15 minutes is required D. It doesn t matter how long you boil the articles, as long as the water reached 100 degree Celsius 59. This type of disinfection is best done in sterilizing drugs, foods and other things that are required to be sterilized before taken in by the human body A. B. C. D. Boiling Water Gas sterilization Steam under pressure Radiation

60. A TB patient was discharged in the hospital. A UV Lamp was placed in the roo m where he stayed for a week. What type of disinfection is this? A. B. C. D. Concurrent disinfection Terminal disinfection Regular disinfection Routine disinfection

61. Which of the following is not true in implementing medical asepsis A. B. C. D. Wash hand before and after patient contact Keep soiled linens from touching the clothings Shake the linens to remove dust Practice good hygiene

62. Which of the following is true about autoclaving or steam under pressure?

A. All kinds of microorganism and their spores are destroyed by autoclave machin e B. The autoclaved instruments can be used for 1 month considering the bags are s till intact C. The instruments are put into unlocked position, on their hinge, during the au toclave D. Autoclaving different kinds of metals at one time is advisable 63. Which of the following is true about masks? A. Mask should only cover the nose B. Mask functions better if they are wet with alcohol C. Masks can provide durable protection even when worn for a long time and after each and every patient care D. N95 Mask or particulate masks can filter organism as mall as 1 micromillimete r 64. Where should you put a wet adult diaper? A. B. C. D. Green trashcan Black trashcan Orange trashcan Yellow trashcan

65. Needles, scalpels, broken glass and lancets are considered as injurious wast es. As a nurse, it is correct to put them at disposal via a/an A. B. C. D. Puncture proof container Reused PET Bottles Black trashcan Yellow trashcan with a tag INJURIOUS WASTES

66. Miranda Priestly, An executive of RAMP magazine, was diagnosed with cancer o f the cervix. You noticed that the radioactive internal implant protrudes to her vagina where supposedly, it should be in her cervix. What should be your initia l action? A. B. C. D. Using a long forceps, Push it back towards the cervix then call the physician Wear gloves, remove it gently and place it on a lead container Using a long forceps, Remove it and place it on a lead container Call the physician, You are not allowed to touch, re insert or remove it

67. After leech therapy, Where should you put the leeches? A. B. C. D. ey In specially marked BIO HAZARD Containers Yellow trashcan Black trashcan Leeches are brought back to the culture room, they are not thrown away for th are reusable

68. Which of the following should the nurse AVOID doing in preventing spread of infection? A. Recapping the needle before disposal to prevent injuries B. Never pointing a needle towards a body part C. Using only Standard precaution to AIDS Patients D. Do not give fresh and uncooked fruits and vegetables to Mr. Gatchie, with Neu tropenia

69. Where should you put Mr. Alejar, with Category II TB? A. B. C. D. In In In In a a a a room room room room with with with with positive positive negative negative air air air air pressure pressure pressure pressure and and and and atleast atleast atleast atleast 3 6 3 6 air air air air exchanges exchanges exchanges exchanges an an an an hour hour hour hour

70. A client has been diagnosed with RUBELLA. What precaution is used for this p atient? A. B. C. D. Standard precaution Airborne precaution Droplet precaution Contact precaution

71. A client has been diagnosed with MEASLES. What precaution is used for this p atient? A. B. C. D. Standard precaution Airborne precaution Droplet precaution Contact precaution

72. A client has been diagnosed with IMPETIGO. What precaution is used for this patient? A. B. C. D. Standard precaution Airborne precaution Droplet precaution Contact precaution

73. The nurse is to insert an NG Tube when suddenly, she accidentally dip the en d of the tube in the client s glass containing distilled drinking water which is d efinitely not sterile. As a nurse, what should you do? A. B. C. D. Don t mind the incident, continue to insert the NG Tube Obtain a new NG Tube for the client Disinfect the NG Tube before reinserting it again Ask your senior nurse what to do

74. All of the following are principle of SURGICAL ASEPSIS except A. B. C. D. ld Microorganism travels to moist surfaces faster than with dry surfaces When in doubt about the sterility of an object, consider it not sterile Once the skin has been sterilized, considered it sterile If you can reach the object by overreaching, just move around the sterile fie to pick it rather than reaching for it

75. Which of the following is true in SURGICAL ASEPSIS? A. Autoclaved linens and gowns are considered sterile for about 4 months as long as the bagging is intact B. Surgical technique is a sole effort of each nurse C. Sterile conscience, is the best method to enhance sterile technique D. If a scrubbed person leaves the area of the sterile field, He/she must do han dwashing and gloving again, but the gown need not be changed. 76. In putting sterile gloves, Which should be gloved first? A. The dominant hand

B. The non dominant hand C. The left hand D. No specific order, Its up to the nurse for her own convenience 77. As the scrubbed nurse, when should you apply the goggles, shoe cap and mask prior to the operation? A. B. C. D. Immediately after entering the sterile field After surgical hand scrub Before surgical hand scrub Before entering the sterile field

78. Which of the following should the nurse do when applying gloves prior to a s urgical procedure? A. Slipping gloved hand with all fingers when picking up the second glove B. Grasping the first glove by inserting four fingers, with thumbs up underneath the cuff C. Putting the gloves into the dominant hand first D. Adjust only the fitting of the gloves after both gloves are on 79. Which gloves should you remove first? A. B. C. D. The glove of the non dominant hand The glove of the dominant hand The glove of the left hand Order in removing the gloves Is unnecessary

80. Before a surgical procedure, Give the sequence on applying the protective it ems listed below 1. 2. 3. 4. 5. A. B. C. D. Eye wear or goggles Cap Mask Gloves Gown 3,2,1,5,4 3,2,1,4,5 2,3,1,5,4 2,3,1,4,5

81. In removing protective devices, which should be the exact sequence? 1. 2. 3. 4. 5. A. B. C. D. Eye wear or goggles Cap Mask Gloves Gown 4,3,5,1,2 2,3,1,5,4 5,4,3,2,1 1,2,3,4,5

82. In pouring a plain NSS into a receptacle located in a sterile field, how hig h should the nurse hold the bottle above the receptacle? A. 1 inch B. 3 inches

C. 6 inches D. 10 inches 83. The tip of the sterile forceps is considered sterile. It is used to manipula te the objects in the sterile field using the non sterile hands. How should the nurse hold a sterile forceps? A. B. C. D. The The The The tip should always be lower than the handle tip should always be above the handle handle and the tip should be at the same level handle should point downward and the tip, always upward

84. The nurse enters the room of the client on airborne precaution due to tuberc ulosis. Which of the following are appropriate actions by the nurse? 1. She wears mask, covering the nose and mouth 2. She washes her hands before and after removing gloves, after suctioning the c lient s secretion 3. She removes gloves and hands before leaving the client s room 4. She discards contaminated suction catheter tip in trashcan found in the clien ts room A. B. C. D. 1,2 1,2,3 1,2,3,4 1,3

85. When performing surgical hand scrub, which of the following nursing action i s required to prevent contamination? 1. 2. 3. 4. A. B. C. D. Keep Open Keep Wear 1,2 2,3 1,2,3 2,3,4 fingernail short, clean and with nail polish faucet with knee or foot control hands above the elbow when washing and rinsing cap, mask, shoe cover after you scrubbed

86. When removing gloves, which of the following is an inappropriate nursing act ion? A. B. C. D. Wash gloved hand first Peel off gloves inside out Use glove to glove skin to skin technique Remove mask and gown before removing gloves

87. Which of the following is TRUE in the concept of stress? A. B. C. D. Stress is not always present in diseases and illnesses Stress are only psychological and manifests psychological symptoms All stressors evoke common adaptive response Hemostasis refers to the dynamic state of equilibrium

88. According to this theorist, in his modern stress theory, Stress is the non s pecific response of the body to any demand made upon it. A. Hans Selye B. Walter Cannon

C. Claude Bernard D. Martha Rogers 89. Which of the following is NOT TRUE with regards to the concept of Modern Str ess Theory? A. B. C. D. Stress is not a nervous energy Man, whenever he encounters stresses, always adapts to it Stress is not always something to be avoided Stress does not always lead to distress

90. Which of the following is TRUE with regards to the concept of Modern Stress Theory? A. B. C. D. Stress is essential Man does not encounter stress if he is asleep A single stress can cause a disease Stress always leads to distress

91. Which of the following is TRUE in the stage of alarm of general adaptation s yndrome? A. B. C. D. Results from the prolonged exposure to stress Levels or resistance is increased Characterized by adaptation Death can ensue

92. The stage of GAS where the adaptation mechanism begins A. B. C. D. Stage Stage Stage Stage of of of of Alarm Resistance Homeostasis Exhaustion

93. Stage of GAS Characterized by adaptation A. B. C. D. Stage Stage Stage Stage of of of of Alarm Resistance Homeostasis Exhaustion

94. Stage of GAS wherein, the Level of resistance are decreased A. B. C. D. Stage Stage Stage Stage of of of of Alarm Resistance Homeostasis Exhaustion

95. Where in stages of GAS does a person moves back into HOMEOSTASIS? A. B. C. D. Stage Stage Stage Stage of of of of Alarm Resistance Homeostasis Exhaustion

96. Stage of GAS that results from prolonged exposure to stress. Here, death wil l ensue unless extra adaptive mechanisms are utilized A. Stage of Alarm B. Stage of Resistance

C. Stage of Homeostasis D. Stage of Exhaustion 97. All but one is a characteristic of adaptive response A. B. C. D. This is an attempt to maintain homeostasis There is a totality of response Adaptive response is immediately mobilized, doesn t require time Response varies from person to person

98. Andy, a newly hired nurse, starts to learn the new technology and electronic devices at the hospital. Which of the following mode of adaptation is Andy expe riencing? A. B. C. D. Biologic/Physiologic adaptive mode Psychologic adaptive mode Sociocultural adaptive mode Technological adaptive mode

99. Andy is not yet fluent in French, but he works in Quebec where majority spea ks French. He is starting to learn the language of the people. What type of adap tation is Andy experiencing? A. B. C. D. Biologic/Physiologic adaptive mode Psychologic adaptive mode Sociocultural adaptive mode Technological adaptive mode

100. Andy made an error and his senior nurse issued a written warning. Andy arri ved in his house mad and kicked the door hard to shut it off. What adaptation mo de is this? A. B. C. D. Biologic/Physiologic adaptive mode Psychologic adaptive mode Sociocultural adaptive mode Technological adaptive mode

Answers & Rationale Here are the answers & rationale for Fundamentals of Nursing Comprehensive Exam: Illness, Infection, Asepsis (100 Items) 1. When the General adaptation syndrome is activated, FLIGHT OR FIGHT response s ets in. Sympathetic nervous system releases norepinephrine while the adrenal med ulla secretes epinephrine. Which of the following is true with regards to that s tatement? A. B. C. D. Pupils will constrict Client will be lethargic Lungs will bronchodilate Gastric motility will increase

Rationale:To better understand the concept : The autonomic nervous system is com posed of SYMPATHETIC and PARASYMPATHETIC Nervous system. It is called AUTONOMIC Because it is Involuntary and stimuli based. You cannot tell your heart to kindl y beat for 60 per minute, Nor, Tell your blood vessels, Please constrict, becaus e you need to wear skirt today and your varicosities are bulging. Sympathetic Ne rvous system is the FIGHT or FLIGHT mechanism. When people FIGHT or RUN, we tend to stimulate the ANS and dominate over SNS. Just Imagine a person FIGHTING and RUNNING to get the idea on the signs of SNS Domination. Imagine a resting and di gesting person to get a picture of PNS Domination. A person RUNNING or FIGHTING

Needs to bronchodilate, because the oxygen need is increased due to higher deman d of the body. Pupils will DILATE to be able to see the enemy clearly. Client wi ll be fully alert to dodge attacks and leap through obstacles during running. Th e client s gastric motility will DECREASE Because you cannot afford to urinate or defecate during fighting nor running. 2. Which of the following response is not expected to a person whose GAS is acti vated and the FIGHT OR FLIGHT response sets in? A. The client B. The client C. Clients BP D. There will ion will not urinate due to relaxation of the detrusor muscle will be restless and alert will increase, there will be vasodilation be increase glycogenolysis, Pancrease will decrease insulin secret

Rationale:If vasodilation will occur, The BP will not increase but decrease. It is true that Blood pressure increases during SNS Stimulation due to the fact tha t we need more BLOOD to circulate during the FIGHT or FLIGHT Response because th e oxygen demand has increased, but this is facilitated by vasoconstriction and n ot vasodilation. A,B and D are all correct. The liver will increase glycogenolys is or glycogen store utilization due to a heightened demand for energy. Pancreas e will decrease insulin secretion because almost every aspect of digestion that is controlled by Parasympathetic nervous system is inhibited when the SNS domina tes. 3. State in which a person s physical, emotional, intellectual and social developm ent or spiritual functioning is diminished or impaired compared with a previous experience. A. B. C. D. Illness Disease Health Wellness

Rationale:Disease is a PROVEN FACT based on a medical theory, standards, diagnos is and clinical feature while ILLNESS Is a subjective state of not feeling well based on subjective appraisal, previous experience, peer advice etc. 4. This is the first stage of illness wherein, the person starts to believe that something is wrong. Also known as the transition phase from wellness to illness . A. B. C. D. Symptom Experience Assumption of sick role Medical care contact Dependent patient role

Rationale:A favorite board question are Stages of Illness. When a person starts to believe something is wrong, that person is experiencing signs and symptoms of an illness. The patient will then ASSUME that he is sick. This is called assump tion of the sick role where the patient accepts he is Ill and try to give up som e activities. Since the client only ASSUMES his illness, he will try to ask some one to validate if what he is experiencing is a disease, This is now called as M EDICAL CARE CONTACT. The client seeks professional advice for validation, reassu rance, clarification and explanation of the symptoms he is experiencing. client will then start his dependent patient role of receiving care from the health car e providers. The last stage of Illness is the RECOVERY stage where the patient g ives up the sick role and assumes the previous normal gunctions. 5. In this stage of illness, the person accepts or rejects a professionals sugge

stion. The person also becomes passive and may regress to an earlier stage. A. B. C. D. Symptom Experience Assumption of sick role Medical care contact Dependent patient role

Rationale:In the dependent patient role stage, Client needs professionals for he lp. They have a choice either to accept or reject the professional s decisions but patients are usually passive and accepting. Regression tends to occur more in t his period. 6. In this stage of illness, The person learns to accept the illness. A. B. C. D. Symptom Experience Assumption of sick role Medical care contact Dependent patient role

Rationale:Acceptance of illness occurs in the Assumption of sick role phase of i llness. 7. In this stage, the person tries to find answers for his illness. He wants his illness to be validated, his symptoms explained and the outcome reassured or pr edicted A. B. C. D. Symptom Experience Assumption of sick role Medical care contact Dependent patient role

Rationale:At this stage, The patient seeks for validation of his symptom experie nce. He wants to find out if what he feels are normal or not normal. He wants so meone to explain why is he feeling these signs and symptoms and wants to know th e probable outcome of this experience. 8. The following are true with regards to aspect of the sick role except A. B. C. D. One One One One should be held responsible for his condition is excused from his societal role is obliged to get well as soon as possible is obliged to seek competent help

Rationale:The nurse should not judge the patient and not view the patient as the cause or someone responsible for his illness. A sick client is excused from his societal roles, Oblige to get well as soon as possible and Obliged to seek comp etent help. 9. Refers to conditions that increases vulnerability of individual or group to i llness or accident A. B. C. D. Predisposing factor Etiology Risk factor Modifiable Risks

10. Refers to the degree of resistance the potential host has against a certain pathogen A. Susceptibility

B. Immunity C. Virulence D. Etiology Rationale:Immunity is the ABSOLUTE Resistance to a pathogen considering that per son has an INTACT IMMUNITY while susceptibility is the DEGREE of resistance. Deg ree of resistance means how well would the individual combat the pathogens and r epel infection or invasion of these disease causing organisms. A susceptible per son is someone who has a very low degree of resistance to combat pathogens. An I mmune person is someone that can easily repel specific pathogens. However, Remem ber that even if a person is IMMUNE [ Vaccination ] Immunity can always be impai red in cases of chemotherapy, HIV, Burns, etc. 11. A group of symptoms that sums up or constitute a disease A. B. C. D. Syndrome Symptoms Signs Etiology

Rationale:Symptoms are individual manifestation of a certain disease. For exampl e, In Tourette syndrome, patient will manifest TICS, but this alone is not enoug h to diagnose the patient as other diseases has the same tic manifestation. Synd rome means COLLECTION of these symptoms that occurs together to characterize a c ertain disease. Tics with coprolalia, echolalia, palilalia, choreas or other mov ement disorders are characteristics of TOURETTE SYNDROME. 12. A woman undergoing radiation therapy developed redness and burning of the sk in around the best. This is best classified as what type of disease? A. B. C. D. Neoplastic Traumatic Nosocomial Iatrogenic

Rationale:Iatrogenic diseases refers to those that resulted from treatment of a certain disease. For example, A child frequently exposed to the X-RAY Machine de velops redness and partial thickness burns over the chest area. Neoplastic are m alignant diseases cause by proliferation of abnormally growing cells. Traumatic are brought about by injuries like Motor vehicular accidents. Nosocomial are inf ections that acquired INSIDE the hospital. Example is UTI Because of catheteriza tion, This is commonly caused by E.Coli. 13. The classification of CANCER according to its etiology Is best described as 1. 2. 3. 4. 5. 6. A. B. C. D. Nosocomial Idiopathic Neoplastic Traumatic Congenital Degenrative 5 2 3 3 and and and and 2 3 4 5

Rationale:Aside from being NEOPLASTIC, Cancer is considered as IDIOPATHIC becaus e the cause is UNKNOWN.

14. Term to describe the reactiviation and recurrence of pronounced symptoms of a disease A. B. C. D. Remission Emission Exacerbation Sub acute

15. A type of illness characterized by periods of remission and exacerbation A. B. C. D. Chronic Acute Sub acute Sub chronic

Rationale:A good example is Multiple sclerosis that characterized by periods of remissions and exacerbation and it is a CHRONIC Disease. An acute and sub acute diseases occurs too short to manifest remissions. Chronic diseases persists long er than 6 months that is why remissions and exacerbation are observable. 16. Diseases that results from changes in the normal structure, from recognizabl e anatomical changes in an organ or body tissue is termed as A. B. C. D. Functional Occupational Inorganic Organic

Rationale:As the word implies, ORGANIC Diseases are those that causes a CHANGE i n the structure of the organs and systems. Inorganic diseases is synonymous with FUNCTIONAL diseases wherein, There is no evident structural, anatomical or phys ical change in the structure of the organ or system but function is altered due to other causes, which is usually due to abnormal response of the organ to stres sors. Therefore, ORGANIC BRAIN SYNDROME are anatomic and physiologic change in t he BRAIN that is NON PROGRESSIVE BUT IRREVERSIBLE caused by alteration in struct ure of the brain and it s supporting structure which manifests different sign and symptoms of neurological, physiologic and psychologic alterations. Mental disord ers manifesting symptoms of psychoses without any evident organic or structural damage are termed as INORGANIC PSYCHOSES while alteration in the organ structure s that causes symptoms of bizaare pyschotic behavior is termed as ORGANIC PSYCHO SES. 17. It is the science of organism as affected by factors in their environment. I t deals with the relationship between disease and geographical environment. A. B. C. D. Epidemiology Ecology Statistics Geography

Rationale:Ecology is the science that deals with the ECOSYSTEM and its effects o n living things in the biosphere. It deals with diseases in relationship with th e environment. Epidimiology is simply the Study of diseases and its occurence an d distribution in man for the purpose of controlling and preventing diseases. Th is was asked during the previous boards. 18. This is the study of the patterns of health and disease. Its occurrence and distribution in man, for the purpose of control and prevention of disease. A. Epidemiology

B. Ecology C. Statistics D. Geography Rationale:Refer to number 17. 19. Refers to diseases that produced no anatomic changes but as a result from ab normal response to a stimuli. A. B. C. D. Functional Occupational Inorganic Organic

Rationale:Refer to number 16. 20. In what level of prevention according to Leavell and Clark does the nurse su pport the client in obtaining OPTIMAL HEALTH STATUS after a disease or injury? A. B. C. D. Primary Secondary Tertiary None of the above

Rationale:Perhaps one of the easiest concept but asked frequently in the NLE. Pr imary refers to preventions that aims in preventing the disease. Examples are he althy lifestyle, good nutrition, knowledge seeking behaviors etc. Secondary prev ention are those that deals with early diagnostics, case finding and treatments. Examples are monthly breast self exam, Chest X-RAY, Antibiotic treatment to cur e infection, Iron therapy to treat anemia etc. Tertiary prevention aims on maint aining optimum level of functioning during or after the impact of a disease that threatens to alter the normal body functioning. Examples are prosthetis fitting for an amputated leg after an accident, Self monitoring of glucose among diabet ics, TPA Therapy after stroke etc. The confusing part is between the treatment in secondary and treatment in tertia ry. To best differentiate the two, A client with ANEMIA that is being treated wi th ferrous sulfate is considered being in the SECONDARY PREVENTION because ANEMI A once treated, will move the client on PRE ILLNESS STATE again. However, In cas es of ASPIRING Therapy in cases of stroke, ASPIRING no longer cure the patient o r PUT HIM IN THE PRE ILLNESS STATE. ASA therapy is done in order to prevent coag ulation of the blood that can lead to thrombus formation and a another possible stroke. You might wonder why I spelled ASPIRIN as ASPIRING, Its side effect is O TOTOXICITY [ CN VIII ] that leads to TINNITUS or ringing of the ears. 21. In what level of prevention does the nurse encourage optimal health and incr eases person s susceptibility to illness? A. B. C. D. Primary Secondary Tertiary None of the above

Rationale:The nurse never increases the person s susceptibility to illness but rat her, LESSEN the person s susceptibility to illness. 22. Also known as HEALTH MAINTENANCE prevention. A. Primary B. Secondary

C. Tertiary D. None of the above Rationale:Secondary prevention is also known as HEALTH MAINTENANCE Prevention. H ere, The person feels signs and symptoms and seeks Diagnosis and treatment in or der to prevent deblitating complications. Even if the person feels healthy, We a re required to MAINTAIN our health by monthly check ups, Physical examinations, Diagnostics etc. 23. PPD In occupational health nursing is what type of prevention? A. B. C. D. Primary Secondary Tertiary None of the above

Rationale:PPD or PERSONAL PROTECTIVE DEVICES are worn by the workes in a hazardo us environment to protect them from injuries and hazards. This is considered as a PRIMARY prevention because the nurse prevents occurence of diseases and injuri es. 24. BCG in community health nursing is what type of prevention? A. B. C. D. Primary Secondary Tertiary None of the above

25. A regular pap smear for woman every 3 years after establishing normal pap sm ear for 3 consecutive years Is advocated. What level of prevention does this bel ongs? A. B. C. D. Primary Secondary Tertiary None of the above

26. Self monitoring of blood glucose for diabetic clients is on what level of pr evention? A. B. C. D. Primary Secondary Tertiary None of the above

27. Which is the best way to disseminate information to the public? A. B. C. D. Newspaper School bulletins Community bill boards Radio and Television

Rationale:An actual board question, The best way to disseminate information to t he public is by TELEVISION followed by RADIO. This is how the DOH establish its IEC Programs other than publising posters, leaflets and brochures. An emerging n ew way to disseminate is through the internet. 28. Who conceptualized health as integration of parts and subparts of an individ ual?

A. B. C. D.

Newman Neuman Watson Rogers

Rationale:The supra and subsystems are theories of Martha Rogers but the parts a nd subparts are Betty Neuman s. She stated that HEALTH is a state where in all par ts and subparts of an individual are in harmony with the whole system. Margarex Newman defined health as an EXPANDING CONSCIOUSNESS. Her name is Margaret not Ma rgarex, I just used that to help you remember her theory of health. 29. The following are concept of health: 1. Health is a state of complete physical, mental and social wellbeing and not m erely an absence of disease or infirmity. 2. Health is the ability to maintain balance 3. Health is the ability to maintain internal milieu 4. Health is integration of all parts and subparts of an individual A. B. C. D. 1,2,3 1,3,4 2,3,4 1,2,3,4

Rationale:All of the following are correct statement about health. The first one is the definition by WHO, The second one is from Walter Cannon s homeostasis theo ry. Third one is from Claude Bernard s concept of Health as Internal Milieu and th e last one is Neuman s Theory. 30. The theorist the advocated that health is the ability to maintain dynamic eq uilibrium is A. B. C. D. Bernard Selye Cannon Rogers

Rationale:Walter Cannon advocated health as HOMEOSTASIS or the ability to mainta in dynamic equilibrium. Hans Selye postulated Concepts about Stress and Adaptati on. Bernard defined health as the ability to maintain internal milieu and Rogers defined Health as Wellness that is influenced by individual s culture. 31. Excessive alcohol intake is what type of risk factor? A. B. C. D. Genetics Age Environment Lifestyle

32. Osteoporosis and degenerative diseases like Osteoarthritis belongs to what t ype of risk factor? A. B. C. D. Genetics Age Environment Lifestyle

33. Also known as STERILE TECHNIQUE A. Surgical Asepsis

B. Medical Asepsis C. Sepsis D. Asepsis Rationale:Surgical Asepsis is also known as STERILE TECHNIQUE while Medical Asep sis is synonymous with CLEAN TECHNIQUE. 34. This is a person or animal, who is without signs of illness but harbors path ogen within his body and can be transferred to another A. B. C. D. Host Agent Environment Carrier

35. Refers to a person or animal, known or believed to have been exposed to a di sease. A. B. C. D. Carrier Contact Agent Host

36. A substance usually intended for use on inanimate objects, that destroys pat hogens but not the spores. A. B. C. D. Sterilization Disinfectant Antiseptic Autoclave

Rationale:Disinfectants are used on inanimate objects while Antiseptics are inte nded for use on persons and other living things. Both can kill and inhibit growt h of microorganism but cannot kill their spores. That is when autoclaving or ste am under pressure gets in, Autoclaving can kill almost ALL type of microoganism including their spores. 37. This is a process of removing pathogens but not their spores A. B. C. D. Sterilization Auto claving Disinfection Medical asepsis

Rationale:Both A and B are capable on killing spores. Autoclaving is a form of S terilization. Medical Asepsis is a PRACTICE designed to minimize or reduce the t ransfer of pathogens, also known as your CLEAN TECHNIQUE. Disinfection is the PR OCESS of removing pathogens but not their spores. 38. The third period of infectious processes characterized by development of spe cific signs and symptoms A. B. C. D. Incubation period Prodromal period Illness period Convalescent period

Rationale:In incubation period, The disease has been introduced to the body but no sign and symptom appear because the pathogen is not yet strong enough to caus e it and may still need to multiply. The second period is called prodromal perio

d. This is when the appearance of non specific signs and symptoms sets in, This is when the sign and symptoms starts to appear. Illness period is characterized by the appearance of specific signs and symptoms or refer tp as time with the gr eatest symptom experience. Acme is the PEAK of illness intensity while the conva lescent period is characterized by the abatement of the disease process or it s gr adual disappearance. 39. A child with measles developed fever and general weakness after being expose d to another child with rubella. In what stage of infectious process does this c hild belongs? A. B. C. D. Incubation period Prodromal period Illness period Convalescent period

Rationale:To be able to categorize MEASLES in the Illness period, the specific s igns of Fever, Koplik s Spot and Rashes must appear. In the situation above, Only general signs and symptoms appeared and the Specific signs and symptoms is yet t o appear, therefore, the illness is still in the Prodromal period. Signs and sym ptoms of measles during the prodromal phase are Fever, fatigue, runny nose, coug h and conjunctivitis. Koplik s spot heralds the Illness period and cough is the la st symptom to disappear. All of this processes take place in 10 days that is why , Measles is also known as 10 day measles. 40. A 50 year old mailman carried a mail with anthrax powder in it. A minute aft er exposure, he still hasn t developed any signs and symptoms of anthrax. In what stage of infectious process does this man belongs? A. B. C. D. Incubation period Prodromal period Illness period Convalescent period

Rationale:Anthrax can have an incubation period of hours to 7 days with an avera ge of 48 hours. Since the question stated exposure, we can now assume that the m ailman is in the incubation period. 41. Considered as the WEAKEST LINK in the chain of infection that nurses can man ipulate to prevent spread of infection and diseases A. B. C. D. Etiologic/Infectious agent Portal of Entry Susceptible host Mode of transmission

Rationale:Mode of transmission is the weakest link in the chain of infection. It is easily manipulated by the Nurses using the tiers of prevention, either by in stituting transmission based precautions, Universal precaution or Isolation tech niques. 42. Which of the following is the exact order of the infection chain? 1. 2. 3. 4. 5. 6. Susceptible host Portal of entry Portal of exit Etiologic agent Reservoir Mode of transmission

A. B. C. D.

1,2,3,4,5,6 5,4,2,3,6,1 4,5,3,6,2,1 6,5,4,3,2,1

Rationale:Chain of infection starts with the SOURCE : The etiologic agent itself . It will first proliferate on a RESERVOIR and will need a PORTAL OF EXIT to be able to TRANSMIT irslef using a PORTAL OF ENTRY to a SUSCEPTIBLE HOST. A simple way to understand the process is by looking at the lives of a young queen ant th at is starting to build her colony. Imagine the QUEEN ANT as a SOURCE or the ETI OLOGIC AGENT. She first need to build a COLONY, OR the RESERVOIR where she will start to lay the first eggs to be able to produce her worker ants and soldier an ts to be able to defend and sustain the new colony. They need to EXIT [PORTAL OF EXIT] their colony and crawl [MODE OF TRANSMISSION] in search of foods by ENTER ING / INVADING [PORTAL OF ENTRY] our HOUSE [SUSCEPTIBLE HOST]. By imagining the Ant s life cycle, we can easily arrange the chain of infection. 43. Markee, A 15 year old high school student asked you. What is the mode of tra nsmission of Lyme disease. You correctly answered him that Lyme disease is trans mitted via A. B. C. D. Direct contact transmission Vehicle borne transmission Air borne transmission Vector borne transmission

Rationale:Lyme disease is caused by Borrelia Burdorferi and is transmitted by a TICK BITE. 44. The ability of the infectious agent to cause a disease primarily depends on all of the following except A. B. C. D. Pathogenicity Virulence Invasiveness Non Specificity

Rationale:To be able to cause a disease, A pathogen should have a TARGET ORGAN/S . The pathogen should be specific to these organs to cause an infection. Mycobac terium Avium is NON SPECIFIC to human organs and therefore, not infective to hum ans but deadly to birds. An immunocompromised individual, specially AIDS Patient , could be infected with these NON SPECIFIC diseases due to impaired immune syst em. 45. Contact transmission of infectious organism in the hospital is usually cause by A. B. C. D. Urinary catheterization Spread from patient to patient Spread by cross contamination via hands of caregiver Cause by unclean instruments used by doctors and nurses

Rationale:The hands of the caregiver like nurses, is the main cause of cross con tamination in hospital setting. That is why HANDWASHING is the single most impor tant procedure to prevent the occurence of cross contamination and nosocomial in fection. D refers to Nosocomial infection and UTI is the most common noscomial i nfection in the hospital caused by urinary catheterization. E.Coli seems to be t he major cause of this incident. B best fits Cross Contamination, It is the spre ad of microogranisms from patient o patient.

46. Transmission occurs when an infected person sneezes, coughs or laugh that is usually projected at a distance of 3 feet. A. B. C. D. Droplet transmission Airborne transmission Vehicle transmission Vector borne transmission

47. Considered as the first line of defense of the body against infection A. B. C. D. Skin WBC Leukocytes Immunization

Rationale:Remember that intact skin and mucus membrane is our first line of defe nse against infection. 48. All of the following contributes to host susceptibility except A. B. C. D. Creed Immunization Current medication being taken Color of the skin

Rationale:Creed, Faith or religious belief do not affect person s susceptibility t o illness. Medication like corticosteroids could supress a person s immune system that will lead to increase susceptibility. Color of the skin could affect person s susceptibility to certain skin diseases. A dark skinned person has lower risk o f skin cancer than a fair skinned person. Fair skinned person also has a higher risk for cholecystitis and cholelithiasis. 49. Graciel has been injected TT5, her last dosed for tetanus toxoid immunizatio n. Graciel asked you, what type of immunity is TT Injections? You correctly answ er her by saying Tetanus toxoid immunization is a/an A. B. C. D. Natural active immunity Natural passive immunity Artificial active immunity Artificial passive immunity

Rationale:TT1 ti TT2 are considered the primary dose, while TT3 to TT5 are the b ooster dose. A woman with completed immunization of DPT need not receive TT1 and TT2. Tetanus toxoid is the actual toxin produce by clostridium tetani but on it s WEAK and INACTIVATED form. It is Artificial because it did not occur in the co urse of actual illness or infection, it is Active because what has been passed i s an actual toxin and not a ready made immunoglobulin. 50. Agatha, was hacked and slashed by a psychotic man while she was crossing the railway. She suffered multiple injuries and was injected Tetanus toxoid Immunog lobulin. Agatha asked you, What immunity does TTIg provides? You best answered h er by saying TTIg provides A. B. C. D. Natural active immunity Natural passive immunity Artificial active immunity Artificial passive immunity

Rationale:In this scenario, Agatha was already wounded and has injuries. Giving the toxin [TT Vaccine] itself would not help Agatha because it will take time be

fore the immune system produce antitoxin. What agatha needs now is a ready made anti toxin in the form of ATS or TTIg. This is artificial, because the body of a gatha did not produce it. It is passive because her immune system is not stimula ted but rather, a ready made Immune globulin is given to immediately supress the invasion. 51. This is the single most important procedure that prevents cross contaminatio n and infection A. B. C. D. Cleaning Disinfecting Sterilizing Handwashing

Rationale:When you see the word HANDWASHING as one of the options, 90% Chance it is the correct answer in the local board. Or should I say, 100% because I have yet to see question from 1988 to 2005 board questions that has option HANDWASHIN G on it but is not the correct answer. 52. This is considered as the most important aspect of handwashing A. B. C. D. Time Friction Water Soap

Rationale:The most important aspect of handwashing is FRICTION. The rest, will j ust enhance friction. The use of soap lowers the surface tension thereby increas ing the effectiveness of friction. Water helps remove transient bacteria by work ing with soap to create the lather that reduces surface tension. Time is of esse nce but friction is the most essential aspect of handwashing. 53. In handwashing by medical asepsis, Hands are held . A. B. C. D. Above Above Below Below the the the the elbow, elbow, elbow, elbow, The hands must always be above the waist The hands are cleaner than the elbow Medical asepsis do not require hands to be above the waist Hands are dirtier than the lower arms

Rationale:Hands are held BELOW the elbow in medical asepsis in contrast with sur gical asepsis, wherein, nurses are required to keep the hands above the waist. T he rationale is because in medical asepsis, Hands are considered dirtier than th e elbow and therefore, to limit contamination of the lower arm, The hands should always be below the elbow. 54. The suggested time per hand on handwashing using the time method is A. B. C. D. 5 to 10 seconds each hand 10 to 15 seconds each hand 15 to 30 seconds each hand 30 to 60 seconds each hand

Rationale:Each hands requires atleast 15 to 30 seconds of handwashing to effecti vely remove transient microorganisms. 55. The minimum time in washing each hand should never be below A. 5 seconds B. 10 seconds C. 15 seconds

D. 30 seconds Rationale:According to Kozier, The minimum time required for watching each hands is 10 seconds and should not be lower than that. The recommended time, again, i s 15 to 30 seconds. 56. How many ml of liquid soap is recommended for handwashing procedure? A. B. C. D. 1-2 ml 2-3 ml 2-4 ml 5-10 ml

Rationale:If a liquid soap is to be used, 1 tsp [ 5ml ] of liquid soap is recomm ended for handwashing procedure. 57. Which of the following is not true about sterilization, cleaning and disinfe ction? A. Equipment with small lumen are easier to clean B. Sterilization is the complete destruction of all viable microorganism includi ng spores C. Some organism are easily destroyed, while other, with coagulated protein requ ires longer time D. The number of organism is directly proportional to the length of time require d for sterilization Rationale:Equipments with LARGE LUMEN are easier to clean than those with small lumen. B C and D are all correct. 58. Karlita asked you, How long should she boil her glass baby bottle in water? You correctly answered her by saying A. The minimum time for boiling articles is 5 minutes B. Boil the glass baby bottler and other articles for atleast 10 minutes C. For boiling to be effective, a minimum of 15 minutes is required D. It doesn t matter how long you boil the articles, as long as the water reached 100 degree Celsius Rationale:Boiling is the most common and least expensive method of sterilization used in home. For it to be effective, you should boil articles for atleast 15 m inutes. 59. This type of disinfection is best done in sterilizing drugs, foods and other things that are required to be sterilized before taken in by the human body A. B. C. D. Boiling Water Gas sterilization Steam under pressure Radiation

Rationale:Imagine foods and drugs that are being sterilized by a boiling water, ethylene oxide gas and autoclave or steam under pressure, They will be inactivat ed by these methods. Ethylene oxide gas used in gas sterlization is TOXIC to hum ans. Boiling the food will alter its consistency and nutrients. Autoclaving the food is never performed. Radiation using microwave oven or Ionizing radiation pe netrates to foods and drugs thus, sterilizing them. 60. A TB patient was discharged in the hospital. A UV Lamp was placed in the roo m where he stayed for a week. What type of disinfection is this?

A. B. C. D.

Concurrent disinfection Terminal disinfection Regular disinfection Routine disinfection

Rationale:Terminal disinfection refers to practices to remove pathogens that sta yed in the belongings or immediate environemnt of an infected client who has bee n discharged. An example would be Killing airborne TB Bacilli using UV Light. Co ncurrent disinfection refers to ongoing efforts implented during the client s stay to remove or limit pathogens in his supplies, belongings, immediate environment in order to control the spread of the disease. An example is cleaning the bedsi de commode of a client with radium implant on her cervix with a bleach disinfect ant after each voiding. 61. Which of the following is not true in implementing medical asepsis A. B. C. D. Wash hand before and after patient contact Keep soiled linens from touching the clothings Shake the linens to remove dust Practice good hygiene

Rationale:NEVER shake the linens. Once soiled, fold it inwards clean surface out . Shaking the linen will further spread pathogens that has been harbored by the fabric. 62. Which of the following is true about autoclaving or steam under pressure? A. All kinds of microorganism and their spores are destroyed by autoclave machin e B. The autoclaved instruments can be used for 1 month considering the bags are s till intact C. The instruments are put into unlocked position, on their hinge, during the au toclave D. Autoclaving different kinds of metals at one time is advisable Rationale:Only C is correct. Metals with locks, like clamps and scissors should be UNLOCKED in order to minimize stiffening caused by autoclave to the hinges of these metals. NOT ALL microorganism are destroyed by autoclaving. There are rec ently discovered microorganism that is invulnarable to extreme heat. Autoclaved instruments are to be used within 2 weeks. Only the same type of metals should b e autoclaved as this will alteration in plating of these metals. 63. Which of the following is true about masks? A. Mask should only cover the nose B. Mask functions better if they are wet with alcohol C. Masks can provide durable protection even when worn for a long time and after each and every patient care D. N95 Mask or particulate masks can filter organism as mall as 1 micromillimete r Rationale:only D is correct. Mask should cover both nose and mouth. Masks will n ot function optimally when wet. Masks should be worn not greater than 4 hours, a s it will lose effectiveness after 4 hours. N95 mask or particulate mask can fil ter organism as small as 1 micromillimeter. 64. Where should you put a wet adult diaper? A. Green trashcan

B. Black trashcan C. Orange trashcan D. Yellow trashcan Rationale:Infectious waste like blood and blood products, wet diapers and dressi ngs are thrown in yellow trashcans. 65. Needles, scalpels, broken glass and lancets are considered as injurious wast es. As a nurse, it is correct to put them at disposal via a/an A. B. C. D. Puncture proof container Reused PET Bottles Black trashcan Yellow trashcan with a tag INJURIOUS WASTES

Rationale:Needles, scalpels and other sharps are to be disposed in a puncture pr oof container. 66. Miranda Priestly, An executive of RAMP magazine, was diagnosed with cancer o f the cervix. You noticed that the radioactive internal implant protrudes to her vagina where supposedly, it should be in her cervix. What should be your initia l action? A. B. C. D. Using a long forceps, Push it back towards the cervix then call the physician Wear gloves, remove it gently and place it on a lead container Using a long forceps, Remove it and place it on a lead container Call the physician, You are not allowed to touch, re insert or remove it implant in brachytherapy are to be pi CONTAINER in order to prevent damage physician is the second most appropriat never attempt to put it back nor, tou

Rationale:A dislodged radioactive cervical cked by a LONG FORCEP and stored in a LEAD on the client s normal tissue. Calling the e action among the choices. A nurse should ch it with her bare hands.

67. After leech therapy, Where should you put the leeches? A. B. C. D. ey In specially marked BIO HAZARD Containers Yellow trashcan Black trashcan Leeches are brought back to the culture room, they are not thrown away for th are reusable

Rationale:Leeches, in leech therapy or LEECH PHLEBOTOMY are to be disposed on a BIO HAZARD container. They are never re used as this could cause transfer of inf ection. These leeches are hospital grown and not the usual leeches found in swam ps. 68. Which of the following should the nurse AVOID doing in preventing spread of infection? A. Recapping the needle before disposal to prevent injuries B. Never pointing a needle towards a body part C. Using only Standard precaution to AIDS Patients D. Do not give fresh and uncooked fruits and vegetables to Mr. Gatchie, with Neu tropenia Rationale:Never recap needles. They are directly disposed in a puncture proof co ntainer after used. Recapping the needles could cause injury to the nurse and sp read of infection. B C and D are all appropriate. Standard precaution is suffici ent for an HIV patient. A client with neutropenia are not given fresh and uncook

ed fruits and vegetables for even the non infective organisms found in these foo ds could cause severe infection on an immunocompromised patients. 69. Where should you put Mr. Alejar, with Category II TB? A. B. C. D. In In In In a a a a room room room room with with with with positive positive negative negative air air air air pressure pressure pressure pressure and and and and atleast atleast atleast atleast 3 6 3 6 air air air air exchanges exchanges exchanges exchanges an an an an hour hour hour hour

Rationale:TB patients should have a private room with negative air pressure and atleast 6 to 12 air exhanges per hour. Negative pressure room will prevent air i nside the room from escaping. Air exchanges are necessary since the client s room do not allow air to get out of the room. 70. A client has been diagnosed with RUBELLA. What precaution is used for this p atient? A. B. C. D. Standard precaution Airborne precaution Droplet precaution Contact precaution

Rationale:Droplet precaution is sufficient on client s with RUBELLA or german meas les. 71. A client has been diagnosed with MEASLES. What precaution is used for this p atient? A. B. C. D. Standard precaution Airborne precaution Droplet precaution Contact precaution

Rationale:Measles is highly communicable and more contagious than Rubella, It re quires airborne precaution as it is spread by small particle droplets that remai ns suspended in air and disperesed by air movements. 72. A client has been diagnosed with IMPETIGO. What precaution is used for this patient? A. B. C. D. Standard precaution Airborne precaution Droplet precaution Contact precaution

Rationale:Impetigo causes blisters or sores in the skin. It is generally caused by GABS or Staph Aureaus. It is spread by skin to skin contact or by scratching the lesions and touching another person s skin. 73. The nurse is to insert an NG Tube when suddenly, she accidentally dip the en d of the tube in the client s glass containing distilled drinking water which is d efinitely not sterile. As a nurse, what should you do? A. B. C. D. Don t mind the incident, continue to insert the NG Tube Obtain a new NG Tube for the client Disinfect the NG Tube before reinserting it again Ask your senior nurse what to do

Rationale:The digestive tract is not sterile, and therefore, simple errors like

this would not cause harm to the patient. NGT tube need not be sterile, and so i s colostomy and rectal tubes. Clean technique is sufficient during NGT and colos tomy care. 74. All of the following are principle of SURGICAL ASEPSIS except A. B. C. D. ld Microorganism travels to moist surfaces faster than with dry surfaces When in doubt about the sterility of an object, consider it not sterile Once the skin has been sterilized, considered it sterile If you can reach the object by overreaching, just move around the sterile fie to pick it rather than reaching for it

Rationale:Human skin is impossible to be sterilized. It contains normal flora of microorganism. A B and D are all correct. 75. Which of the following is true in SURGICAL ASEPSIS? A. Autoclaved linens and gowns are considered sterile for about 4 months as long as the bagging is intact B. Surgical technique is a sole effort of each nurse C. Sterile conscience, is the best method to enhance sterile technique D. If a scrubbed person leaves the area of the sterile field, He/she must do han dwashing and gloving again, but the gown need not be changed. Rationale:Sterile conscience, or the moral imperative of a nurse to be honest in practicing sterile technique, is the best method to enhance sterile technique. Autoclaved linens are considered sterile only within 2 weeks even if the bagging is intact. Surgical technique is a team effort of each nurse. If a scrubbed per son leave the sterile field and area, he must do the process all over again. 76. In putting sterile gloves, Which should be gloved first? A. B. C. D. The dominant hand The non dominant hand The left hand No specific order, Its up to the nurse for her own convenience

Rationale:Gloves are put on the non dominant hands first and then, the dominant hand. The rationale is simply because humans tend to use the dominant hand first before the non dominant hand. Out of 10 humans that will put on their sterile g loves, 8 of them will put the gloves on their non dominant hands first. 77. As the scrubbed nurse, when should you apply the goggles, shoe cap and mask prior to the operation? A. B. C. D. Immediately after entering the sterile field After surgical hand scrub Before surgical hand scrub Before entering the sterile field

Rationale:The nurse should put his goggles, cap and mask prior to washing the ha nds. If he wash his hands prior to putting all these equipments, he must wash hi s hands again as these equipments are said to be UNSTERILE. 78. Which of the following should the nurse do when applying gloves prior to a s urgical procedure? A. Slipping gloved hand with all fingers when picking up the second glove B. Grasping the first glove by inserting four fingers, with thumbs up underneath the cuff

C. Putting the gloves into the dominant hand first D. Adjust only the fitting of the gloves after both gloves are on Rationale:The nurse should only adjust fitting of the gloves when they are both on the hands. Not doing so will break the sterile technique. Only 4 gingers are slipped when picking up the second gloves. You cannot slip all of your fingers a s the cuff is limited and the thumb would not be able to enter the cuff. The fir st glove is grasp by simply picking it up with the first 2 fingers and a thumb i n a pinching motion. Gloves are put on the non dominant hands first. 79. Which gloves should you remove first? A. B. C. D. The glove of the non dominant hand The glove of the dominant hand The glove of the left hand Order in removing the gloves Is unnecessary

Rationale:Gloves are worn in the non dominant hand first, and is removed also fr om the non dominant hand first. Rationale is simply because in 10 people removin g gloves, 8 of them will use the dominant hand first and remove the gloves of th e non dominant hand. 80. Before a surgical procedure, Give the sequence on applying the protective it ems listed below 1. 2. 3. 4. 5. A. B. C. D. Eye wear or goggles Cap Mask Gloves Gown 3,2,1,5,4 3,2,1,4,5 2,3,1,5,4 2,3,1,4,5

Rationale:The nurse should use CaMEy Hand and Body Lotion in moisturizing his ha nd before surgical procedure and after handwashing. Ca stands for CAP, M stands for MASK, Ey stands for eye goggles. The nurse will do handwashing and then [HAN D], Don the gloves first and wear the Gown [BODY]. I created this mnemonic and I advise you use it because you can never forget Camey hand and body lotion. [ Ye s, I know it is spelled as CAMAY ]] 81. In removing protective devices, which should be the exact sequence? 1. 2. 3. 4. 5. A. B. C. D. Eye wear or goggles Cap Mask Gloves Gown 4,3,5,1,2 2,3,1,5,4 5,4,3,2,1 1,2,3,4,5

Rationale:When the nurse is about to remove his protective devices, The nurse wi ll remove the GLOVES first followed by the MASK and GOWN then, other devices lik e cap, shoe cover, etc. This is to prevent contamination of hair, neck and face area.

82. In pouring a plain NSS into a receptacle located in a sterile field, how hig h should the nurse hold the bottle above the receptacle? A. B. C. D. 1 inch 3 inches 6 inches 10 inches

Rationale:Even if you do not know the answer to this question, you can answer it correctly by imagining. If you pour the NSS into a receptacle 1 to 3 inch above it, Chances are, The mouth of the NSS bottle would dip into the receptacle as y ou fill it, making it contaminated. If you pour the NSS bottle into a receptacle 10 inches above it, that is too high, chances are, as you pour the NSS, most wi ll spill out because the force will be too much for the buoyant force to handle. It will also be difficult to pour something precisely into a receptacle as the height increases between the receptacle and the bottle. 6 inches is the correct answer. It is not to low nor too high. 83. The tip of the sterile forceps is considered sterile. It is used to manipula te the objects in the sterile field using the non sterile hands. How should the nurse hold a sterile forceps? A. B. C. D. The The The The tip should always be lower than the handle tip should always be above the handle handle and the tip should be at the same level handle should point downward and the tip, always upward

Rationale:A sterile forcep is usually dipped into a disinfectant or germicidal s olution. Imagine, if the tip is HIGHER than the handle, the solution will go int o the handle and into your hands and as you use the forcep, you will eventually lower its tip making the solution in your hand go BACK into the tip thus contami nating the sterile area of the forcep. To prevent this, the tip should always be lower than the handle. In situation questions like this, IMAGINATION is very im portant. 84. The nurse enters the room of the client on airborne precaution due to tuberc ulosis. Which of the following are appropriate actions by the nurse? 1. She wears mask, covering the nose and mouth 2. She washes her hands before and after removing gloves, after suctioning the c lient s secretion 3. She removes gloves and hands before leaving the client s room 4. She discards contaminated suction catheter tip in trashcan found in the clien ts room A. B. C. D. 1,2 1,2,3 1,2,3,4 1,3

Rationale:All soiled equipments use in an infectious client are disposed INSIDE the client s room to prevent contamination outside the client s room. The nurse is c orrect in using Mask the covers both nose and mouth. Hands are washed before and after removing the gloves and before and after you enter the client s room. Glove s and contaminated suction tip are thrown in trashcan found in the clients room. 85. When performing surgical hand scrub, which of the following nursing action i s required to prevent contamination?

1. 2. 3. 4. A. B. C. D.

Keep Open Keep Wear 1,2 2,3 1,2,3 2,3,4

fingernail short, clean and with nail polish faucet with knee or foot control hands above the elbow when washing and rinsing cap, mask, shoe cover after you scrubbed

Rationale:Cap, mask and shoe cover are worn BEFORE scrubbing. 86. When removing gloves, which of the following is an inappropriate nursing act ion? A. B. C. D. Wash gloved hand first Peel off gloves inside out Use glove to glove skin to skin technique Remove mask and gown before removing gloves

Rationale:Gloves are the dirtiest protective item nurses are wearing and therefo re, the first to be removed to prevent spread of microorganism as you remove the mask and gown. 87. Which of the following is TRUE in the concept of stress? A. B. C. D. Stress is not always present in diseases and illnesses Stress are only psychological and manifests psychological symptoms All stressors evoke common adaptive response Hemostasis refers to the dynamic state of equilibrium

Rationale:All stressors evoke common adaptive response. A psychologic fear like nightmare and a real fear or real perceive threat evokes common manifestation li ke tachycardia, tachypnea, sweating, increase muscle tension etc. ALL diseases a nd illness causes stress. Stress can be both REAL or IMAGINARY. Hemostasis refer s to the ARREST of blood flowing abnormally through a damage vessel. Homeostasis is the one that refers to dynamic state of equilibrium according to Walter Cann on. 88. According to this theorist, in his modern stress theory, Stress is the non s pecific response of the body to any demand made upon it. A. B. C. D. Hans Selye Walter Cannon Claude Bernard Martha Rogers

Rationale:Hans Selye is the only theorist who proposed an intriguing theory abou t stress that has been widely used and accepted by professionals today. He conce ptualized two types of human response to stress, The GAS or general adaptation s yndrome which is characterized by stages of ALARM, RESISTANCE and EXHAUSTION. Th e Local adaptation syndrome controls stress through a particular body part. Exam ple is when you have been wounded in your finger, it will produce PAIN to let yo u know that you should protect that particular damaged area, it will also produc e inflammation to limit and control the spread of injury and facilitate healing process. Another example is when you are frequently lifting heavy objects, event ually, you arm, back and leg muscles hypertorphies to adapt to the stress of hea vy lifting. 89. Which of the following is NOT TRUE with regards to the concept of Modern Str

ess Theory? A. B. C. D. Stress is not a nervous energy Man, whenever he encounters stresses, always adapts to it Stress is not always something to be avoided Stress does not always lead to distress

Rationale:Man, do not always adapt to stress. Sometimes, stress can lead to exha ustion and eventually, death. A,C and D are all correct. 90. Which of the following is TRUE with regards to the concept of Modern Stress Theory? A. B. C. D. Stress is essential Man does not encounter stress if he is asleep A single stress can cause a disease Stress always leads to distress

Rationale:Stress is ESSENTIAL. No man can live normally without stress. It is es sential because it is evoked by the body s normal pattern of response and leads to a favorable adaptive mechanism that are utilized in the future when more stress ors are encountered by the body. Man can encounter stress even while asleep, exa mple is nightmare. Disease are multifactorial, No diseases are caused by a singl e stressors. Stress are sometimes favorable and are not always a cause for distr ess. An example of favorable stress is when a carpenter meets the demand and str ess of everyday work. He then develops calluses on the hand to lessen the pressu re of the hammer against the tissues of his hand. He also develop larger muscle and more dense bones in the arm, thus, a stress will lead to adaptations to decr ease that particular stress. 91. Which of the following is TRUE in the stage of alarm of general adaptation s yndrome? A. B. C. D. Results from the prolonged exposure to stress Levels or resistance is increased Characterized by adaptation Death can ensue

Rationale:Death can ensue as early as the stage of alarm. Exhaustion results to a prolonged exposure to stress. Resistance is when the levels of resistance incr eases and characterized by being able to adapt. 92. The stage of GAS where the adaptation mechanism begins A. B. C. D. Stage Stage Stage Stage of of of of Alarm Resistance Homeostasis Exhaustion

Rationale:Adaptation mechanisms begin in the stage of alarm. This is when the ad aptive mechanism are mobilized. When someone shouts SUNOG!!! your heart will beg in to beat faster, you vessels constricted and bp increased. 93. Stage of GAS Characterized by adaptation A. B. C. D. Stage Stage Stage Stage of of of of Alarm Resistance Homeostasis Exhaustion

94. Stage of GAS wherein, the Level of resistance are decreased A. B. C. D. Stage Stage Stage Stage of of of of Alarm Resistance Homeostasis Exhaustion

Rationale:Resistance are decreased in the stage of alarm. Resistance is absent i n the stage of exhaustion. Resistance is increased in the stage of resistance. 95. Where in stages of GAS does a person moves back into HOMEOSTASIS? A. B. C. D. Stage Stage Stage Stage of of of of Alarm Resistance Homeostasis Exhaustion

96. Stage of GAS that results from prolonged exposure to stress. Here, death wil l ensue unless extra adaptive mechanisms are utilized A. B. C. D. Stage Stage Stage Stage of of of of Alarm Resistance Homeostasis Exhaustion

97. All but one is a characteristic of adaptive response A. B. C. D. This is an attempt to maintain homeostasis There is a totality of response Adaptive response is immediately mobilized, doesn t require time Response varies from person to person

Rationale:Aside from having limits that leads to exhaustion. Adaptive response r equires time for it to act. It requires energy, physical and psychological taxes that needs time for our body to mobilize and utilize. 98. Andy, a newly hired nurse, starts to learn the new technology and electronic devices at the hospital. Which of the following mode of adaptation is Andy expe riencing? A. B. C. D. Biologic/Physiologic adaptive mode Psychologic adaptive mode Sociocultural adaptive mode Technological adaptive mode

99. Andy is not yet fluent in French, but he works in Quebec where majority spea ks French. He is starting to learn the language of the people. What type of adap tation is Andy experiencing? A. B. C. D. Biologic/Physiologic adaptive mode Psychologic adaptive mode Sociocultural adaptive mode Technological adaptive mode

Rationale:Sociocultural adaptive modes include language, communication, dressing , acting and socializing in line with the social and cultural standard of the pe ople around the adapting individual. 100. Andy made an error and his senior nurse issued a written warning. Andy arri ved in his house mad and kicked the door hard to shut it off. What adaptation mo

de is this? A. B. C. D. Biologic/Physiologic adaptive mode Psychologic adaptive mode Sociocultural adaptive mode Technological adaptive mode

1. The coronary vessels, unlike any other blood vessels in the body, respond to sympathetic stimulation by A. B. C. D. Vasoconstriction Vasodilatation Decreases force of contractility Decreases cardiac output

2. What stress response can you expect from a patient with blood sugar of 50 mg / dl? A. B. C. D. Body will try to decrease the glucose level There will be a halt in release of sex hormones Client will appear restless Blood pressure will increase

3. All of the following are purpose of inflammation except A. B. C. D. Increase heat, thereby produce abatement of phagocytosis Localized tissue injury by increasing capillary permeability Protect the issue from injury by producing pain Prepare for tissue repair

4. The initial response of tissue after injury is A. B. C. D. Immediate Transient Immediate Transient Vasodilation Vasoconstriction Vasoconstriction Vasodilation

5. The last expected process in the stages of inflammation is characterized by A. B. C. D. There will be sudden redness of the affected part Heat will increase on the affected part The affected part will loss its normal function Exudates will flow from the injured site

6. What kind of exudates is expected when there is an antibody-antigen reaction as a result of microorganism infection? A. B. C. D. Serous Serosanguinous Purulent Sanguinous

7. The first manifestation of inflammation is A. B. C. D. Redness on the affected area Swelling of the affected area Pain, which causes guarding of the area Increase heat due to transient vasodilation

8. The client has a chronic tissue injury. Upon examining the client s antibody fo

r a particular cellular response, Which of the following WBC component is respon sible for phagocytosis in chronic tissue injury? A. B. C. D. Neutrophils Basophils Eosinophils Monocytes

9. Which of the following WBC component proliferates in cases of Anaphylaxis? A. B. C. D. Neutrophils Basophils Eosinophil Monocytes

10. Icheanne, ask you, her Nurse, about WBC Components. She got an injury yester day after she twisted her ankle accidentally at her gymnastic class. She asked y ou, which WBC Component is responsible for proliferation at the injured site imm ediately following an injury. You answer: A. B. C. D. Neutrophils Basophils Eosinophils Monocytes

11. Icheanne then asked you, what is the first process that occurs in the inflam matory response after injury, You tell her: A. B. C. D. Phagocytosis Emigration Pavementation Chemotaxis

12. Icheanne asked you again, What is that term that describes the magnetic attr action of injured tissue to bring phagocytes to the site of injury? A. B. C. D. Icheanne, you better sleep now, you asked a lot of questions It is Diapedesis We call that Emigration I don t know the answer, perhaps I can tell you after I find it out later

13. This type of healing occurs when there is a delayed surgical closure of infe cted wound A. B. C. D. First intention Second intention Third intention Fourth intention

14. Type of healing when scars are minimal due to careful surgical incision and good healing A. B. C. D. First intention Second intention Third intention Fourth intention

15. Imelda, was slashed and hacked by an unknown suspects. She suffered massive tissue loss and laceration on her arms and elbow in an attempt to evade the crim inal. As a nurse, you know that the type of healing that will most likely occur

to Miss Imelda is A. B. C. D. First intention Second intention Third intention Fourth intention

16. Imelda is in the recovery stage after the incident. As a nurse, you know tha t the diet that will be prescribed to Miss Imelda is A. B. C. D. Low calorie, High protein with Vitamin A and C rich foods High protein, High calorie with Vitamin A and C rich foods High calorie, Low protein with Vitamin A and C rich foods Low calorie, Low protein with Vitamin A and C rich foods

17. Miss Imelda asked you, What is WET TO DRY Dressing method? Your best respons e is A. It is a type of mechanical debridement using Wet dressing that is applied and left to dry to remove dead tissues B. It is a type of surgical debridement with the use of Wet dressing to remove t he necrotic tissues C. It is a type of dressing where in, The wound is covered with Wet or Dry dress ing to prevent contamination D. It is a type of dressing where in, A cellophane or plastic is placed on the w ound over a wet dressing to stimulate healing of the wound in a wet medium 18. The primary cause of pain in inflammation is A. B. C. D. Release of pain mediators Injury to the nerve endings Compression of the local nerve endings by the edema fluids Circulation is lessen, Supply of oxygen is insufficient

19. The client is in stress because he was told by the physician he needs to und ergo surgery for removal of tumor in his bladder. Which of the following are eff ects of sympatho-adreno-medullary response by the client? 1. 2. 3. 4. Constipation Urinary frequency Hyperglycemia Increased blood pressure

A. 3,4 B. 1,3,4 C.1,2,4 D.1,4 20. The client is on NPO post midnight. Which of the following, if done by the c lient, is sufficient to cancel the operation in the morning? A. B. C. D. Eat a Drink Brush Smoke full meal fluids at his teeth cigarette at 10:00 P.M 11:50 P.M the morning before operation around 3:00 A.M

21. The client place on NPO for preparation of the blood test. Adreno-cortical r esponse is activated and which of the following below is an expected response? A. Low BP

B. Decrease Urine output C. Warm, flushed, dry skin D. Low serum sodium levels 22. Which of the following is true about therapeutic relationship? A. B. C. D. Directed towards helping an individual both physically and emotionally Bases on friendship and mutual trust Goals are set by the solely nurse Maintained even after the client doesn t need anymore of the Nurse s help

23. According to her, A nurse patient relationship is composed of 4 stages : Ori entation, Identification, Exploitation and Resolution A. B. C. D. Roy Peplau Rogers Travelbee

24. In what phase of Nurse patient relationship does a nurse review the client s m edical records thereby learning as much as possible about the client? A. B. C. D. Pre Orientation Orientation Working Termination

25. Nurse Aida has seen her patient, Roger for the first time. She establish a c ontract about the frequency of meeting and introduce to Roger the expected termi nation. She started taking baseline assessment and set interventions and outcome s. On what phase of NPR Does Nurse Aida and Roger belong? A. B. C. D. Pre Orientation Orientation Working Termination

26. Roger has been seen agitated, shouting and running. As Nurse Aida approaches , he shouts and swear, calling Aida names. Nurse Aida told Roger That is an unacc eptable behavior Roger, Stop and go to your room now. The situation is most likel y in what phase of NPR? A. B. C. D. Pre Orientation Orientation Working Termination

27. Nurse Aida, in spite of the incident, still consider Roger as worthwhile sim ply because he is a human being. What major ingredient of a therapeutic communic ation is Nurse Aida using? A. B. C. D. Empathy Positive regard Comfortable sense of self Self awareness N

28. Nurse Irma saw Roger and told Nurse Aida Oh look at that psychotic patient urse Aida should intervene and correct Nurse Irma because her statement shows th at she is lacking?

A. B. C. D.

Empathy Positive regard Comfortable sense of self Self awareness

29. Which of the following statement is not true about stress? A. B. C. D. It It It It is a nervous energy is an essential aspect of existence has been always a part of human experience is something each person has to cope

30. Martina, a Tennis champ was devastated after many new competitors outpaced h er in the Wimbledon event. She became depressed and always seen crying. Martina is clearly on what kind of situation? A. B. C. D. Martina Martina Martina Martina is is is is just stressed out Anxious in the exhaustion stage of GAS in Crisis

31. Which of the following statement is not true with regards to anxiety? A. B. C. D. It has physiologic component It has psychologic component The source of dread or uneasiness is from an unrecognized entity The source of dread or uneasiness is from a recognized entity

32. Lorraine, a 27 year old executive was brought to the ER for an unknown reaso n. She is starting to speak but her speech is disorganized and cannot be underst ood. On what level of anxiety does this features belongs? A. B. C. D. Mild Moderate Severe Panic

33. Elton, 21 year old nursing student is taking the board examination. She is s weating profusely, has decreased awareness of his environment and is purely focu sed on the exam questions characterized by his selective attentiveness. What anx iety level is Elton exemplifying? A. B. C. D. Mild Moderate Severe Panic

34. You noticed the patient chart : ANXIETY +3 What will you expect to see in th is client? A. B. C. D. An optimal time for learning, Hearing and perception is greatly increased Dilated pupils Unable to communicate Palliative Coping Mechanism

35. When should the nurse starts giving XANAX? A. When anxiety is +1 B. When the client starts to have a narrow perceptual field and selective inatte

ntiveness C. When problem solving is not possible D. When the client is immobile and disorganized 36. Which of the following behavior is not a sign or a symptom of Anxiety? A. B. C. D. Frequent hand movement Somatization The client asks a question The client is acting out

37. Which of the following intervention is inappropriate for client s with anxiety ? A. B. C. D. Offer choices Provide a quiet and calm environment Provide detailed explanation on each and every procedures and equipments Bring anxiety down to a controllable level

38. Which of the following statement, if made by the nurse, is considered not th erapeutic? A. B. C. D. How did you deal with your anxiety before? It must be awful to feel anxious. How does it feel to be anxious? What makes you feel anxious?

39. Marissa Salva, Uses Benson s relaxation. How is it done? A. en B. ng C. D. Systematically tensing muscle groups from top to bottom for 5 seconds, and th releasing them Concentrating on breathing without tensing the muscle, Letting go and repeati a word or sound after each exhalation Using a strong positive, feeling-rich statement about a desired change Exercise combined with meditation to foster relaxation and mental alacrity

40. What type of relaxation technique does Lyza uses if a machine is showing her pulse rate, temperature and muscle tension which she can visualize and assess? A. B. C. D. Biofeedback Massage Autogenic training Visualization and Imagery

41. This is also known as Self-suggestion or Self-hypnosis A. B. C. D. Biofeedback Meditation Autogenic training Visualization and Imagery

42. Which among these drugs is NOT an anxiolytic? A. B. C. D. Valium Ativan Milltown Luvox

43. Kenneth, 25 year old diagnosed with HIV felt that he had not lived up with G od s expectation. He fears that in the course of his illness, God will be punitive

and not be supportive. What kind of spiritual crisis is Kenneth experiencing? 1. 2. 3. 4. A. B. C. D. Spiritual Spiritual Spiritual Spiritual 1,2 2,3 3,4 1,4 Pain Anxiety Guilt Despair

44. Grace, believes that her relationship with God is broken. She tried to go to church to ask forgiveness everyday to remedy her feelings. What kind of spiritu al distress is Grace experiencing? A. B. C. D. Spiritual Spiritual Spiritual Spiritual Pan Alienation Guilt Despair

45. Remedios felt EMPTY She felt that she has already lost God s favor and love beca use of her sins. This is a type of what spiritual crisis? A. B. C. D. Spiritual Spiritual Spiritual Spiritual Anger Loss Despair Anxiety

46. Budek is working with a schizophrenic patient. He noticed that the client is agitated, pacing back and forth, restless and experiencing Anxiety +3. Budek sa id You appear restless What therapeutic technique did Budek used? A. B. C. D. Offering general leads Seeking clarification Making observation Encouraging description of perception You see dead people? This

47. Rommel told Budek I SEE DEAD PEOPLE Budek responded Is an example of therapeutic communication technique? A. B. C. D. Reflecting Restating Exploring Seeking clarification

48. Rommel told Budek, Do you think Im crazy? Budek responded, azy? Budek uses what example of therapeutic communication? A. B. C. D. Reflecting Restating Exploring Seeking clarification

Do you think your cr

49. Myra, 21 year old nursing student has difficulty sleeping. She told Nurse Bu dek I really think a lot about my x boyfriend recently Budek told Myra And that cau ses you difficulty sleeping? Which therapeutic technique is used in this situatio n? A. Reflecting

B. Restating C. Exploring D. Seeking clarification 50. Myra told Budek I cannot sleep, I stay away all night Budek told her You have d ifficulty sleeping This is what type of therapeutic communication technique? A. B. C. D. Reflecting Restating Exploring Seeking clarification

51. Myra said I saw my dead grandmother here at my bedside a while ago Budek respo nded Really? That is hard to believe, How do you feel about it? What technique did Budek used? A. B. C. D. Disproving Disagreeing Voicing Doubt Presenting Reality

52. Which of the following is a therapeutic communication in response to I am a G OD, bow before me Or ill summon the dreaded thunder to burn you and purge you to pieces! A. You are not a GOD, you are Professor Tadle and you are a PE Teacher, not a Nur se. I am Glen, Your nurse. B. Oh hail GOD Tadle, everyone bow or face his wrath! C. Hello Mr. Tadle, You are here in the hospital, I am your nurse and you are a p atient here D. How can you be a GOD Mr. Tadle? Can you tell me more about it? 53. Erik John Senna, Told Nurse Budek I don t want to that, I don t want that thing. . that s too painful! Which of the following response is NON THERAPEUTIC A. This must be difficult for you, But I need to inject you this for your own go od B. You sound afraid C. Are you telling me you don t want this injection? D. Why are you so anxious? Please tell me more about your feelings Erik 54. Legrande De Salvaje Y Cobrador La Jueteng, was caught by the bacolod police because of his illegal activities. When he got home after paying for the bail, H e shouted at his son. What defense mechanism did Mr. La Jueteng used? A. B. C. D. Restitution Projection Displacement Undoing

55. Later that day, he bought his son ice cream and food. What defense mechanism is Legrande unconsciously doing? A. B. C. D. Restitution Conversion Redoing Reaction formation

56. Crisis is a sudden event in ones life that disturbs a person s homeostasis. Wh ich of the following is NOT TRUE in crisis?

A. B. C. D.

The person experiences heightened feeling of stress Inability to function in the usual organized manner Lasts for 4 months Indicates unpleasant emotional feelings

57. Which of the following is a characteristic of crisis? A. B. C. D. Lasts for an unlimited period of time There is a triggering event Situation is not dangerous to the person Person totality is not involved

58. Levito Devin, The Italian prime minister, is due to retire next week. He fee ls depressed due to the enormous loss of influence, power, fame and fortune. Wha t type of crisis is Devin experiencing? A. B. C. D. Situational Maturational Social Phenomenal

59. Estrada, The Philippine president, has been unexpectedly impeached and was o ut of office before the end of his term. He is in what type of crisis? A. B. C. D. Situational Maturational Social Phenomenal

60. The tsunami in Thailand and Indonesia took thousands of people and change mi llion lives. The people affected by the Tsunami are saddened and do not know how to start all over again. What type of crisis is this? A. B. C. D. Situational Maturational Social Phenomenal

61. Which of the following is the BEST goal for crisis intervention? A. B. C. D. Bring back the client in the pre crisis state Make sure that the client becomes better Achieve independence Provide alternate coping mechanism

62. What is the best intervention when the client has just experienced the crisi s and still at the first phase of the crisis? A. B. C. D. Behavior therapy Gestalt therapy Cognitive therapy Milieu Therapy

63. Therapeutic nurse client relationship is describes as follows 1. Based on friendship and mutual interest 2. It is a professional relationship 3. It is focused on helping the patient solve problems and achieve health-relate d goals

4. Maintained only as long as the patient requires professional help A. B. C. D. 1,2,3 1,2,4 2,3,4 1,3,4

64. The client is scheduled to have surgical removal of the tumor on her left br east. Which of the following manifestation indicates that she is experiencing Mi ld Anxiety? A. B. C. D. She She She She has increased awareness of her environmental details focused on selected aspect of her illness experiences incongruence of action, thoughts and feelings experiences random motor activities

65. Which of the following nursing intervention would least likely be effective when dealing with a client with aggressive behavior? A. B. C. D. Approach him in a calm manner Provide opportunities to express feelings Maintain eye contact with the client Isolate the client from others

66. Whitney, a patient of nurse Budek, verbalizes I have nothing, nothing nothing! Don t make me close one more door, I don t wanna hurt anymore! Which of the following is the most appropriate response by Budek? A. B. C. D. Why are you singing? What makes you say that? Ofcourse you are everything! What is that you said?

67. Whitney verbalizes that she is anxious that the diagnostic test might reveal laryngeal cancer. Which of the following is the most appropriate nursing interv ention? A. Tell the client not to worry until the results are in B. Ask the client to express feelings and concern C. Reassure the client everything will be alright D. Advice the client to divert his attention by watching television and reading newspapers 68. Considered as the most accurate expression of person s thought and feelings A. B. C. D. Verbal communication Non verbal communication Written communication Oral communication

69. Represents inner feeling that a person do not like talking about. A. B. C. D. Overt communication Covert communication Verbal communication Non verbal communication

70. Which of the following is NOT a characteristic of an effective Nurse-Client relationship?

A. B. C. D.

Focused on the patient Based on mutual trust Conveys acceptance Discourages emotional bond

71. A type of record wherein , each person or department makes notation in separ ate records. A nurse will use the nursing notes, The doctor will use the Physici an s order sheet etc. Data is arranged according to information source. A. B. C. D. POMR POR Traditional Resource oriented

72. Type of recording that integrates all data about the problem, gathered by me mbers of the health team. A. B. C. D. POMR Traditional Resource oriented Source oriented

73. These are data that are monitored by using graphic charts or graphs that ind icated the progression or fluctuation of client s Temperature and Blood pressure. A. B. C. D. Progress notes Kardex Flow chart Flow sheet

74. Provides a concise method of organizing and recording data about the client. It is a series of flip cards kept in portable file used in change of shift repo rts. A. B. C. D. Kardex Progress Notes SOAPIE Change of shift report

75. You are about to write an information on the Kardex. There are 4 available w riting instruments to use. Which of the following should you use? A. B. C. D. Mongol #2 Permanent Ink A felt or fountain pen Pilot Pentel Pen marker

76. The client has an allergy to Iodine based dye. Where should you put this vit al information in the client s chart? A. B. C. D. In At At In the the the the first page of the client s chart last page of the client s chart front metal plate of the chart Kardex

77. Which of the following is NOT TRUE about the Kardex A. It provides readily available information B. It is a tool of end of shift reports C. The primary basis of endorsement

D. Where Allergies information are written 78. Which of the following, if seen on the Nurses notes, violates characteristic of good recording? A. The client has a blood pressure of 120/80, Temperature of 36.6 C Pulse rate o f 120 and Respiratory rate of 22 B. Ate 50% of food served C. Refused administration of betaxolol D. Visited and seen By Dr. Santiago 79. The physician ordered : Mannerix a.c , what does a.c means? A. B. C. D. As desired Before meals After meals Before bed time

80. The physician ordered, Maalox, 2 hours p.c, what does p.c means? A. As desired B. Before meals C. After meals D. Before bed time 81. The physician ordered, Maxitrol, Od. What does Od means? A. B. C. D. Left eye Right eye Both eye Once a day

82. The physician orderd, Magnesium Hydroxide cc Aluminum Hydroxide. What does c c means? A. B. C. D. without with one half With one half dose

83. Physician ordered, Paracetamol tablet ss. What does ss means? A. B. C. D. without with one half With one half dose

84. Which of the following indicates that learning has been achieved? A. Matuts starts exercising every morning and eating a balance diet after you ta ught her mag HL tayo program B. Donya Delilah has been able to repeat the steps of insulin administration aft er you taught it to her C. Marsha said I understand after you a health teaching about family planning D. John rated 100% on your given quiz about smoking and alcoholism 85. In his theory of learning as a BEHAVIORISM, he stated that transfer of knowl edge occurs if a new situation closely resembles an old one. A. Bloom B. Lewin

C. Thorndike D. Skinner 86. Which of the following is TRUE with regards to learning? A. Start from complex to simple B. Goals should be hard to achieve so patient can strive to attain unrealistic g oals C. Visual learning is the best for every individual D. Do not teach a client when he is in pain 87. According to Bloom, there are 3 domains in learning. Which of these domains is responsible for the ability of Donya Delilah to inject insulin? A. B. C. D. Cognitive Affective Psychomotor Motivative

88. Which domains of learning is responsible for making John and Marsha understa nd the different kinds of family planning methods? A. B. C. D. Cognitive Affective Psychomotor Motivative

89. Which of the following statement clearly defines therapeutic communication? A. Therapeutic communication is an interaction process which is primarily direct ed by the nurse B. It conveys feeling of warmth, acceptance and empathy from the nurse to a pati ent in relaxed atmosphere C. Therapeutic communication is a reciprocal interaction based on trust and aime d at identifying patient needs and developing mutual goals D. Therapeutic communication is an assessment component of the nursing process 90. Which of the following concept is most important in establishing a therapeut ic nurse patient relationship? A. The nurse must fully understand the patient s feelings, perception and reaction s before goals can be established B. The nurse must be a role model for health fostering behavior C. The nurse must recognize that the patient may manifest maladaptive behavior a fter illness D. The nurse should understand that patients might test her before trust is esta blished 91. Which of the following communication skill is most effective in dealing with covert communication? A. B. C. D. Validation Listening Evaluation Clarification

92. Which of the following are qualities of a good recording? 1. Brevity 2. Completeness and chronology

3. Appropriateness 4. Accuracy A. B. C. D. 1,2 3,4 1,2,3 1,2,3,4

93. All of the following chart entries are correct except A. B. C. D. V/S 36.8 C,80,16,120/80 Complained of chest pain Seems agitated Able to ambulate without assistance

94. Which of the following teaching method is effective in client who needs to b e educated about self injection of insulin? A. B. C. D. Detailed explanation Demonstration Use of pamphlets Film showing

95. What is the most important characteristic of a nurse patient relationship? A. B. C. D. It is growth facilitating Based on mutual understanding Fosters hope and confidence Involves primarily emotional bond

96. Which of the following nursing intervention is needed before teaching a clie nt post spleenectomy deep breathing and coughing exercises? A. Tell the patient that deep breathing and coughing exercises is needed to prom ote good breathing, circulation and prevent complication B. Tell the client that deep breathing and coughing exercises is needed to preve nt Thrombophlebitis, hydrostatic pneumonia and atelectasis C. Medicate client for pain D. Tell client that cooperation is vital to improve recovery 97. The client has an allergy with penicillin. What is the best way to communica te this information? A. B. C. D. Place an allergy alert in the Kardex Notify the attending physician Write it on the patient s chart Take note when giving medications

98. An adult client is on extreme pain. He is moaning and grimacing. What is the best way to assess the client s pain? A. B. C. D. Perform physical assessment Have the client rate his pain on the smiley pain rating scale Active listening on what the patient says Observe the client s behavior

99. Therapeutic communication begins with? A. Knowing your client B. Knowing yourself

C. Showing empathy D. Encoding 100. The PCS gave new guidelines including leaflets to educate cancer patients. As a nurse, When using materials like this, what is your responsibility? A. B. C. D. Read it Give it Let the Read it for the patient for the patient to read himself family member read the material for the patient yourself then, Have the client read the material

Here are the answers for Fundamentals of Nursing Comprehensive Exam 3: Stress, D ocumentation, Crisis Interventions 1. The coronary vessels, unlike any other blood vessels in the body, respond to sympathetic stimulation by A. B. C. D. Vasoconstriction Vasodilatation Decreases force of contractility Decreases cardiac output

2. What stress response can you expect from a patient with blood sugar of 50 mg / dl? A. B. C. D. Body will try to decrease the glucose level There will be a halt in release of sex hormones Client will appear restless Blood pressure will increase

3. All of the following are purpose of inflammation except A. B. C. D. Increase heat, thereby produce abatement of phagocytosis Localized tissue injury by increasing capillary permeability Protect the issue from injury by producing pain Prepare for tissue repair

4. The initial response of tissue after injury is A. B. C. D. Immediate Transient Immediate Transient Vasodilation Vasoconstriction Vasoconstriction Vasodilation

5. The last expected process in the stages of inflammation is characterized by A. B. C. D. There will be sudden redness of the affected part Heat will increase on the affected part The affected part will loss its normal function Exudates will flow from the injured site

6. What kind of exudates is expected when there is an antibody-antigen reaction as a result of microorganism infection? A. B. C. D. Serous Serosanguinous Purulent Sanguinous

7. The first manifestation of inflammation is

A. B. C. D.

Redness on the affected area Swelling of the affected area Pain, which causes guarding of the area Increase heat due to transient vasodilation

8. The client has a chronic tissue injury. Upon examining the client s antibody fo r a particular cellular response, Which of the following WBC component is respon sible for phagocytosis in chronic tissue injury? A. B. C. D. Neutrophils Basophils Eosinophils Monocytes

9. Which of the following WBC component proliferates in cases of Anaphylaxis? A. B. C. D. Neutrophils Basophils Eosinophil Monocytes

10. Icheanne, ask you, her Nurse, about WBC Components. She got an injury yester day after she twisted her ankle accidentally at her gymnastic class. She asked y ou, which WBC Component is responsible for proliferation at the injured site imm ediately following an injury. You answer: A. B. C. D. Neutrophils Basophils Eosinophils Monocytes

11. Icheanne then asked you, what is the first process that occurs in the inflam matory response after injury, You tell her: A. B. C. D. Phagocytosis Emigration Pavementation Chemotaxis

12. Icheanne asked you again, What is that term that describes the magnetic attr action of injured tissue to bring phagocytes to the site of injury? A. B. C. D. Icheanne, you better sleep now, you asked a lot of questions It is Diapedesis We call that Emigration I don t know the answer, perhaps I can tell you after I find it out later

13. This type of healing occurs when there is a delayed surgical closure of infe cted wound A. B. C. D. First intention Second intention Third intention Fourth intention

14. Type of healing when scars are minimal due to careful surgical incision and good healing A. First intention

B. Second intention C. Third intention D. Fourth intention 15. Imelda, was slashed and hacked by an unknown suspects. She suffered massive tissue loss and laceration on her arms and elbow in an attempt to evade the crim inal. As a nurse, you know that the type of healing that will most likely occur to Miss Imelda is A. B. C. D. First intention Second intention Third intention Fourth intention

16. Imelda is in the recovery stage after the incident. As a nurse, you know tha t the diet that will be prescribed to Miss Imelda is A. B. C. D. Low calorie, High protein with Vitamin A and C rich foods High protein, High calorie with Vitamin A and C rich foods High calorie, Low protein with Vitamin A and C rich foods Low calorie, Low protein with Vitamin A and C rich foods

17. Miss Imelda asked you, What is WET TO DRY Dressing method? Your best respons e is A. It is a type of mechanical debridement using Wet dressing that is applied and left to dry to remove dead tissues B. It is a type of surgical debridement with the use of Wet dressing to remove t he necrotic tissues C. It is a type of dressing where in, The wound is covered with Wet or Dry dress ing to prevent contamination D. It is a type of dressing where in, A cellophane or plastic is placed on the w ound over a wet dressing to stimulate healing of the wound in a wet medium 18. The primary cause of pain in inflammation is A. B. C. D. Release of pain mediators Injury to the nerve endings Compression of the local nerve endings by the edema fluids Circulation is lessen, Supply of oxygen is insufficient

19. The client is in stress because he was told by the physician he needs to und ergo surgery for removal of tumor in his bladder. Which of the following are eff ects of sympatho-adreno-medullary response by the client? 1. 2. 3. 4. Constipation Urinary frequency Hyperglycemia Increased blood pressure

A. 3,4 B. 1,3,4 C.1,2,4 D.1,4 20. The client is on NPO post midnight. Which of the following, if done by the c lient, is sufficient to cancel the operation in the morning? A. Eat a full meal at 10:00 P.M B. Drink fluids at 11:50 P.M

C. Brush his teeth the morning before operation D. Smoke cigarette around 3:00 A.M 21. The client place on NPO for preparation of the blood test. Adreno-cortical r esponse is activated and which of the following below is an expected response? A. B. C. D. Low BP Decrease Urine output Warm, flushed, dry skin Low serum sodium levels

22. Which of the following is true about therapeutic relationship? A. B. C. D. Directed towards helping an individual both physically and emotionally Bases on friendship and mutual trust Goals are set by the solely nurse Maintained even after the client doesn t need anymore of the Nurse s help

23. According to her, A nurse patient relationship is composed of 4 stages : Ori entation, Identification, Exploitation and Resolution A. B. C. D. Roy Peplau Rogers Travelbee

24. In what phase of Nurse patient relationship does a nurse review the client s m edical records thereby learning as much as possible about the client? A. B. C. D. Pre Orientation Orientation Working Termination

25. Nurse Aida has seen her patient, Roger for the first time. She establish a c ontract about the frequency of meeting and introduce to Roger the expected termi nation. She started taking baseline assessment and set interventions and outcome s. On what phase of NPR Does Nurse Aida and Roger belong? A. B. C. D. Pre Orientation Orientation Working Termination

26. Roger has been seen agitated, shouting and running. As Nurse Aida approaches , he shouts and swear, calling Aida names. Nurse Aida told Roger That is an unacc eptable behavior Roger, Stop and go to your room now. The situation is most likel y in what phase of NPR? A. B. C. D. Pre Orientation Orientation Working Termination

27. Nurse Aida, in spite of the incident, still consider Roger as worthwhile sim ply because he is a human being. What major ingredient of a therapeutic communic ation is Nurse Aida using? A. Empathy B. Positive regard

C. Comfortable sense of self D. Self awareness 28. Nurse Irma saw Roger and told Nurse Aida Oh look at that psychotic patient urse Aida should intervene and correct Nurse Irma because her statement shows th at she is lacking? A. B. C. D. Empathy Positive regard Comfortable sense of self Self awareness N

29. Which of the following statement is not true about stress? A. B. C. D. It It It It is a nervous energy is an essential aspect of existence has been always a part of human experience is something each person has to cope

30. Martina, a Tennis champ was devastated after many new competitors outpaced h er in the Wimbledon event. She became depressed and always seen crying. Martina is clearly on what kind of situation? A. B. C. D. Martina Martina Martina Martina is is is is just stressed out Anxious in the exhaustion stage of GAS in Crisis

31. Which of the following statement is not true with regards to anxiety? A. B. C. D. It has physiologic component It has psychologic component The source of dread or uneasiness is from an unrecognized entity The source of dread or uneasiness is from a recognized entity

32. Lorraine, a 27 year old executive was brought to the ER for an unknown reaso n. She is starting to speak but her speech is disorganized and cannot be underst ood. On what level of anxiety does this features belongs? A. B. C. D. Mild Moderate Severe Panic

33. Elton, 21 year old nursing student is taking the board examination. She is s weating profusely, has decreased awareness of his environment and is purely focu sed on the exam questions characterized by his selective attentiveness. What anx iety level is Elton exemplifying? A. B. C. D. Mild Moderate Severe Panic

34. You noticed the patient chart : ANXIETY +3 What will you expect to see in th is client? A. An optimal time for learning, Hearing and perception is greatly increased B. Dilated pupils

C. Unable to communicate D. Palliative Coping Mechanism 35. When should the nurse starts giving XANAX? A. When anxiety is +1 B. When the client starts to have a narrow perceptual field and selective inatte ntiveness C. When problem solving is not possible D. When the client is immobile and disorganized 36. Which of the following behavior is not a sign or a symptom of Anxiety? A. B. C. D. Frequent hand movement Somatization The client asks a question The client is acting out

37. Which of the following intervention is inappropriate for client s with anxiety ? A. B. C. D. Offer choices Provide a quiet and calm environment Provide detailed explanation on each and every procedures and equipments Bring anxiety down to a controllable level

38. Which of the following statement, if made by the nurse, is considered not th erapeutic? A. B. C. D. How did you deal with your anxiety before? It must be awful to feel anxious. How does it feel to be anxious? What makes you feel anxious?

39. Marissa Salva, Uses Benson s relaxation. How is it done? A. en B. ng C. D. Systematically tensing muscle groups from top to bottom for 5 seconds, and th releasing them Concentrating on breathing without tensing the muscle, Letting go and repeati a word or sound after each exhalation Using a strong positive, feeling-rich statement about a desired change Exercise combined with meditation to foster relaxation and mental alacrity

40. What type of relaxation technique does Lyza uses if a machine is showing her pulse rate, temperature and muscle tension which she can visualize and assess? A. B. C. D. Biofeedback Massage Autogenic training Visualization and Imagery

41. This is also known as Self-suggestion or Self-hypnosis A. B. C. D. Biofeedback Meditation Autogenic training Visualization and Imagery

42. Which among these drugs is NOT an anxiolytic?

A. B. C. D.

Valium Ativan Milltown Luvox

43. Kenneth, 25 year old diagnosed with HIV felt that he had not lived up with G od s expectation. He fears that in the course of his illness, God will be punitive and not be supportive. What kind of spiritual crisis is Kenneth experiencing? 1. 2. 3. 4. A. B. C. D. Spiritual Spiritual Spiritual Spiritual 1,2 2,3 3,4 1,4 Pain Anxiety Guilt Despair

44. Grace, believes that her relationship with God is broken. She tried to go to church to ask forgiveness everyday to remedy her feelings. What kind of spiritu al distress is Grace experiencing? A. B. C. D. Spiritual Spiritual Spiritual Spiritual Pan Alienation Guilt Despair

45. Remedios felt EMPTY She felt that she has already lost God s favor and love beca use of her sins. This is a type of what spiritual crisis? A. B. C. D. Spiritual Spiritual Spiritual Spiritual Anger Loss Despair Anxiety

46. Budek is working with a schizophrenic patient. He noticed that the client is agitated, pacing back and forth, restless and experiencing Anxiety +3. Budek sa id You appear restless What therapeutic technique did Budek used? A. B. C. D. Offering general leads Seeking clarification Making observation Encouraging description of perception You see dead people? This

47. Rommel told Budek I SEE DEAD PEOPLE Budek responded Is an example of therapeutic communication technique? A. B. C. D. Reflecting Restating Exploring Seeking clarification

48. Rommel told Budek, Do you think Im crazy? Budek responded, azy? Budek uses what example of therapeutic communication? A. B. C. D. Reflecting Restating Exploring Seeking clarification

Do you think your cr

49. Myra, 21 year old nursing student has difficulty sleeping. She told Nurse Bu dek I really think a lot about my x boyfriend recently Budek told Myra And that cau ses you difficulty sleeping? Which therapeutic technique is used in this situatio n? A. B. C. D. Reflecting Restating Exploring Seeking clarification

50. Myra told Budek I cannot sleep, I stay away all night Budek told her You have d ifficulty sleeping This is what type of therapeutic communication technique? A. B. C. D. Reflecting Restating Exploring Seeking clarification

51. Myra said I saw my dead grandmother here at my bedside a while ago Budek respo nded Really? That is hard to believe, How do you feel about it? What technique did Budek used? A. B. C. D. Disproving Disagreeing Voicing Doubt Presenting Reality

52. Which of the following is a therapeutic communication in response to I am a G OD, bow before me Or ill summon the dreaded thunder to burn you and purge you to pieces! A. You are not a GOD, you are Professor Tadle and you are a PE Teacher, not a Nur se. I am Glen, Your nurse. B. Oh hail GOD Tadle, everyone bow or face his wrath! C. Hello Mr. Tadle, You are here in the hospital, I am your nurse and you are a p atient here D. How can you be a GOD Mr. Tadle? Can you tell me more about it? 53. Erik John Senna, Told Nurse Budek I don t want to that, I don t want that thing. . that s too painful! Which of the following response is NON THERAPEUTIC A. This must be difficult for you, But I need to inject you this for your own go od B. You sound afraid C. Are you telling me you don t want this injection? D. Why are you so anxious? Please tell me more about your feelings Erik 54. Legrande De Salvaje Y Cobrador La Jueteng, was caught by the bacolod police because of his illegal activities. When he got home after paying for the bail, H e shouted at his son. What defense mechanism did Mr. La Jueteng used? A. B. C. D. Restitution Projection Displacement Undoing

55. Later that day, he bought his son ice cream and food. What defense mechanism is Legrande unconsciously doing?

A. B. C. D.

Restitution Conversion Redoing Reaction formation

56. Crisis is a sudden event in ones life that disturbs a person s homeostasis. Wh ich of the following is NOT TRUE in crisis? A. B. C. D. The person experiences heightened feeling of stress Inability to function in the usual organized manner Lasts for 4 months Indicates unpleasant emotional feelings

57. Which of the following is a characteristic of crisis? A. B. C. D. Lasts for an unlimited period of time There is a triggering event Situation is not dangerous to the person Person totality is not involved

58. Levito Devin, The Italian prime minister, is due to retire next week. He fee ls depressed due to the enormous loss of influence, power, fame and fortune. Wha t type of crisis is Devin experiencing? A. B. C. D. Situational Maturational Social Phenomenal

59. Estrada, The Philippine president, has been unexpectedly impeached and was o ut of office before the end of his term. He is in what type of crisis? A. B. C. D. Situational Maturational Social Phenomenal

60. The tsunami in Thailand and Indonesia took thousands of people and change mi llion lives. The people affected by the Tsunami are saddened and do not know how to start all over again. What type of crisis is this? A. B. C. D. Situational Maturational Social Phenomenal

61. Which of the following is the BEST goal for crisis intervention? A. B. C. D. Bring back the client in the pre crisis state Make sure that the client becomes better Achieve independence Provide alternate coping mechanism

62. What is the best intervention when the client has just experienced the crisi s and still at the first phase of the crisis? A. B. C. D. Behavior therapy Gestalt therapy Cognitive therapy Milieu Therapy

63. Therapeutic nurse client relationship is describes as follows 1. Based on friendship and mutual interest 2. It is a professional relationship 3. It is focused on helping the patient solve problems and achieve health-relate d goals 4. Maintained only as long as the patient requires professional help A. B. C. D. 1,2,3 1,2,4 2,3,4 1,3,4

64. The client is scheduled to have surgical removal of the tumor on her left br east. Which of the following manifestation indicates that she is experiencing Mi ld Anxiety? A. B. C. D. She She She She has increased awareness of her environmental details focused on selected aspect of her illness experiences incongruence of action, thoughts and feelings experiences random motor activities

65. Which of the following nursing intervention would least likely be effective when dealing with a client with aggressive behavior? A. B. C. D. Approach him in a calm manner Provide opportunities to express feelings Maintain eye contact with the client Isolate the client from others

66. Whitney, a patient of nurse Budek, verbalizes I have nothing, nothing nothing! Don t make me close one more door, I don t wanna hurt anymore! Which of the following is the most appropriate response by Budek? A. B. C. D. Why are you singing? What makes you say that? Ofcourse you are everything! What is that you said?

67. Whitney verbalizes that she is anxious that the diagnostic test might reveal laryngeal cancer. Which of the following is the most appropriate nursing interv ention? A. Tell the client not to worry until the results are in B. Ask the client to express feelings and concern C. Reassure the client everything will be alright D. Advice the client to divert his attention by watching television and reading newspapers 68. Considered as the most accurate expression of person s thought and feelings A. B. C. D. Verbal communication Non verbal communication Written communication Oral communication

69. Represents inner feeling that a person do not like talking about. A. Overt communication

B. Covert communication C. Verbal communication D. Non verbal communication 70. Which of the following is NOT a characteristic of an effective Nurse-Client relationship? A. B. C. D. Focused on the patient Based on mutual trust Conveys acceptance Discourages emotional bond

71. A type of record wherein , each person or department makes notation in separ ate records. A nurse will use the nursing notes, The doctor will use the Physici an s order sheet etc. Data is arranged according to information source. A. B. C. D. POMR POR Traditional Resource oriented

72. Type of recording that integrates all data about the problem, gathered by me mbers of the health team. A. B. C. D. POMR Traditional Resource oriented Source oriented

73. These are data that are monitored by using graphic charts or graphs that ind icated the progression or fluctuation of client s Temperature and Blood pressure. A. B. C. D. Progress notes Kardex Flow chart Flow sheet

74. Provides a concise method of organizing and recording data about the client. It is a series of flip cards kept in portable file used in change of shift repo rts. A. B. C. D. Kardex Progress Notes SOAPIE Change of shift report

75. You are about to write an information on the Kardex. There are 4 available w riting instruments to use. Which of the following should you use? A. B. C. D. Mongol #2 Permanent Ink A felt or fountain pen Pilot Pentel Pen marker

76. The client has an allergy to Iodine based dye. Where should you put this vit al information in the client s chart? A. In the first page of the client s chart B. At the last page of the client s chart C. At the front metal plate of the chart

D. In the Kardex 77. Which of the following is NOT TRUE about the Kardex A. B. C. D. It provides readily available information It is a tool of end of shift reports The primary basis of endorsement Where Allergies information are written

78. Which of the following, if seen on the Nurses notes, violates characteristic of good recording? A. The client has a blood pressure of 120/80, Temperature of 36.6 C Pulse rate o f 120 and Respiratory rate of 22 B. Ate 50% of food served C. Refused administration of betaxolol D. Visited and seen By Dr. Santiago 79. The physician ordered : Mannerix a.c , what does a.c means? A. B. C. D. As desired Before meals After meals Before bed time

80. The physician ordered, Maalox, 2 hours p.c, what does p.c means? A. As desired B. Before meals C. After meals D. Before bed time 81. The physician ordered, Maxitrol, Od. What does Od means? A. B. C. D. Left eye Right eye Both eye Once a day

82. The physician orderd, Magnesium Hydroxide cc Aluminum Hydroxide. What does c c means? A. B. C. D. without with one half With one half dose

83. Physician ordered, Paracetamol tablet ss. What does ss means? A. B. C. D. without with one half With one half dose

84. Which of the following indicates that learning has been achieved? A. Matuts starts exercising every morning and eating a balance diet after you ta ught her mag HL tayo program B. Donya Delilah has been able to repeat the steps of insulin administration aft er you taught it to her C. Marsha said I understand after you a health teaching about family planning

D. John rated 100% on your given quiz about smoking and alcoholism 85. In his theory of learning as a BEHAVIORISM, he stated that transfer of knowl edge occurs if a new situation closely resembles an old one. A. B. C. D. Bloom Lewin Thorndike Skinner

86. Which of the following is TRUE with regards to learning? A. Start from complex to simple B. Goals should be hard to achieve so patient can strive to attain unrealistic g oals C. Visual learning is the best for every individual D. Do not teach a client when he is in pain 87. According to Bloom, there are 3 domains in learning. Which of these domains is responsible for the ability of Donya Delilah to inject insulin? A. B. C. D. Cognitive Affective Psychomotor Motivative

88. Which domains of learning is responsible for making John and Marsha understa nd the different kinds of family planning methods? A. B. C. D. Cognitive Affective Psychomotor Motivative

89. Which of the following statement clearly defines therapeutic communication? A. Therapeutic communication is an interaction process which is primarily direct ed by the nurse B. It conveys feeling of warmth, acceptance and empathy from the nurse to a pati ent in relaxed atmosphere C. Therapeutic communication is a reciprocal interaction based on trust and aime d at identifying patient needs and developing mutual goals D. Therapeutic communication is an assessment component of the nursing process 90. Which of the following concept is most important in establishing a therapeut ic nurse patient relationship? A. The nurse must fully understand the patient s feelings, perception and reaction s before goals can be established B. The nurse must be a role model for health fostering behavior C. The nurse must recognize that the patient may manifest maladaptive behavior a fter illness D. The nurse should understand that patients might test her before trust is esta blished 91. Which of the following communication skill is most effective in dealing with covert communication? A. Validation B. Listening

C. Evaluation D. Clarification 92. Which of the following are qualities of a good recording? 1. 2. 3. 4. A. B. C. D. Brevity Completeness and chronology Appropriateness Accuracy 1,2 3,4 1,2,3 1,2,3,4

93. All of the following chart entries are correct except A. B. C. D. V/S 36.8 C,80,16,120/80 Complained of chest pain Seems agitated Able to ambulate without assistance

94. Which of the following teaching method is effective in client who needs to b e educated about self injection of insulin? A. B. C. D. Detailed explanation Demonstration Use of pamphlets Film showing

95. What is the most important characteristic of a nurse patient relationship? A. B. C. D. It is growth facilitating Based on mutual understanding Fosters hope and confidence Involves primarily emotional bond

96. Which of the following nursing intervention is needed before teaching a clie nt post spleenectomy deep breathing and coughing exercises? A. Tell the patient that deep breathing and coughing exercises is needed to prom ote good breathing, circulation and prevent complication B. Tell the client that deep breathing and coughing exercises is needed to preve nt Thrombophlebitis, hydrostatic pneumonia and atelectasis C. Medicate client for pain D. Tell client that cooperation is vital to improve recovery 97. The client has an allergy with penicillin. What is the best way to communica te this information? A. B. C. D. Place an allergy alert in the Kardex Notify the attending physician Write it on the patient s chart Take note when giving medications

98. An adult client is on extreme pain. He is moaning and grimacing. What is the best way to assess the client s pain? A. Perform physical assessment B. Have the client rate his pain on the smiley pain rating scale

C. Active listening on what the patient says D. Observe the client s behavior 99. Therapeutic communication begins with? A. B. C. D. Knowing your client Knowing yourself Showing empathy Encoding

100. The PCS gave new guidelines including leaflets to educate cancer patients. As a nurse, When using materials like this, what is your responsibility? A. B. C. D. Read it Give it Let the Read it for the patient for the patient to read himself family member read the material for the patient yourself then, Have the client read the material

1. She is the first one to coin the term NURSING PROCESS She introduced 3 steps of nursing process which are Observation, Ministration and Validation. A. B. C. D. Nightingale Johnson Rogers Hall

2. The American Nurses association formulated an innovation of the Nursing proce ss. Today, how many distinct steps are there in the nursing process? A. B. C. D. APIE 4 ADPIE 5 ADOPIE 6 ADOPIER 7

3. They are the first one to suggest a 4 step nursing process which are : APIE , or assessment, planning, implementation and evaluation. 1. 2. 3. 4. A. B. C. D. Yura Walsh Roy Knowles 1,2 1,3 3,4 2,3

4. Which characteristic of nursing process is responsible for proper utilization of human resources, time and cost resources? A. B. C. D. Organized and Systematic Humanistic Efficient Effective

5. Which characteristic of nursing process addresses the INDIVIDUALIZED care a c lient must receive? A. Organized and Systematic B. Humanistic

C. Efficient D. Effective 6. A characteristic of the nursing process that is essential to promote client s atisfaction and progress. The care should also be relevant with the client s needs . A. B. C. D. Organized and Systematic Humanistic Efficient Effective

7. Rhina, who has Menieres disease, said that her environment is moving. Which o f the following is a valid assessment? 1. 2. 3. 4. A. B. C. D. Rhina is giving an objective data Rhina is giving a subjective data The source of the data is primary The source of the data is secondary 1,3 2,3 2.4 1,4

8. Nurse Angela, observe Joel who is very apprehensive over the impending operat ion. The client is experiencing dyspnea, diaphoresis and asks lots of questions. Angela made a diagnosis of ANXIETY R/T INTRUSIVE PROCEDURE. This is what type o f Nursing Diagnosis? A. B. C. D. Actual Probable Possible Risk

9. Nurse Angela diagnosed Mrs. Delgado, who have undergone a BKA. Her diagnosis is SELF ESTEEM DISTURBANCE R/T CHANGE IN BODY IMAGE. Although the client has not yet seen her lost leg, Angela already anticipated the diagnosis. This is what t ype of Diagnosis? A. B. C. D. Actual Probable Possible Risk

10. Nurse Angela is about to make a diagnosis but very unsure because the S/S th e client is experiencing is not specific with her diagnosis of POWERLESSNESS R/T DIFFICULTY ACCEPTING LOSS OF LOVED ONE. She then focus on gathering data to ref ute or prove her diagnosis but her plans and interventions are already ongoing f or the diagnosis. Which type of Diagnosis is this? A. B. C. D. Actual Probable Possible Risk

11. Nurse Angela knew that Stephen Lee Mu Chin, has just undergone an operation with an incision near the diaphragm. She knew that this will contribute to some complications later on. She then should develop what type of Nursing diagnosis?

A. B. C. D.

Actual Probable Possible Risk

12. Which of the following Nursing diagnosis is INCORRECT? A. B. C. D. Fluid volume deficit R/T Diarrhea High risk for injury R/T Absence of side rails Possible ineffective coping R/T Loss of loved one Self esteem disturbance R/T Effects of surgical removal of the leg

13. Among the following statements, which should be given the HIGHEST priority? A. B. C. D. Client Client Client Client is in extreme pain s blood pressure is 60/40 s temperature is 40 deg. Centigrade is cyanotic

14. Which of the following need is given a higher priority among others? A. B. C. D. The The The The client client client client has attempted suicide and safety precaution is needed has disturbance in his body image because of the recent operation is depressed because her boyfriend left her all alone is thirsty and dehydrated

15. Which of the following is TRUE with regards to Client Goals? A. They are specific, measurable, attainable and time bounded B. They are general and broadly stated C. They should answer for WHO, WHAT ACTIONS, WHAT CIRCUMSTANCES, HOW WELL and WH EN. D. Example is : After discharge planning, Client demonstrated the proper psychom otor skills for insulin injection. 16. Which of the following is a NOT a correct statement of an Outcome criteria? A. B. C. D. Ambulates 30 feet with a cane before discharge Discusses fears and concerns regarding the surgical procedure Demonstrates proper coughing and breathing technique after a teaching session Reestablishes a normal pattern of elimination

17. Which of the following is a OBJECTIVE data? A. B. C. D. Dizziness Chest pain Anxiety Blue nails

18. A patient s chart is what type of data source? A. B. C. D. Primary Secondary Tertiary Can be A and B

19. All of the following are characteristic of the Nursing process except A. Dynamic B. Cyclical

C. Universal D. Intrapersonal 20. Which of the following is true about the NURSING CARE PLAN? A. B. C. D. It is nursing centered Rationales are supported by interventions Verbal Atleast 2 goals are needed for every nursing diagnosis

21. A framework for health assessment that evaluates the effects of stressors to the mind, body and environment in relation with the ability of the client to pe rform ADL. A. B. C. D. Functional health framework Head to toe framework Body system framework Cephalocaudal framework

22. Client has undergone Upper GI and Lower GI series. Which type of health asse ssment framework is used in this situation? A. B. C. D. Functional health framework Head to toe framework Body system framework Cephalocaudal framework

23. Which of the following statement is true regarding temperature? A. B. C. D. Oral temperature is more accurate than rectal temperature The bulb used in Rectal temperature reading is pear shaped or round The older the person, the higher his BMR When the client is swimming, BMR Decreases

24. A type of heat loss that occurs when the heat is dissipated by air current A. B. C. D. Convection Conduction Radiation Evaporation

25. Which of the following is TRUE about temperature? A. The highest temperature usually occurs later in a day, around 8 P.M to 12 M.N B. The lowest temperature is usually in the Afternoon, Around 12 P.M C. Thyroxin decreases body temperature D. Elderly people are risk for hyperthermia due to the absence of fats, Decrease d thermoregulatory control and sedentary lifestyle. 26. Hyperpyrexia is a condition in which the temperature is greater than A. B. C. D. 40 degree Celsius 39 degree Celsius 100 degree Fahrenheit 105.8 degree Fahrenheit

27. Tympanic temperature is taken from John, A client who was brought recently i nto the ER due to frequent barking cough. The temperature reads 37.9 Degrees Cel sius. As a nurse, you conclude that this temperature is

A. B. C. D.

High Low At the low end of the normal range At the high end of the normal range

28. John has a fever of 38.5 Deg. Celsius. It surges at around 40 Degrees and go back to 38.5 degrees 6 times today in a typical pattern. What kind of fever is John having? A. B. C. D. Relapsing Intermittent Remittent Constant

29. John has a fever of 39.5 degrees 2 days ago, But yesterday, he has a normal temperature of 36.5 degrees. Today, his temperature surges to 40 degrees. What t ype of fever is John having? A. B. C. D. Relapsing Intermittent Remittent Constant

30. John s temperature 10 hours ago is a normal 36.5 degrees. 4 hours ago, He has a fever with a temperature of 38.9 Degrees. Right now, his temperature is back t o normal. Which of the following best describe the fever john is having? A. B. C. D. Relapsing Intermittent Remittent Constant

31. The characteristic fever in Dengue Virus is characterized as: A. B. C. D. Tricyclic Bicyclic Biphasic Triphasic

32. When John has been given paracetamol, his fever was brought down dramaticall y from 40 degrees Celsius to 36.7 degrees in a matter of 10 minutes. The nurse w ould assess this event as: A. The goal of reducing john s fever has been met with full satisfaction of the ou tcome criteria B. The desired goal has been partially met C. The goal is not completely met D. The goal has been met but not with the desired outcome criteria 33. What can you expect from Marianne, who is currently at the ONSET stage of fe ver? A. B. C. D. Hot, flushed skin Increase thirst Convulsion Pale,cold skin

34. Marianne is now at the Defervescence stage of the fever, which of the follow ing is expected?

A. B. C. D.

Delirium Goose flesh Cyanotic nail beds Sweating

35. Considered as the most accessible and convenient method for temperature taki ng A. B. C. D. Oral Rectal Tympanic Axillary

36. Considered as Safest and most non invasive method of temperature taking A. B. C. D. Oral Rectal Tympanic Axillary

37. Which of the following is NOT a contraindication in taking ORAL temperature? A. B. C. D. Quadriplegic Presence of NGT Dyspnea Nausea and Vomitting

38. Which of the following is a contraindication in taking RECTAL temperature? A. B. C. D. Unconscious Neutropenic NPO Very young children

39. How long should the Rectal Thermometer be inserted to the clients anus? A. B. C. D. 1 to 2 inches .5 to 1.5 inches 3 to 5 inches 2 to 3 inches

40. In cleaning the thermometer after use, The direction of the cleaning to foll ow Medical Asepsis is : A. B. C. D. From From From From bulb stem stem bulb to to to to stem bulb stem bulb

41. How long should the thermometer stay in the Client s Axilla? A. B. C. D. 3 minutes 4 minutes 7 minutes 10 minutes

42. Which of the following statement is TRUE about pulse? A. Young person have higher pulse than older persons B. Males have higher pulse rate than females after puberty

C. Digitalis has a positive chronotropic effect D. In lying position, Pulse rate is higher 43. The following are correct actions when taking radial pulse except: A. B. C. D. Put the palms downward Use the thumb to palpate the artery Use two or three fingers to palpate the pulse at the inner wrist Assess the pulse rate, rhythm, volume and bilateral quality

44. The difference between the systolic and diastolic pressure is termed as A. B. C. D. Apical rate Cardiac rate Pulse deficit Pulse pressure

45. Which of the following completely describes PULSUS PARADOXICUS? A. A greater-than-normal increase in systolic blood pressure with inspiration B. A greater-than-normal decrease in systolic blood pressure with inspiration C. Pulse is paradoxically low when client is in standing position and high when supine. D. Pulse is paradoxically high when client is in standing position and low when supine. 46. Which of the following is TRUE about respiration? A. I:E 2:1 B. I:E : 4:3 C I:E 1:1 D. I:E 1:2 47. Contains the pneumotaxic and the apneutic centers A. B. C. D. Medulla oblongata Pons Carotid bodies Aortic bodies

48. Which of the following is responsible for deep and prolonged inspiration A. B. C. D. Medulla oblongata Pons Carotid bodies Aortic bodies

49. Which of the following is responsible for the rhythm and quality of breathin g? A. B. C. D. Medulla oblongata Pons Carotid bodies Aortic bodies

50. The primary respiratory center A. Medulla oblongata B. Pons C. Carotid bodies

D. Aortic bodies 51. Which of the following is TRUE about the mechanism of action of the Aortic a nd Carotid bodies? A. B. C. D. If the BP is elevated, the RR increases If the BP is elevated, the RR decreases Elevated BP leads to Metabolic alkalosis Low BP leads to Metabolic acidosis

52. All of the following factors correctly influence respiration except one. Whi ch of the following is incorrect? A. B. C. D. Hydrocodone decreases RR Stress increases RR Increase temperature of the environment, Increase RR Increase altitude, Increase RR

53. When does the heart receives blood from the coronary artery? A. B. C. D. Systole Diastole When the valves opens When the valves closes

54. Which of the following is more life threatening? A. B. C. D. BP BP BP BP = = = = 180/100 160/120 90/60 80/50

55. Refers to the pressure when the ventricles are at rest A. B. C. D. Diastole Systole Preload Pulse pressure

56. Which of the following is TRUE about the blood pressure determinants? A. B. C. D. Hypervolemia lowers BP Hypervolemia increases GFR HCT of 70% might decrease or increase BP Epinephrine decreases BP

57. Which of the following do not correctly correlates the increase BP of Ms. Ai da, a 70 year old diabetic? A. B. C. D. Females, after the age 65 tends to have lower BP than males Disease process like Diabetes increase BP BP is highest in the morning, and lowest during the night Africans, have a greater risk of hypertension than Caucasian and Asians.

58. How many minutes are allowed to pass if the client had engaged in strenuous activities, smoked or ingested caffeine before taking his/her BP? A. 5 B. 10 C. 15

D. 30 59. Too narrow cuff will cause what change in the Client s BP? A. B. C. D. True high reading True low reading False high reading False low reading

60. Which is a preferable arm for BP taking? A. B. C. D. An arm with the most contraptions The left arm of the client with a CVA affecting the right brain The right arm The left arm

61. Which of the following is INCORRECT in assessing client s BP? A. Read the mercury at the upper meniscus, preferably at the eye level to preven t error of parallax B. Inflate and deflate slowly, 2-3 mmHg at a time C. The sound heard during taking BP is known as KOROTKOFF sound D. If the BP is taken on the left leg using the popliteal artery pressure, a BP of 160/80 is normal. 62. Which of the following is the correct interpretation of the ERROR OF PARALLA X A. If the eye level lse high reading B. If the eye level lse low reading C. If the eye level se low reading D. If the eye level ding is accurate is higher than the level of the meniscus, it will cause a fa is higher than the level of the meniscus, it will cause a fa is lower than the level of the meniscus, it will cause a fal is equal to that of the level of the upper meniscus, the rea

63. How many minute/s is/are allowed to pass before making a re-reading after th e first one? A. B. C. D. 1 5 15 30

64. Which of the following is TRUE about the auscultation of blood pressure? A. B. C. D. Pulse + 4 is considered as FULL The bell of the stethoscope is use in auscultating BP Sound produced by BP is considered as HIGH frequency sound Pulse +1 is considered as NORMAL

65. In assessing the abdomen, Which of the following is the correct sequence of the physical assessment? A. B. C. D. Inspection, Auscultation, Percussion, Palpation Palpation, Auscultation, Percussion, Inspection Inspection, Palpation, Auscultation, Percussion Inspection, Auscultation, Palpation, Percussion

66. The sequence in examining the quadrants of the abdomen is: A. B. C. D. RUQ,RLQ,LUQ,LLQ RLQ,RUQ,LLQ,LUQ RUQ,RLQ,LLQ,LUQ RLQ,RUQ,LUQ,LLQ

67. In inspecting the abdomen, which of the following is NOT DONE? A. B. C. D. Ask the client to void first Knees and legs are straighten to relax the abdomen The best position in assessing the abdomen is Dorsal recumbent The knees and legs are externally rotated

68. Dr. Fabian De Las Santas, is about to conduct an ophthalmoscope examination. Which of the following, if done by a nurse, is a Correct preparation before the procedure? A. B. C. D. Provide the necessary draping to ensure privacy Open the windows, curtains and light to allow better illumination Pour warm water over the ophthalmoscope to ensure comfort Darken the room to provide better illumination

69. If the client is female, and the doctor is a male and the patient is about t o undergo a vaginal and cervical examination, why is it necessary to have a fema le nurse in attendance? A. B. C. D. To To To To ensure assist assess ensure that the doctor performs the procedure safely the doctor the client s response to examination that the procedure is done in an ethical manner

70. In palpating the client s breast, Which of the following position is necessary for the patient to assume before the start of the procedure? A. B. C. D. Supine Dorsal recumbent Sitting Lithotomy

71. When is the best time to collect urine specimen for routine urinalysis and C /S? A. B. C. D. Early morning Later afternoon Midnight Before breakfast

72. Which of the following is among an ideal way of collecting a urine specimen for culture and sensitivity? A. Use a clean container B. Discard the first flow of urine to ensure that the urine is not contaminated C. Collect around 30-50 ml of urine D. Add preservatives, refrigerate the specimen or add ice according to the agenc y s protocol 73. In a 24 hour urine specimen started Friday, 9:00 A.M, which of the following if done by a Nurse indicate a NEED for further procedural debriefing?

A. The nurse urine in the B. The nurse C. The nurse collection D. The nurse

ask the client to urinate at 9:00 A.M, Friday and she included the 24 hour urine specimen discards the Friday 9:00 A M urine of the client included the Saturday 9:00 A.M urine of the client to the specimen added preservatives as per protocol and refrigerates the specimen

74. This specimen is required to assess glucose levels and for the presence of a lbumin the the urine A. B. C. D. Midstream clean catch urine 24 hours urine collection Postprandial urine collection Second voided urine

75. When should the client test his blood sugar levels for greater accuracy? A. B. C. D. During meals In between meals Before meals 2 Hours after meals

76. In collecting a urine from a catheterized patient, Which of the following st atement indicates an accurate performance of the procedure? A. Clamp ort B. Clamp ort C. Clamp rt D. Clamp rt above the port for 30 to 60 minutes before drawing the urine from the p below the port for 30 to 60 minutes before drawing the urine from the p above the port for 5 to 10 minutes before drawing the urine from the po below the port for 5 to 10 minutes before drawing the urine from the po

77. A community health nurse should be resourceful and meet the needs of the cli ent. A villager ask him, Can you test my urine for glucose? Which of the followi ng technique allows the nurse to test a client s urine for glucose without the nee d for intricate instruments. A. B. C. D. Acetic Acid test Nitrazine paper test Benedict s test Litmus paper test

78. A community health nurse is assessing client s urine using the Acetic Acid sol ution. Which of the following, if done by a nurse, indicates lack of correct kno wledge with the procedure? A. The nurse B. The nurse C. The nurse D. The nurse s cloudy added the Urine as the 2/3 part of the solution heats the test tube after adding 1/3 part acetic acid heats the test tube after adding 2/3 part of Urine determines abnormal result if she noticed that the test tube become

79. Which of the following is incorrect with regards to proper urine testing usi ng Benedict s Solution? A. Heat around 5ml of Benedict s solution together with the urine in a test tube B. Add 8 to 10 drops of urine C. Heat the Benedict s solution without the urine to check if the solution is cont

aminated D. If the color remains BLUE, the result is POSITIVE 80. +++ Positive result after Benedicts test is depicted by what color? A. B. C. D. Blue Green Yellow Orange

81. Clinitest is used in testing the urine of a client for glucose. Which of the following, If committed by a nurse indicates error? A. B. C. D. Specimen is collected after meals The nurse puts 1 clinitest tablet into a test tube She added 5 drops of urine and 10 drops of water If the color becomes orange or red, It is considered postitive

82. Which of the following nursing intervention is important for a client schedu led to have a Guaiac Test? A. B. C. D. Avoid turnips, radish and horseradish 3 days before procedure Continue iron preparation to prevent further loss of Iron Do not eat read meat 12 hours before procedure Encourage caffeine and dark colored foods to produce accurate results

83. In collecting a routine specimen for fecalysis, Which of the following, if d one by a nurse, indicates inadequate knowledge and skills about the procedure? A. B. C. us D. The nurse scoop the specimen specifically at the site with blood and mucus She took around 1 inch of specimen or a teaspoonful Ask the client to call her for the specimen after the client wiped off his an with a tissue Ask the client to defecate in a bedpan, Secure a sterile container

84. In a routine sputum analysis, Which of the following indicates proper nursin g action before sputum collection? A. Secure a clean container B. Discard the container if the outside becomes contaminated with the sputum C. Rinse the client s mouth with Listerine after collection D. Tell the client that 4 tablespoon of sputum is needed for each specimen for a routine sputum analysis 85. Who collects Blood specimen? A. B. C. D. The nurse Medical technologist Physician Physical therapist

86. David, 68 year old male client is scheduled for Serum Lipid analysis. Which of the following health teaching is important to ensure accurate reading? A. B. C. D. Tell the patient to eat fatty meals 3 days prior to the procedure NPO for 12 hours pre procedure Ask the client to drink 1 glass of water 1 hour prior to the procedure Tell the client that the normal serum lipase level is 50 to 140 U/L

87. The primary factor responsible for body heat production is the

A. B. C. D.

Metabolism Release of thyroxin Muscle activity Stress

88. The heat regulating center is found in the A. B. C. D. Medulla oblongata Thalamus Hypothalamus Pons

89. A process of heat loss which involves the transfer of heat from one surface to another is A. B. C. D. Radiation Conduction Convection Evaporation

90. Which of the following is a primary factor that affects the BP? A. B. C. D. Obesity Age Stress Gender

91. The following are social data about the client except A. B. C. D. Patient s lifestyle Religious practices Family home situation Usual health status

92. The best position for any procedure that involves vaginal and cervical exami nation is A. B. C. D. Dorsal recumbent Side lying Supine Lithotomy

93. Measure the leg circumference of a client with bipedal edema is best done in what position? A. B. C. D. Dorsal recumbent Sitting Standing Supine

94. In palpating the client s abdomen, Which of the following is the best position for the client to assume? A. B. C. D. Dorsal recumbent Side lying Supine Lithotomy

95. Rectal examination is done with a client in what position?

A. B. C. D.

Dorsal recumbent Sims position Supine Lithotomy

96. Which of the following is a correct nursing action when collecting urine spe cimen from a client with an Indwelling catheter? A. B. C. D. Collect urine specimen from the drainage bag Detach catheter from the connecting tube and draw the specimen from the port Use sterile syringe to aspirate urine specimen from the drainage port Insert the syringe straight to the port to allow self sealing of the port

97. Which of the following is inappropriate in collecting mid stream clean catch urine specimen for urine analysis? A. B. C. D. Collect early in the morning, First voided specimen Do perineal care before specimen collection Collect 5 to 10 ml for urine Discard the first flow of the urine

98. When palpating the client s neck for lymphadenopathy, where should the nurse p osition himself? A. B. C. D. At At At In the client the client the client front of a s back s right side s left side sitting client

99. Which of the following is the best position for the client to assume if the back is to be examined by the nurse? A. B. C. D. Standing Sitting Side lying Prone

100. In assessing the client s chest, which position best show chest expansion as well as its movements? A. B. C. D. Sitting Prone Sidelying Supine

Answers & Rationale Here are the answers for Fundamentals of Nursing Comprehensive Exam 4: Nursing P rocess, Procedures & Health Assessment 1. She is the first one to coin the term NURSING PROCESS She introduced 3 steps of nursing process which are Observation, Ministration and Validation. A. B. C. D. Nightingale Johnson Rogers Hall

2. The American Nurses association formulated an innovation of the Nursing proce ss. Today, how many distinct steps are there in the nursing process?

A. B. C. D.

APIE 4 ADPIE 5 ADOPIE 6 ADOPIER 7

3. They are the first one to suggest a 4 step nursing process which are : APIE , or assessment, planning, implementation and evaluation. 1. 2. 3. 4. A. B. C. D. Yura Walsh Roy Knowles 1,2 1,3 3,4 2,3

4. Which characteristic of nursing process is responsible for proper utilization of human resources, time and cost resources? A. B. C. D. Organized and Systematic Humanistic Efficient Effective

5. Which characteristic of nursing process addresses the INDIVIDUALIZED care a c lient must receive? A. Organized and Systematic B. Humanistic C. Efficient D. Effective 6. A characteristic of the nursing process that is essential to promote client s atisfaction and progress. The care should also be relevant with the client s needs . A. B. C. D. Organized and Systematic Humanistic Efficient Effective

7. Rhina, who has Menieres disease, said that her environment is moving. Which o f the following is a valid assessment? 1. 2. 3. 4. A. B. C. D. Rhina is giving an objective data Rhina is giving a subjective data The source of the data is primary The source of the data is secondary 1,3 2,3 2.4 1,4

8. Nurse Angela, observe Joel who is very apprehensive over the impending operat ion. The client is experiencing dyspnea, diaphoresis and asks lots of questions. Angela made a diagnosis of ANXIETY R/T INTRUSIVE PROCEDURE. This is what type o f Nursing Diagnosis?

A. B. C. D.

Actual Probable Possible Risk

9. Nurse Angela diagnosed Mrs. Delgado, who have undergone a BKA. Her diagnosis is SELF ESTEEM DISTURBANCE R/T CHANGE IN BODY IMAGE. Although the client has not yet seen her lost leg, Angela already anticipated the diagnosis. This is what t ype of Diagnosis? A. B. C. D. Actual Probable Possible Risk

10. Nurse Angela is about to make a diagnosis but very unsure because the S/S th e client is experiencing is not specific with her diagnosis of POWERLESSNESS R/T DIFFICULTY ACCEPTING LOSS OF LOVED ONE. She then focus on gathering data to ref ute or prove her diagnosis but her plans and interventions are already ongoing f or the diagnosis. Which type of Diagnosis is this? A. B. C. D. Actual Probable Possible Risk

11. Nurse Angela knew that Stephen Lee Mu Chin, has just undergone an operation with an incision near the diaphragm. She knew that this will contribute to some complications later on. She then should develop what type of Nursing diagnosis? A. B. C. D. Actual Probable Possible Risk

12. Which of the following Nursing diagnosis is INCORRECT? A. B. C. D. Fluid volume deficit R/T Diarrhea High risk for injury R/T Absence of side rails Possible ineffective coping R/T Loss of loved one Self esteem disturbance R/T Effects of surgical removal of the leg

13. Among the following statements, which should be given the HIGHEST priority? A. B. C. D. Client Client Client Client is in extreme pain s blood pressure is 60/40 s temperature is 40 deg. Centigrade is cyanotic

14. Which of the following need is given a higher priority among others? A. B. C. D. The The The The client client client client has attempted suicide and safety precaution is needed has disturbance in his body image because of the recent operation is depressed because her boyfriend left her all alone is thirsty and dehydrated

15. Which of the following is TRUE with regards to Client Goals? A. They are specific, measurable, attainable and time bounded

B. They are general and broadly stated C. They should answer for WHO, WHAT ACTIONS, WHAT CIRCUMSTANCES, HOW WELL and WH EN. D. Example is : After discharge planning, Client demonstrated the proper psychom otor skills for insulin injection. 16. Which of the following is a NOT a correct statement of an Outcome criteria? A. B. C. D. Ambulates 30 feet with a cane before discharge Discusses fears and concerns regarding the surgical procedure Demonstrates proper coughing and breathing technique after a teaching session Reestablishes a normal pattern of elimination

17. Which of the following is a OBJECTIVE data? A. B. C. D. Dizziness Chest pain Anxiety Blue nails

18. A patient s chart is what type of data source? A. B. C. D. Primary Secondary Tertiary Can be A and B

19. All of the following are characteristic of the Nursing process except A. B. C. D. Dynamic Cyclical Universal Intrapersonal

20. Which of the following is true about the NURSING CARE PLAN? A. B. C. D. It is nursing centered Rationales are supported by interventions Verbal Atleast 2 goals are needed for every nursing diagnosis

21. A framework for health assessment that evaluates the effects of stressors to the mind, body and environment in relation with the ability of the client to pe rform ADL. A. B. C. D. Functional health framework Head to toe framework Body system framework Cephalocaudal framework

22. Client has undergone Upper GI and Lower GI series. Which type of health asse ssment framework is used in this situation? A. B. C. D. Functional health framework Head to toe framework Body system framework Cephalocaudal framework

23. Which of the following statement is true regarding temperature?

A. B. C. D.

Oral temperature is more accurate than rectal temperature The bulb used in Rectal temperature reading is pear shaped or round The older the person, the higher his BMR When the client is swimming, BMR Decreases

24. A type of heat loss that occurs when the heat is dissipated by air current A. B. C. D. Convection Conduction Radiation Evaporation

25. Which of the following is TRUE about temperature? A. The highest temperature usually occurs later in a day, around 8 P.M to 12 M.N B. The lowest temperature is usually in the Afternoon, Around 12 P.M C. Thyroxin decreases body temperature D. Elderly people are risk for hyperthermia due to the absence of fats, Decrease d thermoregulatory control and sedentary lifestyle. 26. Hyperpyrexia is a condition in which the temperature is greater than A. B. C. D. 40 degree Celsius 39 degree Celsius 100 degree Fahrenheit 105.8 degree Fahrenheit

27. Tympanic temperature is taken from John, A client who was brought recently i nto the ER due to frequent barking cough. The temperature reads 37.9 Degrees Cel sius. As a nurse, you conclude that this temperature is A. B. C. D. High Low At the low end of the normal range At the high end of the normal range

28. John has a fever of 38.5 Deg. Celsius. It surges at around 40 Degrees and go back to 38.5 degrees 6 times today in a typical pattern. What kind of fever is John having? A. B. C. D. Relapsing Intermittent Remittent Constant

29. John has a fever of 39.5 degrees 2 days ago, But yesterday, he has a normal temperature of 36.5 degrees. Today, his temperature surges to 40 degrees. What t ype of fever is John having? A. B. C. D. Relapsing Intermittent Remittent Constant

30. John s temperature 10 hours ago is a normal 36.5 degrees. 4 hours ago, He has a fever with a temperature of 38.9 Degrees. Right now, his temperature is back t o normal. Which of the following best describe the fever john is having? A. Relapsing B. Intermittent

C. Remittent D. Constant 31. The characteristic fever in Dengue Virus is characterized as: A. B. C. D. Tricyclic Bicyclic Biphasic Triphasic

32. When John has been given paracetamol, his fever was brought down dramaticall y from 40 degrees Celsius to 36.7 degrees in a matter of 10 minutes. The nurse w ould assess this event as: A. The goal of reducing john s fever has been met with full satisfaction of the ou tcome criteria B. The desired goal has been partially met C. The goal is not completely met D. The goal has been met but not with the desired outcome criteria 33. What can you expect from Marianne, who is currently at the ONSET stage of fe ver? A. B. C. D. Hot, flushed skin Increase thirst Convulsion Pale,cold skin

34. Marianne is now at the Defervescence stage of the fever, which of the follow ing is expected? A. B. C. D. Delirium Goose flesh Cyanotic nail beds Sweating

35. Considered as the most accessible and convenient method for temperature taki ng A. B. C. D. Oral Rectal Tympanic Axillary

36. Considered as Safest and most non invasive method of temperature taking A. B. C. D. Oral Rectal Tympanic Axillary

37. Which of the following is NOT a contraindication in taking ORAL temperature? A. B. C. D. Quadriplegic Presence of NGT Dyspnea Nausea and Vomitting

38. Which of the following is a contraindication in taking RECTAL temperature?

A. B. C. D.

Unconscious Neutropenic NPO Very young children

39. How long should the Rectal Thermometer be inserted to the clients anus? A. B. C. D. 1 to 2 inches .5 to 1.5 inches 3 to 5 inches 2 to 3 inches

40. In cleaning the thermometer after use, The direction of the cleaning to foll ow Medical Asepsis is : A. From bulb to stem B. From stem to bulb C. From stem to stem D. From bulb to bulb 41. How long should the thermometer stay in the Client s Axilla? A. B. C. D. 3 minutes 4 minutes 7 minutes 10 minutes

42. Which of the following statement is TRUE about pulse? A. B. C. D. Young person have higher pulse than older persons Males have higher pulse rate than females after puberty Digitalis has a positive chronotropic effect In lying position, Pulse rate is higher

43. The following are correct actions when taking radial pulse except: A. B. C. D. Put the palms downward Use the thumb to palpate the artery Use two or three fingers to palpate the pulse at the inner wrist Assess the pulse rate, rhythm, volume and bilateral quality

44. The difference between the systolic and diastolic pressure is termed as A. B. C. D. Apical rate Cardiac rate Pulse deficit Pulse pressure

45. Which of the following completely describes PULSUS PARADOXICUS? A. A greater-than-normal increase in systolic blood pressure with inspiration B. A greater-than-normal decrease in systolic blood pressure with inspiration C. Pulse is paradoxically low when client is in standing position and high when supine. D. Pulse is paradoxically high when client is in standing position and low when supine. 46. Which of the following is TRUE about respiration? A. I:E 2:1 B. I:E : 4:3

C I:E 1:1 D. I:E 1:2 47. Contains the pneumotaxic and the apneutic centers A. B. C. D. Medulla oblongata Pons Carotid bodies Aortic bodies

48. Which of the following is responsible for deep and prolonged inspiration A. B. C. D. Medulla oblongata Pons Carotid bodies Aortic bodies

49. Which of the following is responsible for the rhythm and quality of breathin g? A. B. C. D. Medulla oblongata Pons Carotid bodies Aortic bodies

50. The primary respiratory center A. B. C. D. Medulla oblongata Pons Carotid bodies Aortic bodies

51. Which of the following is TRUE about the mechanism of action of the Aortic a nd Carotid bodies? A. B. C. D. If the BP is elevated, the RR increases If the BP is elevated, the RR decreases Elevated BP leads to Metabolic alkalosis Low BP leads to Metabolic acidosis

52. All of the following factors correctly influence respiration except one. Whi ch of the following is incorrect? A. B. C. D. Hydrocodone decreases RR Stress increases RR Increase temperature of the environment, Increase RR Increase altitude, Increase RR

53. When does the heart receives blood from the coronary artery? A. B. C. D. Systole Diastole When the valves opens When the valves closes

54. Which of the following is more life threatening? A. BP = 180/100 B. BP = 160/120 C. BP = 90/60

D. BP = 80/50 55. Refers to the pressure when the ventricles are at rest A. B. C. D. Diastole Systole Preload Pulse pressure

56. Which of the following is TRUE about the blood pressure determinants? A. B. C. D. Hypervolemia lowers BP Hypervolemia increases GFR HCT of 70% might decrease or increase BP Epinephrine decreases BP

57. Which of the following do not correctly correlates the increase BP of Ms. Ai da, a 70 year old diabetic? A. B. C. D. Females, after the age 65 tends to have lower BP than males Disease process like Diabetes increase BP BP is highest in the morning, and lowest during the night Africans, have a greater risk of hypertension than Caucasian and Asians.

58. How many minutes are allowed to pass if the client had engaged in strenuous activities, smoked or ingested caffeine before taking his/her BP? A. B. C. D. 5 10 15 30

59. Too narrow cuff will cause what change in the Client s BP? A. B. C. D. True high reading True low reading False high reading False low reading

60. Which is a preferable arm for BP taking? A. B. C. D. An arm with the most contraptions The left arm of the client with a CVA affecting the right brain The right arm The left arm

61. Which of the following is INCORRECT in assessing client s BP? A. Read the mercury at the upper meniscus, preferably at the eye level to preven t error of parallax B. Inflate and deflate slowly, 2-3 mmHg at a time C. The sound heard during taking BP is known as KOROTKOFF sound D. If the BP is taken on the left leg using the popliteal artery pressure, a BP of 160/80 is normal. 62. Which of the following is the correct interpretation of the ERROR OF PARALLA X A. If the eye level is higher than the level of the meniscus, it will cause a fa lse high reading

B. If the eye level is higher than the level of the meniscus, it will cause a fa lse low reading C. If the eye level is lower than the level of the meniscus, it will cause a fal se low reading D. If the eye level is equal to that of the level of the upper meniscus, the rea ding is accurate 63. How many minute/s is/are allowed to pass before making a re-reading after th e first one? A. B. C. D. 1 5 15 30

64. Which of the following is TRUE about the auscultation of blood pressure? A. B. C. D. Pulse + 4 is considered as FULL The bell of the stethoscope is use in auscultating BP Sound produced by BP is considered as HIGH frequency sound Pulse +1 is considered as NORMAL

65. In assessing the abdomen, Which of the following is the correct sequence of the physical assessment? A. B. C. D. Inspection, Auscultation, Percussion, Palpation Palpation, Auscultation, Percussion, Inspection Inspection, Palpation, Auscultation, Percussion Inspection, Auscultation, Palpation, Percussion

66. The sequence in examining the quadrants of the abdomen is: A. B. C. D. RUQ,RLQ,LUQ,LLQ RLQ,RUQ,LLQ,LUQ RUQ,RLQ,LLQ,LUQ RLQ,RUQ,LUQ,LLQ

67. In inspecting the abdomen, which of the following is NOT DONE? A. B. C. D. Ask the client to void first Knees and legs are straighten to relax the abdomen The best position in assessing the abdomen is Dorsal recumbent The knees and legs are externally rotated

68. Dr. Fabian De Las Santas, is about to conduct an ophthalmoscope examination. Which of the following, if done by a nurse, is a Correct preparation before the procedure? A. B. C. D. Provide the necessary draping to ensure privacy Open the windows, curtains and light to allow better illumination Pour warm water over the ophthalmoscope to ensure comfort Darken the room to provide better illumination

69. If the client is female, and the doctor is a male and the patient is about t o undergo a vaginal and cervical examination, why is it necessary to have a fema le nurse in attendance? A. To ensure that the doctor performs the procedure safely B. To assist the doctor C. To assess the client s response to examination

D. To ensure that the procedure is done in an ethical manner 70. In palpating the client s breast, Which of the following position is necessary for the patient to assume before the start of the procedure? A. B. C. D. Supine Dorsal recumbent Sitting Lithotomy

71. When is the best time to collect urine specimen for routine urinalysis and C /S? A. B. C. D. Early morning Later afternoon Midnight Before breakfast

72. Which of the following is among an ideal way of collecting a urine specimen for culture and sensitivity? A. Use a clean container B. Discard the first flow of urine to ensure that the urine is not contaminated C. Collect around 30-50 ml of urine D. Add preservatives, refrigerate the specimen or add ice according to the agenc y s protocol 73. In a 24 hour urine specimen started Friday, 9:00 A.M, which of the following if done by a Nurse indicate a NEED for further procedural debriefing? A. The nurse urine in the B. The nurse C. The nurse collection D. The nurse ask the client to urinate at 9:00 A.M, Friday and she included the 24 hour urine specimen discards the Friday 9:00 A M urine of the client included the Saturday 9:00 A.M urine of the client to the specimen added preservatives as per protocol and refrigerates the specimen

74. This specimen is required to assess glucose levels and for the presence of a lbumin the the urine A. B. C. D. Midstream clean catch urine 24 hours urine collection Postprandial urine collection Second voided urine

75. When should the client test his blood sugar levels for greater accuracy? A. B. C. D. During meals In between meals Before meals 2 Hours after meals

76. In collecting a urine from a catheterized patient, Which of the following st atement indicates an accurate performance of the procedure? A. Clamp above the port for 30 to 60 minutes before drawing the urine from the p ort B. Clamp below the port for 30 to 60 minutes before drawing the urine from the p ort C. Clamp above the port for 5 to 10 minutes before drawing the urine from the po

rt D. Clamp below the port for 5 to 10 minutes before drawing the urine from the po rt 77. A community health nurse should be resourceful and meet the needs of the cli ent. A villager ask him, Can you test my urine for glucose? Which of the followi ng technique allows the nurse to test a client s urine for glucose without the nee d for intricate instruments. A. B. C. D. Acetic Acid test Nitrazine paper test Benedict s test Litmus paper test

78. A community health nurse is assessing client s urine using the Acetic Acid sol ution. Which of the following, if done by a nurse, indicates lack of correct kno wledge with the procedure? A. The nurse B. The nurse C. The nurse D. The nurse s cloudy added the Urine as the 2/3 part of the solution heats the test tube after adding 1/3 part acetic acid heats the test tube after adding 2/3 part of Urine determines abnormal result if she noticed that the test tube become

79. Which of the following is incorrect with regards to proper urine testing usi ng Benedict s Solution? A. Heat around 5ml of Benedict s solution together with the urine in a test tube B. Add 8 to 10 drops of urine C. Heat the Benedict s solution without the urine to check if the solution is cont aminated D. If the color remains BLUE, the result is POSITIVE 80. +++ Positive result after Benedicts test is depicted by what color? A. B. C. D. Blue Green Yellow Orange

81. Clinitest is used in testing the urine of a client for glucose. Which of the following, If committed by a nurse indicates error? A. B. C. D. Specimen is collected after meals The nurse puts 1 clinitest tablet into a test tube She added 5 drops of urine and 10 drops of water If the color becomes orange or red, It is considered postitive

82. Which of the following nursing intervention is important for a client schedu led to have a Guaiac Test? A. B. C. D. Avoid turnips, radish and horseradish 3 days before procedure Continue iron preparation to prevent further loss of Iron Do not eat read meat 12 hours before procedure Encourage caffeine and dark colored foods to produce accurate results

83. In collecting a routine specimen for fecalysis, Which of the following, if d one by a nurse, indicates inadequate knowledge and skills about the procedure? A. The nurse scoop the specimen specifically at the site with blood and mucus

B. C. us D.

She took around 1 inch of specimen or a teaspoonful Ask the client to call her for the specimen after the client wiped off his an with a tissue Ask the client to defecate in a bedpan, Secure a sterile container

84. In a routine sputum analysis, Which of the following indicates proper nursin g action before sputum collection? A. Secure a clean container B. Discard the container if the outside becomes contaminated with the sputum C. Rinse the client s mouth with Listerine after collection D. Tell the client that 4 tablespoon of sputum is needed for each specimen for a routine sputum analysis 85. Who collects Blood specimen? A. B. C. D. The nurse Medical technologist Physician Physical therapist

86. David, 68 year old male client is scheduled for Serum Lipid analysis. Which of the following health teaching is important to ensure accurate reading? A. B. C. D. Tell the patient to eat fatty meals 3 days prior to the procedure NPO for 12 hours pre procedure Ask the client to drink 1 glass of water 1 hour prior to the procedure Tell the client that the normal serum lipase level is 50 to 140 U/L

87. The primary factor responsible for body heat production is the A. B. C. D. Metabolism Release of thyroxin Muscle activity Stress

88. The heat regulating center is found in the A. B. C. D. Medulla oblongata Thalamus Hypothalamus Pons

89. A process of heat loss which involves the transfer of heat from one surface to another is A. B. C. D. Radiation Conduction Convection Evaporation

90. Which of the following is a primary factor that affects the BP? A. B. C. D. Obesity Age Stress Gender

91. The following are social data about the client except

A. B. C. D.

Patient s lifestyle Religious practices Family home situation Usual health status

92. The best position for any procedure that involves vaginal and cervical exami nation is A. B. C. D. Dorsal recumbent Side lying Supine Lithotomy

93. Measure the leg circumference of a client with bipedal edema is best done in what position? A. B. C. D. Dorsal recumbent Sitting Standing Supine

94. In palpating the client s abdomen, Which of the following is the best position for the client to assume? A. B. C. D. Dorsal recumbent Side lying Supine Lithotomy

95. Rectal examination is done with a client in what position? A. B. C. D. Dorsal recumbent Sims position Supine Lithotomy

96. Which of the following is a correct nursing action when collecting urine spe cimen from a client with an Indwelling catheter? A. B. C. D. Collect urine specimen from the drainage bag Detach catheter from the connecting tube and draw the specimen from the port Use sterile syringe to aspirate urine specimen from the drainage port Insert the syringe straight to the port to allow self sealing of the port

97. Which of the following is inappropriate in collecting mid stream clean catch urine specimen for urine analysis? A. B. C. D. Collect early in the morning, First voided specimen Do perineal care before specimen collection Collect 5 to 10 ml for urine Discard the first flow of the urine

98. When palpating the client s neck for lymphadenopathy, where should the nurse p osition himself? A. B. C. D. At At At In the client the client the client front of a s back s right side s left side sitting client

99. Which of the following is the best position for the client to assume if the back is to be examined by the nurse? A. B. C. D. Standing Sitting Side lying Prone

100. In assessing the client s chest, which position best show chest expansion as well as its movements? A. B. C. D. Sitting Prone Sidelying Supine

1. Which one of the following is NOT a function of the Upper airway? A. B. C. D. For clearance mechanism such as coughing Transport gases to the lower airways Warming, Filtration and Humidification of inspired air Protect the lower airway from foreign mater

2. It is the hair the lines the vestibule which function as a filtering mechanis m for foreign objects A. B. C. D. Cilia Nares Carina Vibrissae

3. This is the paranasal sinus found between the eyes and the nose that extends backward into the skull A. B. C. D. Ehtmoid Sphenoid Maxillary Frontal

4. Which paranasal sinus is found over the eyebrow? A. B. C. D. Ehtmoid Sphenoid Maxillary Frontal

5. Gene De Vonne Katrouchuacheulujiki wants to change her surname to something s horter, The court denied her request which depresses her and find herself binge eating. She accidentally aspirate a large piece of nut and it passes the carina. Probabilty wise, Where will the nut go? A. B. C. D. Right main stem bronchus Left main stem bronchus Be dislodged in between the carina Be blocked by the closed epiglottis

6. Which cell secretes mucus that help protect the lungs by trapping debris in t he respiratory tract? A. Type I pneumocytes

B. Type II pneumocytes C. Goblet cells D. Adipose cells 7. How many lobes are there in the RIGHT LUNG? A. B. C. D. One Two Three Four

8. The presence of the liver causes which anatomical difference of the Kidneys a nd the Lungs? A. B. C. D. Left kidney slightly lower, Left lung slightly shorter Left kidney slightly higher, Left lung slightly shorter Right kidney lower, Right lung shorter Right kidney higher, Right lung shorter

9. Surfactant is produced by what cells in the alveoli? A. B. C. D. Type I pneumocytes Type II pneumocytes Goblet cells Adipose cells

10. The normal L:S Ratio to consider the newborn baby viable is A. B. C. D. 1:2 2:1 3:1 1:3

11. Refers to the extra air that can be inhaled beyond the normal tidal volume A. B. C. D. Inspiratory reserve volume Expiratory reserve volume Functional residual capacity Residual volume

12. This is the amount of air remained in the lungs after a forceful expiration A. B. C. D. Inspiratory reserve volume Expiratory reserve volume Functional residual capacity Residual volume

13. Casssandra, A 22 year old grade Agnostic, Asked you, how many spikes of bone s are there in my ribs? Your best response is which of the following? A. B. C. D. We have 13 pairs of ribs Cassandra We have 12 pairs of ribs Cassandra Humans have 16 pairs of ribs, and that was noted by Vesalius in 1543 Humans have 8 pairs of ribs. 4 of which are floating

14. Which of the following is considered as the main muscle of respiration? A. Lungs B. Intercostal Muscles C. Diaphragm

D. Pectoralis major 15. Cassandra asked you : How many air is there in the oxygen and how many does human requires? Which of the following is the best response : A. B. C. D. God is good, Man requires 21% of oxygen and we have 21% available in our air Man requires 16% of oxygen and we have 35% available in our air Man requires 10% of oxygen and we have 50% available in our air Human requires 21% of oxygen and we have 21% available in our air

16. Which of the following is TRUE about Expiration? A. B. C. D. A passive process The length of which is half of the length of Inspiration Stridor is commonly heard during expiration Requires energy to be carried out

17. Which of the following is TRUE in postural drainage? A. B. C. D. Patient assumes position for 10 to 15 minutes Should last only for 60 minutes Done best P.C An independent nursing action

18. All but one of the following is a purpose of steam inhalation A. B. C. D. Mucolytic Warm and humidify air Administer medications Promote bronchoconstriction

19. Which of the following is NOT TRUE in steam inhalation? A. B. C. D. It is a dependent nursing action Spout is put 12-18 inches away from the nose Render steam inhalation for atleast 60 minutes Cover the client s eye with wash cloth to prevent irritation

20. When should a nurse suction a client? A. B. C. D. As desired As needed Every 1 hour Every 4 hours

21. Ernest Arnold Hamilton, a 60 year old American client was mobbed by teen gan gsters near New york, Cubao. He was rushed to John John Hopio Medical Center and was Unconscious. You are his nurse and you are to suction his secretions. In wh ich position should you place Mr. Hamilton? A. B. C. D. High fowlers Semi fowlers Prone Side lying

22. You are about to set the suction pressure to be used to Mr. Hamilton. You ar e using a Wall unit suction machine. How much pressure should you set the valve before suctioning Mr. Hamilton? A. 50-95 mmHg

B. 200-350 mmHg C. 100-120 mmHg D. 10-15 mmHg 23. The wall unit is not functioning; You then try to use the portable suction e quipment available. How much pressure of suction equipment is needed to prevent trauma to mucus membrane and air ways in case of portable suction units? A. B. C. D. 2-5 mmHg 5-10 mmHg 10-15 mmHg 15-25 mmHg

24. There are four catheter sizes available for use, which one of these should y ou use for Mr. Hamilton? A. B. C. D. Fr. Fr. Fr. Fr, 18 12 10 5

25. Which of the following, if done by the nurse, indicates incompetence during suctioning an unconscious client? A. he B. C. D. Measure the length of the suction catheter to be inserted by measuring from t tip of the nose, to the earlobe, to the xiphoid process Use KY Jelly if suctioning nasopharyngeal secretion The maximum time of suctioning should not exceed 15 seconds Allow 30 seconds interval between suctioning

26. Which of the following is the initial sign of hypoxemia in an adult client? 1. 2. 3. 4. 5. 6. A. B. C. D. Tachypnea Tachycardia Cyanosis Pallor Irritability Flaring of Nares 1,2 2,5 2,6 3,4

27. Which method of oxygenation least likely produces anxiety and apprehension? A. B. C. D. Nasal Cannula Simple Face mask Non Rebreather mask Partial Rebreather mask

28. Which of the following oxygen delivery method can deliver 100% Oxygen at 15 LPM? A. B. C. D. Nasal Cannula Simple Face mask Non Rebreather mask Partial Rebreather mask

29. Which of the following is not true about OXYGEN?

A. B. C. D.

Oxygen is odorless, tasteless and colorless gas. Oxygen can irritate mucus membrane Oxygen supports combustion Excessive oxygen administration results in respiratory acidosis

30. Roberto San Andres, A new nurse in the hospital is about to administer oxyge n on patient with Respiratory distress. As his senior nurse, you should interven e if Roberto will: A. B. C. D. Uses venture mask in oxygen administration Put a non rebreather mask in the patient before opening the oxygen source Use a partial rebreather mask to deliver oxygen Check for the doctor s order for Oxygen administration

31. Which of the following will alert the nurse as an early sign of hypoxia? A. B. C. D. Client is tired and dyspneic The client is coughing out blood The client s heart rate is 50 BPM Client is frequently turning from side to side

32. Miguelito de balboa, An OFW presents at the admission with an A:P Diameter r atio of 2:1, Which of the following associated finding should the nurse expect? A. B. C. D. Pancytopenia Anemia Fingers are Club-like Hematocrit of client is decreased

33. The best method of oxygen administration for client with COPD uses: A. B. C. D. Cannula Simple Face mask Non rebreather mask Venturi mask

34. Mang dagul, a 50 year old chronic smoker was brought to the E.R because of d ifficulty in breathing. Pleural effusion was the diagnosis and CTT was ordered. What does C.T.T Stands for? A. B. C. D. Chest tube thoracotomy Chest tube thoracostomy Closed tube thoracotomy Closed tube thoracostmy

35. Where will the CTT be inserted if we are to drain fluids accumulated in Mang dagul s pleura? A. B. C. D. 2nd 4th 5th 8th ICS ICS ICS ICS

36. There is a continuous bubbling in the water sealed drainage system with suct ion. And oscillation is observed. As a nurse, what should you do? A. Consider this as normal findings B. Notify the physician C. Check for tube leak

D. Prepare a petrolatum gauze dressing 37. Which of the following is true about nutrition? A. It is the process in which food are broken down, for the body to use in growt h and development B. It is a process in which digested proteins, fats, minerals, vitamins and carb ohydrates are transported into the circulation C. It is a chemical process that occurs in the cell that allows for energy produ ction, energy use, growth and tissue repair D. It is the study of nutrients and the process in which they are use by the bod y 38. The majority of the digestion processes take place in the A. B. C. D. Mouth Small intestine Large intestine Stomach

39. All of the following is true about digestion that occurs in the Mouth except A. It is where the digestion process starts B. Mechanical digestion is brought about by mastication C. The action of ptyalin or the salivary tyrpsin breaks down starches into malto se D. Deglutition occurs after food is broken down into small pieces and well mixed with saliva 40. Which of the following foods lowers the cardiac sphincter pressure? A. B. C. D. Roast beef, Steamed cauliflower and Rice Orange juice, Non fat milk, Dry crackers Decaffeinated coffee, Sky flakes crackers, Suman Coffee with coffee mate, Bacon and Egg

41. Where does the digestion of carbohydrates start? A. B. C. D. Mouth Esophagus Small intestine Stomach

42. Protein and Fat digestion begins where? A. B. C. D. Mouth Esophagus Small intestine Stomach

43. All but one is true about digestion that occurs in the Stomach A. Carbohydrates are the fastest to be digested, in about an hour B. Fat is the slowest to be digested, in about 5 hours C. HCl inhibits absorption of Calcium in the gastric mucosa D. HCl converts pepsinogen to pepsin, which starts the complex process of protei n digestion 44. Which of the following is NOT an enzyme secreted by the small intestine?

A. B. C. D.

Sucrase Enterokinase Amylase Enterokinase

45. The hormone secreted by the Small intestine that stimulates the production o f pancreatic juice which primarily aids in buffering the acidic bolus passed by the Stomach A. B. C. D. Enterogastrone Cholecystokinin Pancreozymin Enterokinase

46. When the duodenal enzyme sucrase acts on SUCROSE, which 2 monosaccharides ar e formed? A. B. C. D. Galactose + Galactose Glucose + Fructose Glucose + Galactose Fructose + Fructose

47. This is the enzyme secreted by the pancrease that completes the protein dige stion A. B. C. D. Trypsin Enterokinase Enterogastrone Amylase Building blocks of Protein is what

48. The end product of protein digestion or the we call A. B. C. D. Nucleotides Fatty acids Glucose Amino Acids

49. Enzyme secreted by the small intestine after it detects a bolus of fatty foo d. This will contract the gallbladder to secrete bile and relax the sphincter of Oddi to aid in the emulsification of fats and its digestion. A. B. C. D. Lipase Amylase Cholecystokinin Pancreozymin

50. Which of the following is not true about the Large Intestine? A. d B. C. D. It absorbs around 1 L of water making the feces around 75% water and 25% soli The stool formed in the transverse colon is not yet well formed It is a sterile body cavity It is called large intestine because it is longer than the small intestine

51. This is the amount of heat required to raise the temperature of 1 kg water t o 1 degree Celsius A. Calorie B. Joules

C. Metabolism D. Basal metabolic rate 52. Assuming a cup of rice provides 50 grams of carbohydrates. How many calories are there in that cup of rice? A. B. C. D. 150 200 250 400 calories calories calories calories

53. An average adult filipino requires how many calories in a day? A. B. C. D. 1,000 1,500 2,000 2,500 calories calories calories calories

54. Which of the following is true about an individual s caloric needs? A. B. C. D. All individual have the same caloric needs Females in general have higher BMR and therefore, require more calories During cold weather, people need more calories due to increase BMR Dinner should be the heaviest meal of the day

55. Among the following people, who requires the greatest caloric intake? A. B. C. D. An individual in a long state of gluconeogenesis An individual in a long state of glycogenolysis A pregnant individual An adolescent with a BMI of 25

56. Which nutrient deficiency is associated with the development of Pellagra, De rmatitis and Diarrhea? A. B. C. D. Vitamin Vitamin Vitamin Vitamin B1 B2 B3 B6

57. Which Vitamin is not given in conjunction with the intake of LEVODOPA in cas es of Parkinson s Disease due to the fact that levodopa increases its level in the body? A. B. C. D. Vitamin Vitamin Vitamin Vitamin B1 B2 B3 B6

58. A vitamin taken in conjunction with ISONIAZID to prevent peripheral neuritis A. B. C. D. Vitamin Vitamin Vitamin Vitamin B1 B2 B3 B6

59. The inflammation of the Lips, Palate and Tongue is associated in the deficie ncy of this vitamin A. Vitamin B1

B. Vitamin B2 C. Vitamin B3 D. Vitamin B6 60. Beri beri is caused by the deficiency of which Vitamin? A. B. C. D. Vitamin Vitamin Vitamin Vitamin B1 B2 B3 C

61. Which of the following is the best source of Vitamin E? A. B. C. D. Green leafy vegetables Vegetable oil Fortified Milk Fish liver oil

62. Among the following foods, which food should you emphasize giving on an Alco holic client? A. B. C. D. Pork liver and organ meats, Pork Red meat, Eggs and Dairy products Green leafy vegetables, Yellow vegetables, Cantaloupe and Dairy products Chicken, Peanuts, Bananas, Wheat germs and yeasts

63. Which food group should you emphasize giving on a pregnant mother in first t rimester to prevent neural tube defects? A. B. C. D. Broccoli, Guava, Citrus fruits, Tomatoes Butter, Sardines, Tuna, Salmon, Egg yolk Wheat germ, Vegetable Oil, soybeans, corn, peanuts Organ meats, Green leafy vegetables, Liver, Eggs

64. A client taking Coumadin is to be educated on his diet. As a nurse, which of the following food should you instruct the client to avoid? A. B. C. D. Spinach, Green leafy vegetables, Cabbage, Liver Salmon, Sardines, Tuna Butter, Egg yolk, breakfast cereals Banana, Yeast, Wheat germ, Chicken

65. Vitamin E plus this mineral works as one of the best anti oxidant in the bod y according to the latest research. They are combined with 5 Alpha reductase inh ibitor to reduce the risk of acquiring prostate cancer A. B. C. D. Zinc Iron Selenium Vanadium

66. Incident of prostate cancer is found to have been reduced on a population ex posed in tolerable amount of sunlight. Which vitamin is associated with this phe nomenon? A. B. C. D. Vitamin Vitamin Vitamin Vitamin A B C D

67. Micronutrients are those nutrients needed by the body in a very minute amoun t. Which of the following vitamin is considered as a MICRONUTRIENT A. B. C. D. Phosphorous Iron Calcium Sodium

68. Deficiency of this mineral results in tetany, osteomalacia, osteoporosis and rickets. A. B. C. D. Vitamin D Iron Calcium Sodium

69. Among the following foods, which has the highest amount of potassium per are a of their meat? A. B. C. D. Cantaloupe Avocado Raisin Banana

70. A client has HEMOSIDEROSIS. Which of the following drug would you expect to be given to the client? A. B. C. D. Acetazolamide Deferoxamine Calcium EDTA Activated charcoal

71. Which of the following provides the richest source of Iron per area of their meat? A. B. C. D. Pork meat Lean read meat Pork liver Green mongo

72. Which of the following is considered the best indicator of nutritional statu s of an individual? A. B. C. D. Height Weight Arm muscle circumference BMI

73. Jose Miguel, a 50 year old business man is 6 0 Tall and weights 179 lbs. As a nurse, you know that Jose Miguel is : A. B. C. D. Overweight Underweight Normal Obese

74. Jose Miguel is a little bit nauseous. Among the following beverages, Which c ould help relieve JM s nausea? A. Coke

B. Sprite C. Mirinda D. Orange Juice or Lemon Juice 75. Which of the following is the first sign of dehydration? A. B. C. D. Tachycardia Restlessness Thirst Poor skin turgor

76. What Specific gravity lab result is compatible with a dehydrated client? A. B. C. D. 1.007 1.020 1.039 1.029

77. Which hematocrit value is expected in a dehydrated male client? A. B. C. D. 67% 50% 36% 45%

78. Which of the following statement by a client with prolonged vomiting indicat es the initial onset of hypokalemia? A. B. C. D. My arm feels so weak I felt my heart beat just right now My face muscle is twitching Nurse, help! My legs are cramping

79. Which of the following is not an anti-emetic? A. B. C. D. Marinol Dramamine Benadryl Alevaire

80. Which is not a clear liquid diet? A. B. C. D. Hard candy Gelatin Coffee with Coffee mate Bouillon

81. Which of the following is included in a full liquid diet? A. B. C. D. Popsicles Pureed vegetable meat Pineapple juice with pulps Mashed potato

82. Which food is included in a BLAND DIET? A. B. C. D. Steamed broccoli Creamed potato Spinach in garlic Sweet potato

83. Which of the following if done by the nurse, is correct during NGT Insertion ? A. Use an oil based lubricant B. Measure the amount of the tube to be inserted from the Tip of the nose, to th e earlobe, to the xiphoid process C. Soak the NGT in a basin of ice water to facilitate easy insertion D. Check the placement of the tube by introducing 10 cc of sterile water and aus cultating for bubbling sound 84. Which of the following is the BEST method in assessing for the correct place ment of the NGT? A. X-Ray B. Immerse tip of the tube in water to check for bubbles produced C. Aspirating gastric content to check if the content is acidic D. Instilling air in the NGT and listening for a gurgling sound at the epigastri c area 85. A terminally ill cancer patient is scheduled for an NGT feeding today. How s hould you position the patient? A. B. C. D. Semi fowlers in bed Bring the client into a chair Slightly elevated right side lying position Supine in bed

86. A client is scheduled for NGT Feeding. Checking the residual volume, you det ermined that he has 40 cc residual from the last feeding. You reinstill the 40 c c of residual volume and added the 250 cc of feeding ordered by the doctor. You then instill 60 cc of water to clear the lumen and the tube. How much will you p ut in the client s chart as input? A. B. C. D. 250 290 350 310 cc cc cc cc

87. Which of the following if done by a nurse indicates deviation from the stand ards of NGT feeding? A. Do not give the feeding and notify the doctor of residual of the last feeding is greater than or equal to 50 ml B. Height of the feeding should be 12 inches about the tube point of insertion t o allow slow introduction of feeding C. Ask the client to position in supine position immediately after feeding to pr event dumping syndrome D. Clamp the NGT before all of the water is instilled to prevent air entry in th e stomach 88. What is the most common problem in TUBE FEEDING? A. B. C. D. Diarrhea Infection Hyperglycemia Vomiting

89. Which of the following is TRUE in colostomy feeding?

A. B. C. D.

Hold the syringe 18 inches above the stoma and administer the feeding slowly Pour 30 ml of water before and after feeding administration Insert the ostomy feeding tube 1 inch towards the stoma A Pink stoma means that circulation towards the stoma is all well

90. A client with TPN suddenly develops tremors, dizziness, weakness and diaphor esis. The client said I feel weak You saw that his TPN is already empty and anothe r TPN is scheduled to replace the previous one but its provision is already 3 ho urs late. Which of the following is the probable complication being experienced by the client? A. B. C. D. Hyperglycemia Hypoglycemia Infection Fluid overload

91. To assess the adequacy of food intake, which of the following assessment par ameters is best used? A. B. C. D. Food likes and dislikes Regularity of meal times 3 day diet recall Eating style and habits

92. The vomiting center is found in the A. B. C. D. Medulla Oblongata Pons Hypothalamus Cerebellum

93. The most threatening complication of vomiting in client s with stroke is A. B. C. D. Aspiration Dehydration Fluid and electrolyte imbalance Malnutrition

94. Which among this food is the richest source of Iron? A. B. C. D. Ampalaya Broccoli Mongo Malunggay leaves

95. Which of the following is a good source of Vitamin A? A. B. C. D. Egg yolk Liver Fish Peanuts

96. The most important nursing action before gastrostomy feeding is A. B. C. D. Check V/S Assess for patency of the tube Measure residual feeding Check the placement of the tube

97. The primary advantage of gastrostomy feeding is

A. B. C. D.

Ensures adequate nutrition It prevents aspiration Maintains Gastro esophageal sphincter integrity Minimizes fluid-electrolyte imbalance

98. What is the BMI Of Budek, weighing 120 lbs and has a height of 5 feet 7 inch es. A. B. C. D. 20 19 15 25

99. Which finding is consistent with PERNICIOUS ANEMIA? A. B. C. D. Strawberry tongue Currant Jelly stool Beefy red tongue Pale [ HYPOCHROMIC ] RBC

100. The nurse is browsing the chart of the patient and notes a normal serum lip ase level. Which of the following is a normal serum lipase value? A. B. C. D. 10 U/L 100 U/L 200 U/L 350 U/L

A,D,A,D,A,C,C,B,B,A,D,B,C,DAADCBDCCAABACDBDCACDADBCDADCCCBADCCABCCACDDBABADACDBC ABCBCACCADDCABBABDCABBCAACBBCBCC 1. When assessing the adequacy of sperm for conception to occur, which of the fo llowing is the most useful criterion? A. B. C. D. Sperm Sperm Sperm Semen count motility maturity volume

2. A couple who wants to conceive but has been unsuccessful during the last 2 ye ars has undergone many diagnostic procedures. When discussing the situation with the nurse, one partner states, We know several friends in our age group and all of them have their own child already, Why can t we have one? . Which of the followin g would be the most pertinent nursing diagnosis for this couple? A. B. C. D. Fear related to the unknown Pain related to numerous procedures. Ineffective family coping related to infertility. Self-esteem disturbance related to infertility.

3. Which of the following urinary symptoms does the pregnant woman most frequent ly experience during the first trimester? A. B. C. D. Dysuria Frequency Incontinence Burning

4. Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following? A. B. C. D. Increased plasma HCG levels Decreased intestinal motility Decreased gastric acidity Elevated estrogen levels

5. On which of the following areas would the nurse expect to observe chloasma? A. B. C. D. Breast, areola, and nipples Chest, neck, arms, and legs Abdomen, breast, and thighs Cheeks, forehead, and nose

6. A pregnant client states that she waddles when she walks. The nurse s explanation is based on which of the following as the cause? A. B. C. D. The large size of the newborn Pressure on the pelvic muscles Relaxation of the pelvic joints Excessive weight gain

7. Which of the following represents the average amount of weight gained during pregnancy? A. 12 to 22 lb B 15 to 25 lb C. 24 to 30 lb D. 25 to 40 lb 8. When talking with a pregnant client who is experiencing aching swollen, leg v eins, the nurse would explain that this is most probably the result of which of the following? A. B. C. D. Thrombophlebitis Pregnancy-induced hypertension Pressure on blood vessels from the enlarging uterus The force of gravity pulling down on the uterus

9. Cervical softening and uterine souffle are classified as which of the followi ng? A. B. C. D. Diagnostic signs Presumptive signs Probable signs Positive signs

10. Which of the following would the nurse identify as a presumptive sign of pre gnancy? A. B. C. D. Hegar sign Nausea and vomiting Skin pigmentation changes Positive serum pregnancy test

11. Which of the following common emotional reactions to pregnancy would the nur se expect to occur during the first trimester?

A. B. C. D.

Introversion, egocentrism, narcissism Awkwardness, clumsiness, and unattractiveness Anxiety, passivity, extroversion Ambivalence, fear, fantasies

12. During which of the following would the focus of classes be mainly on physio logic changes, fetal development, sexuality, during pregnancy, and nutrition? A. B. C. D. Prepregnant period First trimester Second trimester Third trimester

13. Which of the following would be disadvantage of breast feeding? A. B. C. D. Involution occurs more rapidly The incidence of allergies increases due to maternal antibodies The father may resent the infant s demands on the mother s body There is a greater chance for error during preparation

14. Which of the following would cause a false-positive result on a pregnancy te st? A. B. C. D. The test was performed less than 10 days after an abortion The test was performed too early or too late in the pregnancy The urine sample was stored too long at room temperature A spontaneous abortion or a missed abortion is impending

15. FHR can be auscultated with a fetoscope as early as which of the following? A. B. C. D. 5 weeks gestation 10 weeks gestation 15 weeks gestation 20 weeks gestation

16. A client LMP began July 5. Her EDD should be which of the following? A. B. C. D. January 2 March 28 April 12 October 12

17. Which of the following fundal heights indicates less than 12 weeks gestation when the date of the LMP is unknown? A. B. C. D. Uterus Uterus Uterus Uterus in at in at the the the the pelvis xiphoid abdomen umbilicus

18. Which of the following danger signs should be reported promptly during the a ntepartum period? A. B. C. D. Constipation Breast tenderness Nasal stuffiness Leaking amniotic fluid

19. Which of the following prenatal laboratory test values would the nurse consi der as significant?

A. B. C. D.

Hematocrit 33.5% Rubella titer less than 1:8 White blood cells 8,000/mm3 One hour glucose challenge test 110 g/dL

20. Which of the following characteristics of contractions would the nurse expec t to find in a client experiencing true labor? A. B. C. D. Occurring at irregular intervals Starting mainly in the abdomen Gradually increasing intervals Increasing intensity with walking crowning ?

21. During which of the following stages of labor would the nurse assess A. B. C. D. First stage Second stage Third stage Fourth stage

22. Barbiturates are usually not given for pain relief during active labor for w hich of the following reasons? A. The neonatal effects include hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first few days. B. These drugs readily cross the placental barrier, causing depressive effects i n the newborn 2 to 3 hours after intramuscular injection. C. They rapidly transfer across the placenta, and lack of an antagonist make the m generally inappropriate during labor. D. Adverse reactions may include maternal hypotension, allergic or toxic reactio n or partial or total respiratory failure 23. Which of the following nursing interventions would the nurse perform during the third stage of labor? A. B. C. D. Obtain a urine specimen and other laboratory tests. Assess uterine contractions every 30 minutes. Coach for effective client pushing Promote parent-newborn interaction.

24. Which of the following actions demonstrates the nurse s understanding about th e newborn s thermoregulatory ability? A. B. C. D. Placing the newborn under a radiant warmer. Suctioning with a bulb syringe Obtaining an Apgar score Inspecting the newborn s umbilical cord

25. Immediately before expulsion, which of the following cardinal movements occu r? A. B. C. D. Descent Flexion Extension External rotation

26. Before birth, which of the following structures connects the right and left auricles of the heart?

A. B. C. D.

Umbilical vein Foramen ovale Ductus arteriosus Ductus venosus

27. Which of the following when present in the urine may cause a reddish stain o n the diaper of a newborn? A. B. C. D. Mucus Uric acid crystals Bilirubin Excess iron

28. When assessing the newborn s heart rate, which of the following ranges would b e considered normal if the newborn were sleeping? A. B. C. D. 80 beats per minute 100 beats per minute 120 beats per minute 140 beats per minute

29. Which of the following is true regarding the fontanels of the newborn? A. B. C. D. The The The The anterior is triangular shaped; the posterior is diamond shaped. posterior closes at 18 months; the anterior closes at 8 to 12 weeks. anterior is large in size when compared to the posterior fontanel. anterior is bulging; the posterior appears sunken.

30. Which of the following groups of newborn reflexes below are present at birth and remain unchanged through adulthood? A. B. C. D. Blink, cough, rooting, and gag Blink, cough, sneeze, gag Rooting, sneeze, swallowing, and cough Stepping, blink, cough, and sneeze

31. Which of the following describes the Babinski reflex? A. The newborn s toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward from the ball of the heel and across the ball of the foot. B. The newborn abducts and flexes all extremities and may begin to cry when expo sed to sudden movement or loud noise. C. The newborn turns the head in the direction of stimulus, opens the mouth, and begins to suck when cheek, lip, or corner of mouth is touched. D. The newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface 32. Which of the following statements best describes hyperemesis gravidarum? A. Severe anemia leading to electrolyte, metabolic, and nutritional imbalances i n the absence of other medical problems. B. Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems. C. Loss of appetite and continuous vomiting that commonly results in dehydration and ultimately decreasing maternal nutrients D. Severe nausea and diarrhea that can cause gastrointestinal irritation and pos sibly internal bleeding 33. Which of the following would the nurse identify as a classic sign of PIH?

A. B. C. D.

Edema of the feet and ankles Edema of the hands and face Weight gain of 1 lb/week Early morning headache

34. In which of the following types of spontaneous abortions would the nurse ass ess dark brown vaginal discharge and a negative pregnancy tests? A. B. C. D. Threatened Imminent Missed Incomplete

35. Which of the following factors would the nurse suspect as predisposing a cli ent to placenta previa? A. B. C. D. Multiple gestation Uterine anomalies Abdominal trauma Renal or vascular disease

36. Which of the following would the nurse assess in a client experiencing abrup tio placenta? A. B. C. D. Bright red, painless vaginal bleeding Concealed or external dark red bleeding Palpable fetal outline Soft and nontender abdomen

37. Which of the following is described as premature separation of a normally im planted placenta during the second half of pregnancy, usually with severe hemorr hage? A. B. C. D. Placenta previa Ectopic pregnancy Incompetent cervix Abruptio placentae

38. Which of the following may happen if the uterus becomes overstimulated by ox ytocin during the induction of labor? A. B. C. D. Weak contraction prolonged to more than 70 seconds Tetanic contractions prolonged to more than 90 seconds Increased pain with bright red vaginal bleeding Increased restlessness and anxiety

39. When preparing a client for cesarean delivery, which of the following key co ncepts should be considered when implementing nursing care? A. Instruct the mother s support person to remain in the family lounge until after the delivery B. Arrange for a staff member of the anesthesia department to explain what to ex pect postoperatively C. Modify preoperative teaching to meet the needs of either a planned or emergen cy cesarean birth D. Explain the surgery, expected outcome, and kind of anesthetics 40. Which of the following best describes preterm labor?

A. B. C. D.

Labor Labor Labor Labor

that that that that

begins begins begins begins

after after after after

20 15 24 28

weeks weeks weeks weeks

gestation gestation gestation gestation

and and and and

before before before before

37 37 28 40

weeks weeks weeks weeks

gestation gestation gestation gestation

41. When PROM occurs, which of the following provides evidence of the nurse s unde rstanding of the client s immediate needs? A. B. C. D. The chorion and amnion rupture 4 hours before the onset of labor. PROM removes the fetus most effective defense against infection Nursing care is based on fetal viability and gestational age. PROM is associated with malpresentation and possibly incompetent cervix

42. Which of the following factors is the underlying cause of dystocia? A. B. C. D. Nurtional Mechanical Environmental Medical

43. When uterine rupture occurs, which of the following would be the priority? A. B. C. D. Limiting hypovolemic shock Obtaining blood specimens Instituting complete bed rest Inserting a urinary catheter

44. Which of the following is the nurse s initial action when umbilical cord prola pse occurs? A. B. C. D. Begin monitoring maternal vital signs and FHR Place the client in a knee-chest position in bed Notify the physician and prepare the client for delivery Apply a sterile warm saline dressing to the exposed cord

45. Which of the following amounts of blood loss following birth marks the crite rion for describing postpartum hemorrhage? A. B. C. D. More More More More than than than than 200 300 400 500 ml ml ml ml

46. Which of the following is the primary predisposing factor related to mastiti s? A. Epidemic infection from nosocomial sources localizing in the lactiferous glan ds and ducts B. Endemic infection occurring randomly and localizing in the periglandular conn ective tissue C. Temporary urinary retention due to decreased perception of the urge to avoid D. Breast injury caused by overdistention, stasis, and cracking of the nipples 47. Which of the following best describes thrombophlebitis? A. Inflammation and clot formation that result when blood components combine to form an aggregate body B. Inflammation and blood clots that eventually become lodged within the pulmona ry blood vessels C. Inflammation and blood clots that eventually become lodged within the femoral

vein D. Inflammation of the vascular endothelium with clot formation on the vessel wa ll 48. Which of the following assessment findings would the nurse expect if the cli ent develops DVT? A. B. C. D. Midcalf pain, tenderness and redness along the vein Chills, fever, malaise, occurring 2 weeks after delivery Muscle pain the presence of Homans sign, and swelling in the affected limb Chills, fever, stiffness, and pain occurring 10 to 14 days after delivery

49. Which of the following are the most commonly assessed findings in cystitis? A. B. C. D. Frequency, urgency, dehydration, nausea, chills, and flank pain Nocturia, frequency, urgency dysuria, hematuria, fever and suprapubic pain Dehydration, hypertension, dysuria, suprapubic pain, chills, and fever High fever, chills, flank pain nausea, vomiting, dysuria, and frequency

50. Which of the following best reflects the frequency of reported postpartum blu es ? A. B. C. D. Between Between Between Between 10% 30% 50% 25% and and and and 40% 50% 80% 70% of of of of all all all all new new new new mothers mothers mothers mothers report report report report some some some some form form form form of of of of postpartum postpartum postpartum postpartum blues blues blues blues

Here are the answers & rationales for Maternal & Child Health Nursing Exam 1 (50 Items) B. Although all of the factors listed are important, sperm motility is the most significant criterion when assessing male infertility. Sperm count, sperm maturi ty, and semen volume are all significant, but they are not as significant sperm motility. D. Based on the partner s statement, the couple is verbalizing feelings of inadequ acy and negative feelings about themselves and their capabilities. Thus, the nur sing diagnosis of self-esteem disturbance is most appropriate. Fear, pain, and i neffective family coping also may be present but as secondary nursing diagnoses. B. Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency. Dysuria, incontinence, andburning are symptoms associated with urinary tract infections. C. During the second trimester, the reduction in gastric acidity in conjunction with pressure from the growing uterus and smooth muscle relaxation, can cause he artburn and flatulence. HCG levels increase in the first, not the second, trimes ter. Decrease intestinal motility would most likely be the cause of constipation and bloating. Estrogen levels decrease in the second trimester. D. Chloasma, also called the mask of pregnancy, is an irregular hyperpigmented a rea found on the face. It is not seen on the breasts, areola, nipples, chest, ne ck, arms, legs, abdomen, or thighs. C. During pregnancy, hormonal changes cause relaxation of the pelvic joints, res ulting in the typical waddling gait. Changes in posture are related to the growing fetus. Pressure on the surrounding muscles causing discomfort is due to the gro wing uterus. Weight gain has no effect on gait. C. The average amount of weight gained during pregnancy is 24 to 30 lb. This wei ght gain consists of the following: fetus 7.5 lb; placenta and membrane 1.5 lb; amniotic fluid 2 lb; uterus 2.5 lb; breasts 3 lb; and increased blood volume 2 t o 4 lb; extravascular fluid and fat 4 to 9 lb. A gain of 12 to 22 lb is insuffic ient, whereas a weight gain of 15 to 25 lb is marginal. A weight gain of 25 to 4 0 lb is considered excessive. C. Pressure of the growing uterus on blood vessels results in an increased risk

for venous stasis in the lower extremities. Subsequently, edema and varicose vei n formation may occur. Thrombophlebitis is an inflammation of the veins due to t hrombus formation. Pregnancy-induced hypertension is not associated with these s ymptoms. Gravity plays only a minor role with these symptoms. C. Cervical softening (Goodell sign) and uterine souffl are two probable signs of pregnancy. Probable signs are objective findings that strongly suggest pregnanc y. Other probable signs include Hegar sign, which is softening of the lower uter ine segment; Piskacek sign, which is enlargement and softening of the uterus; se rum laboratory tests; changes in skin pigmentation; and ultrasonic evidence of a gestational sac. Presumptive signs are subjective signs and include amenorrhea; nausea and vomiting; urinary frequency; breast tenderness and changes; excessiv e fatigue; uterine enlargement; and quickening. B. Presumptive signs of pregnancy are subjective signs. Of the signs listed, onl y nausea and vomiting are presumptive signs. Hegar sign,skin pigmentation change s, and a positive serum pregnancy test are considered probably signs, which are strongly suggestive of pregnancy. D. During the first trimester, common emotional reactions include ambivalence, f ear, fantasies, or anxiety. The second trimester is a period of well-being accom panied by the increased need to learn about fetal growth and development. Common emotional reactions during this trimester include narcissism, passivity, or int roversion. At times the woman may seem egocentric and self-centered. During the third trimester, the woman typically feels awkward, clumsy, and unattractive, of ten becoming more introverted or reflective of her own childhood. B. First-trimester classes commonly focus on such issues as early physiologic ch anges, fetal development, sexuality during pregnancy, and nutrition. Some early classes may include pregnant couples. Second and third trimester classes may foc us on preparation for birth, parenting, and newborn care. C. With breast feeding, the father s body is not capable of providing the milk for the newborn, which may interfere with feeding the newborn, providing fewer chan ces for bonding, or he may be jealous of the infant s demands on his wife s time and body. Breast feeding is advantageous because uterine involution occurs more rap idly, thus minimizing blood loss. The presence of maternal antibodies in breast milk helps decrease the incidence of allergies in the newborn. A greater chance for error is associated with bottle feeding. No preparation is required for brea st feeding. A. A false-positive reaction can occur if the pregnancy test is performed less t han 10 days after an abortion. Performing the tests too early or too late in the pregnancy, storing the urine sample too long at room temperature, or having a s pontaneous or missed abortion impending can all produce false-negative results. D. The FHR can be auscultated with a fetoscope at about 20 week s gestation. FHR u sually is ausculatated at the midline suprapubic region with Doppler ultrasound transducer at 10 to 12 week s gestation. FHR, cannot be heard any earlier than 10 weeks gestation. C. To determine the EDD when the date of the client s LMP is known use Nagele rule . To the first day of the LMP, add 7 days, subtract 3 months, and add 1 year (if applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (Apr il). Therefore, the client s EDD is April 12. A. When the LMP is unknown, the gestational age of the fetus is estimated by ute rine size or position (fundal height). The presence of the uterus in the pelvis indicates less than 12 weeks gestation. At approximately 12 to 14 weeks, the fund us is out of the pelvis above the symphysis pubis. The fundus is at the level of the umbilicus at approximately 20 weeks gestation and reaches the xiphoid at ter m or 40 weeks. D. Danger signs that require prompt reporting leaking of amniotic fluid, vaginal bleeding, blurred vision, rapid weight gain, and elevated blood pressure. Const ipation, breast tenderness, and nasal stuffiness are common discomforts associat ed with pregnancy. B. A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less th an 1:8 is significant, indicating that the client may not possess immunity to ru bella. A hematocrit of 33.5% a white blood cell count of 8,000/mm3, and a 1 hour

glucose challenge test of 110 g/dl are with normal parameters. D. With true labor, contractions increase in intensity with walking. In addition , true labor contractions occur at regular intervals, usually starting in the ba ck and sweeping around to the abdomen. The interval of true labor contractions g radually shortens. B. Crowing, which occurs when the newborn s head or presenting part appears at the vaginal opening, occurs during the second stage of labor. During the first stag e of labor, cervical dilation and effacement occur. During the third stage of la bor, the newborn and placenta are delivered. The fourth stage of labor lasts fro m 1 to 4 hours after birth, during which time the mother and newborn recover fro m the physical process of birth and the mother s organs undergo the initial readju stment to the nonpregnant state. C. Barbiturates are rapidly transferred across the placental barrier, and lack o f an antagonist makes them generally inappropriate during active labor. Neonatal side effects of barbiturates include central nervous system depression, prolong ed drowsiness, delayed establishment of feeding (e.g. due to poor sucking reflex or poor sucking pressure). Tranquilizers are associated with neonatal effects s uch as hypotonia, hypothermia, generalized drowsiness, and reluctance to feed fo r the first few days. Narcotic analgesic readily cross the placental barrier, ca using depressive effects in the newborn 2 to 3 hours after intramuscular injecti on. Regional anesthesia is associated with adverse reactions such as maternal hy potension, allergic or toxic reaction, or partial or total respiratory failure. D. During the third stage of labor, which begins with the delivery of the newbor n, the nurse would promote parent-newborn interaction by placing the newborn on the mother s abdomen and encouraging the parents to touch the newborn. Collecting a urine specimen and other laboratory tests is done on admission during the firs t stage of labor. Assessing uterine contractions every 30 minutes is performed d uring the latent phase of the first stage of labor. Coaching the client to push effectively is appropriate during the second stage of labor. A. The newborn s ability to regulate body temperature is poor. Therefore, placing the newborn under a radiant warmer aids in maintaining his or her body temperatu re. Suctioning with a bulb syringe helps maintain a patent airway. Obtaining an Apgar score measures the newborn s immediate adjustment to extrauterine life. Insp ecting the umbilical cord aids in detecting cord anomalies. D. Immediately before expulsion or birth of the rest of the body, the cardinal m ovement of external rotation occurs. Descent flexion, internal rotation, extensi on, and restitution (in this order) occur before external rotation. B. The foramen ovale is an opening between the right and left auricles (atria) t hat should close shortly after birth so the newborn will not have a murmur or mi xed blood traveling through the vascular system. The umbilical vein, ductus arte riosus, and ductus venosus are obliterated at birth. B. Uric acid crystals in the urine may produce the reddish brick dust stain on the diaper. Mucus would not produce a stain. Bilirubin and iron are from hepatic ad aptation. B. The normal heart rate for a newborn that is sleeping is approximately 100 bea ts per minute. If the newborn was awake, the normal heart rate would range from 120 to 160 beats per minute. C. The anterior fontanel is larger in size than the posterior fontanel. Addition ally, the anterior fontanel, which is diamond shaped, closes at 18 months, where as the posterior fontanel, which is triangular shaped, closes at 8 to 12 weeks. Neither fontanel should appear bulging, which may indicate increased intracrani al pressure, or sunken, which may indicate dehydration. B. Blink, cough, sneeze, swallowing and gag reflexes are all present at birth an d remain unchanged through adulthood. Reflexes such as rooting and stepping subs ide within the first year. A. With the babinski reflex, the newborn s toes hyperextend and fan apart from dor siflexion of the big toe when one side of foot is stroked upward form the heel a nd across the ball of the foot. With the startle reflex, the newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement of loud noise. With the rooting and sucking reflex, the newborn turns his head in t

he direction of stimulus, opens the mouth, and begins to suck when the cheeks, l ip, or corner of mouth is touched. With the crawl reflex, the newborn will attem pt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface. B. The description of hyperemesis gravidarum includes severe nausea and vomiting , leading to electrolyte, metabolic, and nutritional imbalances in the absence o f other medical problems. Hyperemesis is not a form of anemia. Loss of appetite may occur secondary to the nausea and vomiting of hyperemesis, which, if it cont inues, can deplete the nutrients transported to the fetus. Diarrhea does not occ ur with hyperemesis. B. Edema of the hands and face is a classic sign of PIH. Many healthy pregnant w oman experience foot and ankle edema. A weight gain of 2 lb or more per week ind icates a problem. Early morning headache is not a classic sign of PIH. C. In a missed abortion, there is early fetal intrauterine death, and products o f conception are not expelled. The cervix remains closed; there may be a dark br own vaginal discharge, negative pregnancy test, and cessation of uterine growth and breast tenderness. A threatened abortion is evidenced with cramping and vagi nal bleeding in early pregnancy, with no cervical dilation. An incomplete aborti on presents with bleeding, cramping, and cervical dilation. An incomplete aborti on involves only expulsion of part of the products of conception and bleeding oc curs with cervical dilation. A. Multiple gestation is one of the predisposing factors that may cause placenta previa. Uterine anomalies abdominal trauma, and renal or vascular disease may p redispose a client to abruptio placentae. B. A client with abruptio placentae may exhibit concealed or dark red bleeding, possibly reporting sudden intense localized uterine pain. The uterus is typicall y firm to boardlike, and the fetal presenting part may be engaged. Bright red, p ainless vaginal bleeding, a palpable fetal outline and a soft nontender abdomen are manifestations of placenta previa. D. Abruptio placentae is described as premature separation of a normally implant ed placenta during the second half of pregnancy, usually with severe hemorrhage. Placenta previa refers to implantation of the placenta in the lower uterine seg ment, causing painless bleeding in the third trimester of pregnancy. Ectopic pre gnancy refers to the implantation of the products of conception in a site other than the endometrium. Incompetent cervix is a conduction characterized by painfu l dilation of the cervical os without uterine contractions. B. Hyperstimulation of the uterus such as with oxytocin during the induction of labor may result in tetanic contractions prolonged to more than 90seconds, which could lead to such complications as fetal distress, abruptio placentae, amnioti c fluid embolism, laceration of the cervix, and uterine rupture. Weak contractio ns would not occur. Pain, bright red vaginal bleeding, and increased restlessnes s and anxiety are not associated with hyperstimulation. C. A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching to meet the needs of either a planned or eme rgency cesarean birth, the depth and breadth of instruction will depend on circu mstances and time available. Allowing the mother s support person to remain with h er as much as possible is an important concept, although doing so depends on man y variables. Arranging for necessary explanations by various staff members to be involved with the client s care is a nursing responsibility. The nurse is respons ible for reinforcing the explanations about the surgery, expected outcome, and t ype of anesthetic to be used. The obstetrician is responsible for explaining abo ut the surgery and outcome and the anesthesiology staff is responsible for expla nations about the type of anesthesia to be used. A. Preterm labor is best described as labor that begins after 20 weeks gestation and before 37 weeks gestation. The other time periods are inaccurate. B. PROM can precipitate many potential and actual problems; one of the most seri ous is the fetus loss of an effective defense against infection. This is the cli ent s most immediate need at this time. Typically, PROM occurs about 1 hour, not 4 hours, before labor begins. Fetal viability and gestational age are less immedi ate considerations that affect the plan of care. Malpresentation and an incompet

ent cervix may be causes of PROM. B. Dystocia is difficult, painful, prolonged labor due to mechanical factors inv olving the fetus (passenger), uterus (powers), pelvis (passage), or psyche. Nutr itional, environment, and medical factors may contribute to the mechanical facto rs that cause dystocia. A. With uterine rupture, the client is at risk for hypovolemic shock. Therefore, the priority is to prevent and limit hypovolemic shock. Immediate steps should include giving oxygen, replacing lost fluids, providing drug therapy as needed, evaluating fetal responses and preparing for surgery. Obtaining blood specimens, instituting complete bed rest, and inserting a urinary catheter are necessary i n preparation for surgery to remedy the rupture. B. The immediate priority is to minimize pressure on the cord. Thus the nurse s in itial action involves placing the client on bed rest and then placing the client in a knee-chest position or lowering the head of the bed, and elevating the mat ernal hips on a pillow to minimize the pressure on the cord. Monitoring maternal vital signs and FHR, notifying the physician and preparing the client for deliv ery, and wrapping the cord with sterile saline soaked warm gauze are important. But these actions have no effect on minimizing the pressure on the cord. D. Postpartum hemorrhage is defined as blood loss of more than 500 ml following birth. Any amount less than this not considered postpartum hemorrhage. D. With mastitis, injury to the breast, such as overdistention, stasis, and crac king of the nipples, is the primary predisposing factor. Epidemic and endemic in fections are probable sources of infection for mastitis. Temporary urinary reten tion due to decreased perception of the urge to void is a contributory factor to the development of urinary tract infection, not mastitis. D. Thrombophlebitis refers to an inflammation of the vascular endothelium with c lot formation on the wall of the vessel. Blood components combining to form an a ggregate body describe a thrombus or thrombosis. Clots lodging in the pulmonary vasculature refers to pulmonary embolism; in the femoral vein, femoral thromboph lebitis. C. Classic symptoms of DVT include muscle pain, the presence of Homans sign, and swelling of the affected limb. Midcalf pain, tenderness, and redness, along the vein reflect superficial thrombophlebitis. Chills, fever and malaise occurring 2 weeks after delivery reflect pelvic thrombophlebitis. Chills, fever, stiffnes s and pain occurring 10 to 14 days after delivery suggest femoral thrombophlebit is. B. Manifestations of cystitis include, frequency, urgency, dysuria, hematuria no cturia, fever, and suprapubic pain. Dehydration, hypertension, and chills are no t typically associated with cystitis. High fever chills, flank pain, nausea, vom iting, dysuria, and frequency are associated with pvelonephritis. C. According to statistical reports, between 50% and 80% of all new mothers repo rt some form of postpartum blues. The ranges of 10% to 40%, 30% to 50%, and 25% to 70% are incorrect. 1. For the client who is using oral contraceptives, the nurse informs the client about the need to take the pill at the same time each day to accomplish which o f the following? A. B. C. D. Decrease the incidence of nausea Maintain hormonal levels Reduce side effects Prevent drug interactions

2. When teaching a client about contraception. Which of the following would the nurse include as the most effective method for preventing sexually transmitted i nfections? A. Spermicides B. Diaphragm C. Condoms

D. Vasectomy 3. When preparing a woman who is 2 days postpartum for discharge, recommendation s for which of the following contraceptive methods would be avoided? A. B. C. D. Diaphragm Female condom Oral contraceptives Rhythm method

4. For which of the following clients would the nurse expect that an intrauterin e device would not be recommended? A. B. C. D. Woman over age 35 Nulliparous woman Promiscuous young adult Postpartum client I m constipated all the time! Wh

5. A client in her third trimester tells the nurse, ich of the following should the nurse recommend? A. B. C. D. Daily enemas Laxatives Increased fiber intake Decreased fluid intake

6. Which of the following would the nurse use as the basis for the teaching plan when caring for a pregnant teenager concerned about gaining too much weight dur ing pregnancy? A. B. C. D. 10 pounds per trimester 1 pound per week for 40 weeks pound per week for 40 weeks 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 rule, the nurse determines her EDD to b e which of the following? A. B. C. D. September 27 October 21 November 7 December 27

8. When taking an obstetrical history on a pregnant client who states, I had a so n born at 38 weeks gestation, a daughter born at 30 weeks gestation and I lost a baby at about 8 weeks, the nurse should record her obstetrical history as which o f the following? A. B. C. D. G2 G3 G3 G4 T2 T1 T2 T1 P0 P1 P0 P1 A0 A0 A0 A1 L2 L2 L2 L2 gestation, the nu

9. When preparing to listen to the fetal heart rate at 12 weeks rse would use which of the following?

A. Stethoscope placed midline at the umbilicus B. Doppler placed midline at the suprapubic region C. Fetoscope placed midway between the umbilicus and the xiphoid process

D. External electronic fetal monitor placed at the umbilicus 10. When developing a plan of care for a client newly diagnosed with gestational diabetes, which of the following instructions would be the priority? A. B. C. D. Dietary intake Medication Exercise Glucose monitoring

11. A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the following would be the priority when assessing the client? A. B. C. D. Glucosuria Depression Hand/face edema Dietary intake

12. A client 12 weeks pregnant come to the emergency department with abdominal cr amping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cms ce rvical dilation.The nurse would document these findings as which of the followin g? A. B. C. D. Threatened abortion Imminent abortion Complete abortion Missed abortion

13. Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy? A. B. C. D. Risk for infection Pain Knowledge Deficit Anticipatory Grieving

14. Before assessing the postpartum client s uterus for firmness and position in r elation to the umbilicus and midline, which of the following shouldthe nurse do first? A. B. C. D. Assess the vital signs Administer analgesia Ambulate her in the hall Assist her to urinate

15. Which of the following should the nurse do when a primipara who is lactating tells the nurse that she has sore nipples? A. B. C. D. Tell her to breast feed more frequently Administer a narcotic before breast feeding Encourage her to wear a nursing brassiere Use soap and water to clean the nipples

16. The nurse assesses the vital signs of a client, 4 hours postpartum that are a s follows: BP 90/60; temperature 100.4F; pulse 100 weak, thready; R 20 per minute . Which of the following shouldthe nurse do first? A. Report the temperature to the physician B. Recheck the blood pressure with another cuff C. Assess the uterus for firmness and position

D. Determine the amount of lochia 17. The nurse assesses the postpartum vaginal discharge (lochia) on four clients . Which of the following assessments would warrant notification of the physician ? A. B. C. D. A dark red discharge on a 2-day postpartum client A pink to brownish discharge on a client who is 5 days postpartum Almost colorless to creamy discharge on a client 2 weeks after delivery A bright red discharge 5 days after delivery

18. A postpartum client has a temperature of 101.4F, with a uterus that is tender when palpated, remains unusually large, and not descending as normally expected . Which of the following shouldthe nurse assess next? A. B. C. D. Lochia Breasts Incision Urine

19. Which of the following is the priority focus of nursing practice with the cu rrent early postpartum discharge? A. B. C. D. Promoting comfort and restoration of health Exploring the emotional status of the family Facilitating safe and effective self-and newborn care Teaching about the importance of family planning

20. Which of the following actions would be least effective in maintaining a neu tral thermal environment for the newborn? A. B. C. D. Placing infant under radiant warmer after bathing Covering the scale with a warmed blanket prior to weighing Placing crib close to nursery window for family viewing Covering the infant s head with a knit stockinette

21. A newborn who has an asymmetrical Moro reflex response should be further ass essed for which of the following? A. B. C. D. Talipes equinovarus Fractured clavicle Congenital hypothyroidism Increased intracranial pressure

22. During the first 4 hours after a male circumcision, assessing for which of t he following is the priority? A. B. C. D. Infection Hemorrhage Discomfort Dehydration

23. The mother asks the nurse. What s wrong with my son s breasts? Why are they so en larged? Whish of the following would be the best response by the nurse? A. B. C. D. The breast A decrease You should The tissue tissue is inflamed from the trauma experienced with birth in material hormones present before birth causes enlargement, discuss this with your doctor. It could be a malignancy has hypertrophied while the baby was in the uterus

24. Immediately after birth the nurse notes the following on a male newborn: res pirations 78; apical hearth rate 160 BPM, nostril flaring; mild intercostal retr actions; and grunting at the end of expiration. Which of the following shouldthe nurse do? A. B. C. D. Call the assessment data to the physician s attention Start oxygen per nasal cannula at 2 L/min. Suction the infant s mouth and nares Recognize this as normal first period of reactivity

25. The nurse hears a mother telling a friend on the telephone about umbilical c ord care. Which of the following statements by the mother indicates effective te aching? A. B. C. D. Daily soap and water cleansing is best Alcohol helps it dry and kills germs An antibiotic ointment applied daily prevents infection He can have a tub bath each day

26. A newborn weighing 3000 grams and feeding every 4 hours needs 120 calories/k g of body weight every 24 hours for proper growth and development. How many ounc es of 20 cal/oz formula should this newborn receive at each feeding to meet nutr itional needs? A. B. C. D. 2 3 4 6 ounces ounces ounces ounces

27. The postterm neonate with meconium-stained amniotic fluid needs care designe d to especially monitor for which of the following? A. B. C. D. Respiratory problems Gastrointestinal problems Integumentary problems Elimination problems

28. When measuring a client s fundal height, which of the following techniques den otes the correct method of measurement used by the nurse? A. B. C. D. From From From From the the the the xiphoid process to the umbilicus symphysis pubis to the xiphoid process symphysis pubis to the fundus fundus to the umbilicus

29. A client with severe preeclampsia is admitted with of BP 160/110, proteinuri a, and severe pitting edema. Which of the following would be most important to i nclude in the client s plan of care? A. B. C. D. Daily weights Seizure precautions Right lateral positioning Stress reduction

30. A postpartum primipara asks the nurse, When can we have sexual intercourse ag ain? Which of the following would be the nurse s best response? A. Anytime you both want to. B. As soon as choose a contraceptive method. C. When the discharge has stopped and the incision is healed.

D.

After your 6 weeks examination.

31. When preparing to administer the vitamin K injection to a neonate, the nurse would select which of the following sites as appropriate for the injection? A. B. C. D. Deltoid muscle Anterior femoris muscle Vastus lateralis muscle Gluteus maximus muscle

32. When performing a pelvic examination, the nurse observes a red swollen area on the right side of the vaginal orifice. The nurse would document this as enlar gement of which of the following? A. B. C. D. Clitoris Parotid gland Skene s gland Bartholin s gland

33. To differentiate as a female, the hormonal stimulation of the embryo that mu st occur involves which of the following? A. B. C. D. Increase in maternal estrogen secretion Decrease in maternal androgen secretion Secretion of androgen by the fetal gonad Secretion of estrogen by the fetal gonad

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. B. C. D. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water Eating a few low-sodium crackers before getting out of bed Avoiding the intake of liquids in the morning hours Eating six small meals a day instead of thee large meals

35. The nurse documents positive ballottement in the client s prenatal record. The nurse understands that this indicates which of the following? A. B. C. D. Palpable contractions on the abdomen Passive movement of the unengaged fetus Fetal kicking felt by the client Enlargement and softening of the uterus

36. During a pelvic exam the nurse notes a purple-blue tinge of the cervix. The nurse documents this as which of the following? A. B. C. D. Braxton-Hicks sign Chadwick s sign Goodell s sign McDonald s sign

37. During a prenatal class, the nurse explains the rationale for breathing tech niques during preparation for labor based on the understanding that breathing te chniques are most important in achieving which of the following? A. B. C. D. Eliminate pain and give the expectant parents something to do Reduce the risk of fetal distress by increasing uteroplacental perfusion Facilitate relaxation, possibly reducing the perception of pain Eliminate pain so that less analgesia and anesthesia are needed

38. After 4 hours of active labor, the nurse notes that the contractions of a pr imigravida client are not strong enough to dilate the cervix. Which of the follo wing would the nurse anticipate doing? A. B. C. D. Obtaining an order to begin IV oxytocin infusion Administering a light sedative to allow the patient to rest for several hour Preparing for a cesarean section for failure to progress Increasing the encouragement to the patient when pushing begins

39. A multigravida at 38 weeks gestation is admitted with painless, bright red bl eeding and mild contractions every 7 to 10 minutes. Which of the following asses sments should be avoided? A. B. C. D. Maternal vital sign Fetal heart rate Contraction monitoring Cervical dilation

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. B. C. D. You You The The will have to ask your physician when he returns. need a cesarean to prevent hemorrhage. placenta is covering most of your cervix. placenta is covering the opening of the uterus and blocking your baby.

41. The nurse understands that the fetal head is in which of the following posit ions with a face presentation? A. B. C. D. Completely flexed Completely extended Partially extended Partially flexed

42. With a fetus in the left-anterior breech presentation, the nurse would expec t the fetal heart rate would be most audible in which of the following areas? A. B. C. D. Above the maternal umbilicus and to the right of midline In the lower-left maternal abdominal quadrant In the lower-right maternal abdominal quadrant Above the maternal umbilicus and to the left of midline

43. The amniotic fluid of a client has a greenish tint. The nurse interprets thi s to be the result of which of the following? A. B. C. D. Lanugo Hydramnio Meconium 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. B. C. D. Quickening Ophthalmia neonatorum Pica Prolapsed umbilical cord

45. When describing dizygotic twins to a couple, on which of the following would

the nurse base the explanation? A. B. C. D. Two ova fertilized by separate sperm Sharing of a common placenta Each ova with the same genotype Sharing of a common chorion

46. Which of the following refers to the single cell that reproduces itself afte r conception? A. B. C. D. Chromosome Blastocyst Zygote Trophoblast

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. B. C. D. Labor, delivery, recovery, postpartum (LDRP) Nurse-midwifery Clinical nurse specialist Prepared childbirth

48. A client has a midpelvic contracture from a previous pelvic injury due to a motor vehicle accident as a teenager. The nurse is aware that this could prevent a fetus from passing through or around which structure during childbirth? A. B. C. D. Symphysis pubis Sacral promontory Ischial spines Pubic arch

49. When teaching a group of adolescents about variations in the length of the m enstrual cycle, the nurse understands that the underlying mechanism is due to va riations in which of the following phases? A. B. C. D. Menstrual phase Proliferative phase Secretory phase Ischemic phase

50. When teaching a group of adolescents about male hormone production, which of the following would the nurse include as being produced by the Leydig cells? A. B. C. D. Follicle-stimulating hormone Testosterone Leuteinizing hormone Gonadotropin releasing hormone

Here are the answers and rationale for Maternal & Child Health Nursing Exam 2 (5 0 Items) B. Regular timely ingestion of oral contraceptives is necessary to maintain horm onal levels of the drugs to suppress the action of the hypothalamus and anterior pituitary leading to inappropriate secretion of FSH and LH. Therefore, follicle s do not mature, ovulation is inhibited, and pregnancy is prevented. The estroge n content of the oral site contraceptive may cause the nausea, regardless of whe n the pill is taken. Side effects and drug interactions may occur withoral contr aceptives regardless of the time the pill is taken.

C. Condoms, when used correctly and consistently, are the most effective contrac eptive method or barrier against bacterial and viral sexually transmitted infect ions. Although spermicides kill sperm, they do not provide reliable protection a gainst the spread of sexually transmitted infections, especially intracellular o rganisms such as HIV. Insertion and removal of the diaphragm along with the use of the spermicides may cause vaginal irritations, which could place the client a t risk for infection transmission. Male sterilization eliminates spermatozoa fro m the ejaculate, but it does not eliminate bacterial and/or viral microorganisms that can cause sexually transmitted infections. A. The diaphragm must be fitted individually to ensure effectiveness. Because of the changes to the reproductive structures during pregnancy and following deliv ery, 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 e ffectiveness, spermicidal jelly should be placed in the dome and around the rim. However, spermicidal jelly should not be inserted into the vagina until involut ion is completed at approximately 6 weeks. Use of a female condom protects there 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 ha s determined the female s fertile period, using the rhythm method, avoidance of in tercourse during this period, is safe and effective. C. An IUD may increase the risk of pelvic inflammatory disease, especially in wo men with more than one sexual 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 carc inoma, or uterine abnormalities. Age is not a factor in determining the risks as sociated with IUD use. Most IUD users are over the age of 30. Although there is a slightly higher risk for infertility in women who have never been pregnant, th e IUD is an acceptable option as long as the risk-benefit ratio is discussed. IU Ds may be inserted immediately after delivery, but this is not recommended becau se of the increased risk and rate of expulsion at this time. C. During the third trimester, the enlarging uterus places pressure on the intes tines. This coupled with the effect of hormones on smooth muscle relaxation caus es decreased intestinal motility (peristalsis). Increasing fiber in the diet wil l help fecal matter pass more quickly through the intestinal tract, thus decreas ing the amount of water that is absorbed. As a result, stool is softer and easie r to pass. Enemas could precipitate preterm labor and/or electrolyte loss and sh ould be avoided. Laxatives may cause preterm labor by stimulating peristalsis an d may interfere with the absorption of nutrients. Use for more than 1 week can a lso lead to laxative dependency. Liquid in the diet helps provide a semisolid, s oft consistency to the stool. Eight to ten glasses of fluid per day are essentia l to maintain hydration and promote stool evacuation. D. To ensure adequate fetal growth and development during the 40 weeks of a preg nancy, a total weight gain 25 to 30 pounds is recommended: 1.5 pounds in the fir st 10 weeks; 9 pounds by 30 weeks; and 27.5 pounds by 40 weeks. The pregnant wom an should gain less weight in the first and second trimester than in the third. During the first trimester, the client should only gain 1.5 pounds in the first 10 weeks, not 1 pound per week. A weight gain of pound per week would be 20 poun ds for the total pregnancy, less than the recommended amount. B. To calculate the EDD by Nagele s rule, add 7 days to the first day of the last menstrual period and count back 3 months, changing the year appropriately. To ob tain a date of September 27, 7 days have been added to the last day of the LMP ( rather than the first day of the LMP), plus 4 months (instead of 3 months) were counted back. To obtain the date of November 7, 7 days have been subtracted (ins tead of added) from the first day of LMP plus November indicates counting back 2 months (instead of 3 months) from January. To obtain the date of December 27, 7 days were added to the last day of the LMP (rather than the first day of the LM P) and December indicates counting back only 1 month (instead of 3 months) from January. D. The client has been pregnant four times, including current pregnancy (G). Bir

th at 38 weeks gestation is considered full term (T), while birth form 20 weeks t o 38 weeks is considered preterm (P). A spontaneous abortion occurred at 8 weeks (A). She has two living children (L). B. At 12 weeks gestation, the uterus rises out of the pelvis and is palpable abo ve the symphysis pubis. The Doppler intensifies the sound of the fetal pulse rat e so it is audible. The uterus has merely risen out of the pelvis into the abdom inal cavity and is not at the level of the umbilicus. The fetal heart rate at th is age is not audible with a stethoscope. The uterus at 12 weeks is just above t he symphysis pubis in the abdominal cavity, not midway between the umbilicus and the xiphoid process. At 12 weeks the FHR would be difficult to auscultate with a fetoscope. Although the external electronic fetal monitor would project the FH R, the uterus has not risen to the umbilicus at 12 weeks. 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 priority . Women diagnosed with gestational diabetes generally need only diet therapy wit hout medication to control their blood sugar levels. Exercise, is important for all pregnant women and especially for diabetic women, because it burns up glucos e, thus decreasing blood sugar. However, dietary intake, not exercise, is the pr iority. All pregnant women with diabetes should have periodic monitoring of seru m glucose. However, those with gestational diabetes generally do not need daily glucose monitoring. The standard of care recommends a fasting and 2-hour postpra ndial blood sugar level every 2 weeks. C. After 20 weeks gestation, when there is a rapid weight gain, preeclampsia shou ld be suspected, which may be caused by fluid retention manifested by edema, esp ecially of the hands and face. The three classic signs of preeclampsia are hyper tension, edema, and proteinuria. Although urine is checked for glucose at each c linic visit, this is not the priority. Depression may cause either anorexia or e xcessive food intake, leading to excessive weight gain or loss. This is not, how ever, the priority consideration at this time. Weight gain thought to be caused by excessive food intake would require a 24-hour diet recall. However, excessive intake would not be the primary consideration for this client at this time. B. Cramping and vaginal bleeding coupled with cervical dilation signifies that t ermination of the pregnancy is inevitable and cannot be prevented. Thus, the nur se would document an imminent abortion. In a threatened abortion, cramping and v aginal 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 con ception are expelled. A missed abortion is early fetal intrauterine death withou t expulsion of the products of conception. B. For the client with an ectopic pregnancy, lower abdominal pain, usually unila teral, is the primary symptom. Thus, pain is the priority. Although the potentia l for infection is always present, the risk is low in ectopic pregnancy because pathogenic microorganisms have not been introduced from external sources. The cl ient may have a limited knowledge of the pathology and treatment of the conditio n and will most likely experience grieving, but this is not the priority at this time. D. Before uterine assessment is performed, it is essential that the woman empty her bladder. A full bladder will interfere with the accuracy of the assessment b y elevating the uterus and displacing to the side of the midline. Vital sign ass essment is not necessary unless an abnormality in uterine assessment is identifi ed. Uterine assessment should not cause acute pain that requires administration of analgesia. Ambulating the client is an essential component of postpartum care , but is not necessary prior to assessment of the uterus. A. Feeding more frequently, about every 2 hours, will decrease the infant s franti c, vigorous sucking from hunger and will decrease breast engorgement, soften the breast, and promote ease of correct latching-on for feeding. Narcotics administ ered prior to breast feeding are passed through the breast milk to the infant, c ausing excessive sleepiness. Nipple soreness is not severe enough to warrant nar cotic analgesia. All postpartum clients, especially lactating mothers, should we ar a supportive brassiere with wide cotton straps. This does not, however, preve nt or reduce nipple soreness. Soaps are drying to the skin of the nipples and sh

ould not be used on the breasts of lactating mothers. Dry nipple skin predispose s to cracks and fissures, which can become sore and painful. D. A weak, thready pulse elevated to 100 BPM may indicate impending hemorrhagic shock. An increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. Thus, the nurse should check the amount of lochia prese nt. Temperatures up to 100.48F in the first 24 hours after birth are related to the dehydrating effects of labor and are considered normal. Although rechecking the blood pressure may be a correct choice of action, it is not the first action that should be implemented in light of the other data. The data indicate a pote ntial impending hemorrhage. Assessing the uterus for firmness and position in re lation to the umbilicus and midline is important, but the nurse should check the extent of vaginal bleeding first. Then it would be appropriate to check the ute rus, which may be a possible cause of the hemorrhage. D. Any bright red vaginal discharge would be considered abnormal, but especially 5 days after delivery, when the lochia is typically pink to brownish. Lochia ru bra, a dark red discharge, is present for 2 to 3 days after delivery. Bright red vaginal bleeding at this time suggests late postpartum hemorrhage, which occurs after the first 24 hours following delivery and is generally caused by retained placental fragments or bleeding disorders. Lochia rubra is the normal dark red discharge occurring in the first 2 to 3 days after delivery, containing epitheli al cells, erythrocyes, leukocytes and decidua. Lochia serosa is a pink to browni sh serosanguineous discharge occurring from 3 to 10 days after delivery that con tains decidua, erythrocytes, leukocytes, cervical mucus, and microorganisms. Loc hia alba is an almost colorless to yellowish discharge occurring from 10 days to 3 weeks after delivery and containing leukocytes, decidua, epithelial cells, fa t, cervical mucus, cholesterol crystals, and bacteria. A. The data suggests an infection of the endometrial lining of the uterus. The l ochia may be decreased or copious, dark brown in appearance, and foul smelling, providing further evidence of a possible infection. All the client s data indicate a uterine problem, not a breast problem. Typically, transient fever, usually 10 1F, may be present with breast engorgement. Symptoms of mastitis include influenz a-like manifestations. Localized infection of an episiotomy or C-section incisio n rarely causes systemic symptoms, and uterine involution would not be affected. The client data do not include dysuria, frequency, or urgency, symptoms of urin ary tract infections, which would necessitate assessing the client s urine. C. Because of early postpartum discharge and limited time for teaching, the nurs e s priority is to facilitate the safe and effective care of the client and newbor n. Although promoting comfort and restoration of health, exploring the family s em otional status, and teaching about family planning are important in postpartum/n ewborn nursing care, they are not the priority focus in the limited time present ed by early post-partum discharge. C. Heat loss by radiation occurs when the infant s crib is placed too near cold wa lls or windows. Thus placing the newborn s crib close to the viewing window would be least effective. Body heat is lost through evaporation during bathing. Placin g the infant under the radiant warmer after bathing will assist the infant to be rewarmed. Covering the scale with a warmed blanket prior to weighing prevents h eat 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. B. A fractured clavicle would prevent the normal Moro response of symmetrical se quential extension and abduction of the arms followed by flexion and adduction. In talipes equinovarus (clubfoot) the foot is turned medially, and in plantar fl exion, with the heel elevated. The feet are not involved with the Moro reflex. H ypothyroiddism has no effect on the primitive reflexes. Absence of the Moror ref lex is the most significant single indicator of central nervous system status, b ut it is not a sign of increased intracranial pressure. B. Hemorrhage is a potential risk following any surgical procedure. Although the infant has been given vitamin K to facilitate clotting, the prophylactic dose i s often not sufficient to prevent bleeding. Although infection is a possibility, signs will not appear within 4 hours after the surgical procedure. The primary discomfort of circumcision occurs during the surgical procedure, not afterward.

Although feedings are withheld prior to the circumcision, the chances of dehydra tion are minimal. B. The presence of excessive estrogen and progesterone in the maternal-fetal blo od followed by prompt withdrawal at birth precipitates breast engorgement, which will spontaneously resolve in 4 to 5 days after birth. The trauma of the birth process does not cause inflammation of the newborn s breast tissue. Newborns do no t have breast malignancy. This reply by the nurse would cause the mother to have undue anxiety. Breast tissue does not hypertrophy in the fetus or newborns. D. The first 15 minutes to 1 hour after birth is the first period of reactivity involving respiratory and circulatory adaptation to extrauterine life. The data given reflect the normal changes during this time period. The infant s assessment data reflect normal adaptation. Thus, the physician does not need to be notified and oxygen is not needed. The data do not indicate the presence of choking, gag ging or coughing, which are signs of excessive secretions. Suctioning is not nec essary. B. Application of 70% isopropyl alcohol to the cord minimizes microorganisms (ge rmicidal) and promotes drying. The cord should be kept dry until it falls off an d the stump has healed. Antibiotic ointment should only be used to treat an infe ction, not as a prophylaxis. Infants should not be submerged in a tub of water u ntil the cord falls off and the stump has completely healed. B. To determine the amount of formula needed, do the following mathematical calc ulation. 3 kg x 120 cal/kg per day = 360 calories/day feeding q 4 hours = 6 feed ings per day = 60 calories per feeding: 60 calories per feeding; 60 calories per feeding with formula 20 cal/oz = 3 ounces per feeding. Based on the calculatio n. 2, 4 or 6 ounces are incorrect. A. Intrauterine anoxia may cause relaxation of the anal 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 st ained with meconium, it is noninfectious (sterile) and nonirritating. The postte rm meconium-stained infant is not at additional risk for bowel or urinary proble ms. C. The nurse should use a nonelastic, flexible, paper measuring tape, placing t he zero point on the superior border of the symphysis pubis and stretching the t ape across the abdomen at the midline to the top of the fundus. The xiphoid and umbilicus are not appropriate landmarks to use when measuring the height of the fundus (McDonald s measurement). B. Women hospitalized with severe preeclampsia need decreased CNS stimulation to prevent a seizure. Seizure precautions provide environmental safety should a se izure occur. Because of edema, daily weight is important but not the priority. P reclampsia causes vasospasm and therefore can reduce utero-placental perfusion. The client should be placed on her left side to maximize blood flow, reduce bloo d pressure, and promote diuresis. Interventions to reduce stress and anxiety are very important to facilitate coping and a sense of control, but seizure precaut ions are the priority. C. Cessation of the lochial discharge signifies healing of the endometrium. Risk of hemorrhage and infection are minimal 3 weeks after a normal vaginal delivery . Telling the client anytime is inappropriate because this response does not pro vide the client with the specific information she is requesting. Choice of a con traceptive method is important, but not the specific criteria for safe resumptio n of sexual activity. Culturally, the 6-weeks examination has been used as the ti me frame for resuming sexual activity, but it may be resumed earlier. C. The middle third of the vastus lateralis is the preferred injection site for vitamin K administration because it is free of blood vessels and nerves and is l arge enough to absorb the medication. The deltoid muscle of a newborn is not lar ge enough for a newborn IM injection. Injections into this muscle in a small chi ld might cause damage to the radial nerve. The anterior femoris muscle is the ne xt safest muscle to use in a newborn but is not the safest. Because of the proxi mity of the sciatic nerve, the gluteus maximus muscle should not be until the ch ild has been walking 2 years.

D. Bartholin s glands are the glands on either side of the vaginal orifice. The cl itoris is female erectile tissue found in the perineal area above the urethra. T he parotid glands are open into the mouth. Skene s glands open into the posterior wall of the female urinary meatus. D. The fetal gonad must secrete estrogen for the embryo to differentiate as a fe male. An increase in maternal estrogen secretion does not effect differentiation of the embryo, and maternal estrogen secretion occurs in every pregnancy. Mater nal androgen secretion remains the same as before pregnancy and does not effect differentiation. Secretion of androgen by the fetal gonad would produce a male f etus. A. Using bicarbonate would increase the amount of sodium ingested, which can cau se complications. Eating low-sodium crackers would be appropriate. Since liquids can increase nausea avoiding them in the morning hours when nausea is usually t he strongest is appropriate. Eating six small meals a day would keep the stomach full, which often decrease nausea. B. Ballottement indicates passive movement of the unengaged fetus. Ballottement is not a contraction. Fetal kicking felt by the client represents quickening. En largement and softening of the uterus is known as Piskacek s sign. B. Chadwick s sign refers to the purple-blue tinge of the cervix. Braxton Hicks co ntractions are painless contractions beginning around the 4th month. Goodell s sig n indicates softening of the cervix. Flexibility of the uterus against the cervi x is known as McDonald s sign. C. Breathing techniques can raise the pain threshold and reduce the perception o f pain. They also promote relaxation. Breathing techniques do not eliminate pain , but they can reduce it. Positioning, not breathing, increases uteroplacental p erfusion. A. The client s labor is hypotonic. The nurse should call the physical and obtain an order for an infusion of oxytocin, which will assist the uterus to contact mo re forcefully in an attempt to dilate the cervix. Administering light sedative w ould be done for hypertonic uterine contractions. Preparing for cesarean section is unnecessary at this time. Oxytocin would increase the uterine contractions a nd hopefully progress labor before a cesarean would be necessary. It is too earl y to anticipate client pushing with contractions. D. The signs indicate placenta previa and vaginal exam to determine cervical dil ation would not be done because it could cause hemorrhage. Assessing maternal vi tal signs can help determine maternal physiologic status. Fetal heart rate is im portant to assess fetal well-being and should be done. Monitoring the contractio ns will help evaluate the progress of labor. D. A complete placenta previa occurs when the placenta covers the opening of the uterus, thus blocking the passageway for the baby. This response explains what a complete previa is and the reason the baby cannot come out except by cesarean delivery. Telling the client to ask the physician is a poor response and would i ncrease the patient s anxiety. Although a cesarean would help to prevent hemorrhag e, the statement does not explain why the hemorrhage could occur. With a complet e previa, the placenta is covering all the cervix, not just most of it. 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. D. With this presentation, the fetal upper torso and back face the left upper ma ternal abdominal wall. The fetal heart rate would be most audible above the mate rnal umbilicus and to the left of the middle. The other positions would be incor rect. C. The greenish tint is due to the presence of meconium. Lanugo is the soft, dow ny hair on the shoulders and back of the fetus. Hydramnios represents excessive amniotic fluid. Vernix is the white, cheesy substance covering the fetus. D. In a breech position, because of the space between the presenting part and th e cervix, prolapse of the umbilical cord is common. Quickening is the woman s firs t perception of fetal movement. Ophthalmia neonatorum usually results from mater nal gonorrhea and is conjunctivitis. Pica refers to the oral intake of nonfood s ubstances.

A. Dizygotic (fraternal) twins involve two ova fertilized by separate sperm. Mon ozygotic (identical) twins involve a common placenta, same genotype, and common chorion. C. The zygote is the single cell that reproduces itself after conception. The ch romosome 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. D. Prepared childbirth was the direct result of the 1950 s challenging of the rout ine use of analgesic and anesthetics during childbirth. The LDRP was a much late r concept and was not a direct result of the challenging of routine use of analg esics and anesthetics during childbirth. Roles for nurse midwives and clinical nurse specialists did not develop from this challenge. C. The ischial spines are located in the mid-pelvic region and could be narrowed due to the previous pelvic injury. The symphysis pubis, sacral promontory, and pubic arch are not part of the mid-pelvis. 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 contrib ute to this variation. B. Testosterone is produced by the Leyding cells in the seminiferous tubules. Fo llicle-stimulating hormone and leuteinzing hormone are released by the anterior pituitary gland. The hypothalamus is responsible for releasing gonadotropin-rele asing hormone. 1. While performing physical assessment of a 12 month-old, the nurse notes that the infant s anterior fontanelle is still slightly open. Which of the following is the nurse s most appropriate action? A. B. C. D. Notify the Perform an Perform an Do nothing physician immediately because there is a problem. intensive neurologic examination. intensive developmental examination. because this is a normal finding for the age.

2. When teaching a mother about introducing solid foods to her child, which of t he following indicates the earliest age at which this should be done? A. B. C. D. 1 2 3 4 month months months months

3. The infant of a substance-abusing mother is at risk for developing a sense of which of the following? A. B. C. D. Mistrust Shame Guilt Inferiority

4. Which of the following toys should the nurse recommend for a 5-month-old? A. B. C. D. A A A A big red balloon teddy bear with button eyes push-pull wooden truck colorful busy box

5. The mother of a 2-month-old is concerned that she may be spoiling her baby by picking her up when she cries. Which of the following would be the nurse s best r esponse? A. Let her cry for a while before picking her up, so you don t spoil her B. Babies need to be held and cuddled; you won t spoil her this way

C. D.

Crying at this age means the baby is hungry; give her a bottle If you leave her alone she will learn how to cry herself to sleep

6. When assessing an 18-month-old, the nurse notes a characteristic protruding a bdomen. Which of the following would explain the rationale for this finding? A. B. C. D. Increased food intake owing to age Underdeveloped abdominal muscles Bowlegged posture Linear growth curve

7. If parents keep a toddler dependent in areas where he is capable of using ski lls, the toddle will develop a sense of which of the following? A. B. C. D. Mistrust Shame Guilt Inferiority

8. Which of the following is an appropriate toy for an 18-month-old? A. B. C. D. Multiple-piece puzzle Miniature cars Finger paints Comic book

9. When teaching parents about the child s readiness for toilet training, which of the following signs should the nurse instruct them to watch for in the toddler? A. B. C. D. Demonstrates dryness for 4 hours Demonstrates ability to sit and walk Has a new sibling for stimulation Verbalizes desire to go to the bathroom

10. When teaching parents about typical toddler eating patterns, which of the fo llowing should be included? A .Food jags B. Preference to eat alone C. Consistent table manners D. Increase in appetite 11. Which of the following suggestions should the nurse offer the parents of a 4 -year-old boy who resists going to bed at night? A. B. e. C. . D. p. Allow him to fall asleep in your room, then move him to his own bed. Tell him that you will lock him in his room if he gets out of bed one more tim Encourage active play at bedtime to tire him out so he will fall asleep faster Read him a story and allow him to play quietly in his bed until he falls aslee

12. When providing therapeutic play, which of the following toys would best prom ote imaginative play in a 4-year-old? A. B. C. D. Large blocks Dress-up clothes Wooden puzzle Big wheels

13. Which of the following activities, when voiced by the parents following a te aching session about the characteristics of school-age cognitive development wou ld indicate the need for additional teaching? A. B. C. D. Collecting baseball cards and marbles Ordering dolls according to size Considering simple problem-solving options Developing plans for the future

14. A hospitalized schoolager states: I m not afraid of this place, I m not afraid of anything. This statement is most likely an example of whichof the following? A. B. C. D. Regression Repression Reaction formation Rationalization

15. After teaching a group of parents about accident prevention for schoolagers, which of the following statements by the group would indicate the need for more teaching? A. B. C. D. Schoolagers are more active and adventurous than are younger children. Schoolagers are more susceptible to home hazards than are younger children. Schoolagers are unable to understand potential dangers around them. Schoolargers are less subject to parental control than are younger children.

16. Which of the following skills is the most significant one learned during the schoolage period? A. B. C. D. Collecting Ordering Reading Sorting

17. A child age 7 was unable to receive the measles, mumps, and rubella (MMR) va ccine at the recommended scheduled time. When would the nurse expect to administ er MMR vaccine? A. B. C. D. In In At At a month from now a year from now age 10 age 13

18. The adolescent s inability to develop a sense of who he is and what he can bec ome results in a sense of which of the following? A. B. C. D. Shame Guilt Inferiority Role diffusion

19. Which of the following would be most appropriate for a nurse to use when des cribing menarche to a 13-year-old? A. B. C. D. A female s first menstruation or menstrual periods The first year of menstruation or period The entire menstrual cycle or from one period to another The onset of uterine maturation or peak growth

20. A 14-year-old boy has acne and according to his parents, dominates the bathr oom by using the mirror all the time. Which of the following remarks by the nurse would be least helpful in talking to the boy and his parents? A. This is probably the only concern he has about his body. So don t worry about it or the time he spends on it. B. Teenagers are anxious about how their peers perceive them. So they spend a lot of time grooming. C. A teen may develop a poor self-image when experiencing acne. Do you feel this way sometimes? D. You appear to be keeping your face well washed. Would you feel comfortable dis cussing your cleansing method? 21. Which of the following should the nurse suspect when noting that a 3-year-ol d is engaging in explicit sexual behavior during doll play? A. B. C. D. The The The The child child child child is exhibiting normal pre-school curiosity is acting out personal experiences does not know how to play with dolls is probably developmentally delayed.

22. Which of the following statements by the parents of a child with school phob ia would indicate the need for further teaching? A. B. C. D. We We We We ll ll ll ll keep him at home until phobia subsides. work with his teachers and counselors at school. try to encourage him to talk about his problem. discuss possible solutions with him and his counselor.

23. When developing a teaching plan for a group of high school students about te enage pregnancy, the nurse would keep in mind which of the following? A. B. C. D. The incidence of teenage pregnancies is increasing. Most teenage pregnancies are planned. Denial of the pregnancy is common early on. The risk for complications during pregnancy is rare.

24. When assessing a child with a cleft palate, the nurse is aware that the chil d is at risk for more frequent episodes of otitis media due to whichof the follo wing? A. B. C. D. Lowered resistance from malnutrition Ineffective functioning of the Eustachian tubes Plugging of the Eustachian tubes with food particles Associated congenital defects of the middle ear.

25. While performing a neurodevelopmental assessment on a 3-month-old infant, wh ich of the following characteristics would be expected? A. B. C. D. A strong Moro reflex A strong parachute reflex Rolling from front to back Lifting of head and chest when prone

26. By the end of which of the following would the nurse most commonly expect a child s birth weight to triple? A. 4 months B. 7 months

C. 9 months D. 12 months 27. Which of the following best describes parallel play between two toddlers? A. B. C. D. Sharing Playing Sitting Sharing crayons to color separate pictures a board game with a nurse near each other while playing with separate dolls their dolls with two different nurses

28. Which of the following would the nurse identify as the initial priority for a child with acute lymphocytic leukemia? A. B. C. D. Instituting infection control precautions Encouraging adequate intake of iron-rich foods Assisting with coping with chronic illness Administering medications via IM injections

29. Which of the following information, when voiced by the mother, would indicat e to the nurse that she understands home care instructions following the adminis tration of a diphtheria, tetanus, and pertussis injection? A. B. C. D. Measures to reduce fever Need for dietary restrictions Reasons for subsequent rash Measures to control subsequent diarrhea

30. Which of the following actions by a community health nurse is most appropria te when noting multiple bruises and burns on the posterior trunk of an 18-monthold child during a home visit? A. B. C. D. Report the child s condition to Protective Services immediately. Schedule a follow-up visit to check for more bruises. Notify the child s physician immediately. Don nothing because this is a normal finding in a toddler.

31. Which of the following is being used when the mother of a hospitalized child calls the student nurse and states, You idiot, you have no idea how to care for my sick child ? A. B. C. D. Displacement Projection Repression Psychosis

32. Which of the following should the nurse expect to note as a frequent complic ation for a child with congenital heart disease? A. B. C. D. Susceptibility to respiratory infection Bleeding tendencies Frequent vomiting and diarrhea Seizure disorder

33. Which of the following would the nurse do first for a 3-year-old boy who arr ives in the emergency room with a temperature of 105 degrees, inspiratory strido r, and restlessness, who is learning forward and drooling? A. Auscultate his lungs and place him in a mist tent. B. Have him lie down and rest after encouraging fluids. C. Examine his throat and perform a throat culture

D. Notify the physician immediately and prepare for intubation. 34. Which of the following would the nurse need to keep in mind as a predisposin g factor when formulating a teaching plan for child with a urinary tract infecti on? A. B. C. D. A shorter urethra in females Frequent emptying of the bladder Increased fluid intake Ingestion of acidic juices

35. Which of the following should the nurse do first for a 15-year-old boy with a full leg cast who is screaming in unrelenting pain and exhibiting right foot p allor signifying compartment syndrome? A. B. C. D. Medicate him with acetaminophen. Notify the physician immediately Release the traction Monitor him every 5 minutes

36. At which of the following ages would the nurse expect to administer the vari cella zoster vaccine to child? A. B. C. D. At birth 2 months 6 months 12 months

37. When discussing normal infant growth and development with parents, which of the following toys would the nurse suggest as most appropriate for an 8-month-ol d? A. B. C. D. Push-pull toys Rattle Large blocks Mobile

38. Which of the following aspects of psychosocial development is necessary for the nurse to keep in mind when providing care for the preschool child? A. B. C. D. The child can use complex reasoning to think out situations. Fear of body mutilation is a common preschool fear The child engages in competitive types of play Immediate gratification is necessary to develop initiative.

39. Which of the following is characteristic of a preschooler with mid mental re tardation? A. B. C. D. Slow to feed self Lack of speech Marked motor delays Gait disability

40. Which of the following assessment findings would lead the nurse to suspect D own syndrome in an infant? A. B. C. D. Small tongue Transverse palmar crease Large nose Restricted joint movement

41. While assessing a newborn with cleft lip, the nurse would be alert that whic h of the following will most likely be compromised? A. B. C. D. Sucking ability Respiratory status Locomotion GI function

42. When providing postoperative care for the child with a cleft palate, the nur se should position the child in which of the following positions? A. B. C. D. Supine Prone In an infant seat On the side

43. While assessing a child with pyloric stenosis, the nurse is likely to note w hich of the following? A. Regurgitation B. Steatorrhea C. Projectile vomiting D. Currant jelly stools 44. Which of the following nursing diagnoses would be inappropriate for the infa nt with gastroesophageal reflux (GER)? A. B. C. D. Fluid volume deficit Risk for aspiration Altered nutrition: less than body requirements Altered oral mucous membranes

45. Which of the following parameters would the nurse monitor to evaluate the ef fectiveness of thickened feedings for an infant with gastroesophageal reflux (GE R)? A. B. C. D. Vomiting Stools Uterine Weight

46. Discharge teaching for a child with celiac disease would include instruction s about avoiding which of the following? A. B. C. D. Rice Milk Wheat Chicken

47. Which of the following would the nurse expect to assess in a child with celi ac disease having a celiac crisis secondary to an upper respiratory infection? A. B. C. D. Respiratory distress Lethargy Watery diarrhea Weight gain

48. Which of the following should the nurse do first after noting that a child w ith Hirschsprung disease has a fever and watery explosive diarrhea?

A. B. C. D.

Notify the physician immediately Administer antidiarrheal medications Monitor child ever 30 minutes Nothing, this is characteristic of Hirschsprung disease

49. A newborn s failure to pass meconium within the first 24 hours after birth may indicate which of the following? A. B. C. D. Hirschsprung disease Celiac disease Intussusception Abdominal wall defect

50. When assessing a child for possible intussusception, which of the following would be least likely to provide valuable information? A. B. C. D. Stool inspection Pain pattern Family history Abdominal palpation

Here are the answers and rationale for Maternal & Child Health Nursing Exam 3 (5 0 Items) 1. D. The anterior fontanelle typically closes anywhere between 12 to 18 months of age. Thus, assessing the anterior fontanelle as still being slightly open is a normal finding requiring no further action. Because it is normal finding for t his age, notifying he physician or performing additional examinations are inappr opriate. 2. D. Solid foods are not recommended before age 4 to 6 months because of the su cking reflex and the immaturity of the gastrointestinal tract and immune system. Therefore, the earliest age at which to introduce foods is 4 months. Any time e arlier would be inappropriate. 3. A. According to Erikson, infants need to have their needs met consistently an d effectively to develop a sense of trust. An infant whose needs are consistentl y unmet or who experiences significant delays in having them met, such as in the case of the infant of a substance-abusing mother, will develop a sense of uncer tainty, leading to mistrust of caregivers and the environment. Toddlers develop a sense of shame when their autonomy needs are not met consistently. Preschooler s develop a sense of guilt when their sense of initiative is thwarted. Schoolage rs develop a sense of inferiority when they do not develop a sense of industry. 4. D. A busy box facilitates the fine motor development that occurs between 4 an d 6 months. Balloons are contraindicated because small children may aspirate bal loons. Because the button eyes of a teddy bear may detach and be aspirated, this toy is unsafe for children younger than 3 years. A 5-month-old is too young to use a push-pull toy. 5. B. Infants need to have their security needs met by being held and cuddled. A t 2 months of age, they are unable to make the connection between crying and att ention. This association does not occur until late infancy or early toddlerhood. Letting the infant cry for a time before picking up the infant or leaving the i nfant alone to cry herself to sleep interferes with meeting the infant s need for security at this very young age. Infants cry for many reasons. Assuming that the child s hungry may cause overfeeding problems such as obesity. 6. B. Underdeveloped abdominal musculature gives the toddler a characteristicall

y protruding abdomen. During toddlerhood, food intake decreases, not increases. Toddlers are characteristically bowlegged because the leg muscles must bear the weight of the relatively large trunk. Toddler growth patterns occur in a steplik e, not linear pattern. 7. B. According to Erikson, toddlers experience a sense of shame when they are n ot allowed to develop appropriate independence and autonomy. Infants develop mis trust when their needs are not consistently gratified. Preschoolers develop guil t when their initiative needs are not met while schoolagers develop a sense of i nferiority when their industry needs are not met. 8. C. Young toddlers are still sensorimotor learners and they enjoy the experien ce of feeling different textures. Thus, finger paints would be an appropriate to y choice. Multiple-piece toys, such as puzzle, are too difficult to manipulate a nd may be hazardous if the pieces are small enough to be aspirated. Miniature ca rs also have a high potential for aspiration. Comic books are on too high a leve l for toddlers. Although they may enjoy looking at some of the pictures, toddler s are more likely to rip a comic book apart. 9. D. The child must be able to sate the need to go to the bathroom to initiate toilet training. Usually, a child needs to be dry for only 2 hours, not 4 hours. The child also must be able to sit, walk, and squat. A new sibling would most l ikely hinder toilet training. 10. A. Toddlers become picky eaters, experiencing food jags and eating large amo unts one day and very little the next. A toddler s food gags express a preference for the ritualism of eating one type of food for several days at a time. Toddler s typically enjoy socialization and limiting others at meal time. Toddlers prefe r to feed themselves and thus are too young to have table manners. A toddler s app etite and need for calories, protein, and fluid decrease due to the dramatic slo wing of growth rate. 11. D. Preschoolers commonly have fears of the dark, being left alone especially at bedtime, and ghosts, which may affect the child s going to bed at night. Quiet play and time with parents is a positive bedtime routine that provides security and also readies the child for sleep. The child should sleep in his own bed. Te lling the child about locking him in his room will viewed by the child as a thre at. Additionally, a locked door is frightening and potentially hazardous. Vigoro us activity at bedtime stirs up the child and makes more difficult to fall aslee p. 12. B. Dress-up clothes enhance imaginative play and imagination, allowing presc hoolers to engage in rich fantasy play. Building blocks and wooden puzzles are a ppropriate for encouraging fine motordevelopment. Big wheels and tricycles encou rage gross motor development. 13. D. The school-aged child is in the stage of concrete operations, marked by i nductive reasoning, logical operations, and reversible concrete thought. The abi lity to consider the future requires formal thought operations, which are not de veloped until adolescence. Collecting baseball cards and marbles, ordering dolls by size, and simple problem-solving options are examples of the concrete operat ional thinking of the schoolager. 14. C. Reaction formation is the schoolager s typical defensive response when hosp italized. In reaction formation, expression of unacceptable thoughts or behavior s is prevented (or overridden) by the exaggerated expression of opposite thought s or types of behaviors. Regression is seen in toddlers and preshcoolers when th ey retreat or return to an earlier level ofdevelopment . Repression refers to th e involuntary blocking of unpleasant feelings and experiences from one s awareness . Rationalization is the attempt to make excuses to justify unacceptable feeling

s or behaviors. 15. C. The schoolager s cognitive level is sufficiently developed to enable good u nderstanding of and adherence to rules. Thus, schoolagers should be able to unde rstand the potential dangers around them. With growth comes greater freedom andc hildren become more adventurous and daring. The school-aged child is also still prone to accidents and home hazards, especially because of increased motor abili ties and independence. Plus the home hazards differ from other age groups. These hazards, which are potentially lethal but tempting, may include firearms, alcoh ol, and medications. School-agechildren begin to internalize their own controls and need less outside direction. Plus the child is away from home more often. So me parental or caregiver assistance is still needed to answer questions and prov ide guidance for decisions and responsibilities. 16. C. The most significant skill learned during the school-age period is readin g. During this time the child develops formal adult articulation patterns and le arns that words can be arranged in structure. Collective, ordering, and sorting, although important, are not most significant skills learned. 17. C. Based on the recommendations of the American Academy of Family Physicians and the American Academy of Pediatrics, the MMR vaccine should be given at the age of 10 if the child did not receive it between the ages of 4 to 6 years as re commended. Immunization for diphtheria and tetanus is required at age 13. 18. D. According to Erikson, role diffusion develops when the adolescent does no t develop a sense of identity and a sense or where he fits in. Toddlers develop a sense of shame when they do not achieve autonomy. Preschoolers develop a sense of guilt when they do not develop a sense of initiative. School-agechildren dev elop a sense of inferiority when they do not develop a sense of industry. 19. A. Menarche refers to the onset of the first menstruation or menstrual perio d and refers only to the first cycle. Uterine growth and broadening of the pelvi c girdle occurs before menarche. 20. A. Stating that this is probably the only concern the adolescent has and tel ling the parents not to worry about it or the time her spends on it shuts off fu rther investigation and is likely to make the adolescent and his parents feel de fensive. The statement about peer acceptance and time spent in front of the mirr or for the development of self image provides information about the adolescent s n eeds to the parents and may help to gain trust with the adolescent. Asking the a dolescent how he feels about the acne will encourage the adolescent to share his feelings. Discussing the cleansing method shows interest and concern for the ad olescent and also can help to identify any patient-teaching needs for the adoles cent regarding cleansing. 21. B. Preschoolers should be developmentally incapable of demonstrating explici t sexual behavior. If a child does so, the child has been exposed to such behavi or, and sexual abuse should be suspected. Explicit sexual behavior during doll p lay is not a characteristic of preschool development nor symptomatic of developm ental delay. Whether or nor the child knows how to play with dolls is irrelevant . 22. A. The parents need more teaching if they state that they will keep the chil d home until the phobia subsides. Doing so reinforces the child s feelings of wort hlessness and dependency. The child should attend school even during resolution of the problem. Allowing the child to verbalize helps the child to ventilate fee lings and may help to uncover causes and solutions. Collaboration with the teach ers and counselors at school may lead to uncovering the cause of the phobia and to the development of solutions. The child should participate and play an active role in developing possible solutions.

23. C. The adolescent who becomes pregnant typically denies the pregnancy early on. Early recognition by a parent or health care provider may be crucial to time ly initiation of prenatal care. The incidence of adolescent pregnancy has declin ed since 1991, yet morbidity remains high. Most teenage pregnancies are unplanne d and occur out of wedlock. The pregnant adolescent is at high risk for physical complications including premature labor and low-birth-weight infants, high neon atal mortality, iron deficiency anemia, prolonged labor, and fetopelvic dispropo rtion as well as numerous psychological crises. 24. B. Because of the structural defect, children with cleft palate may have ine ffective functioning of their Eustachian tubes creating frequent bouts of otitis media. Most children with cleft palate remain well-nourished and maintain adequ ate nutrition through the use of proper feeding techniques. Food particles do no t pass through the cleft and into the Eustachian tubes. There is no association between cleft palate and congenial ear deformities. 25. D. A 3-month-old infant should be able to lift the head and chest when prone . The Moro reflex typically diminishes or subsides by 3 months. The parachute re flex appears at 9 months. Rolling from front to back usually is accomplished at about 5 months. 26. D. A child s birth weight usually triples by 12 months and doubles by 4 months . No specific birth weight parameters are established for 7 or 9 months. 27. C. Toddlers engaging in parallel play will play near each other, but not wit h each other. Thus, when two toddlers sit near each other but play with separate dolls, they are exhibiting parallel play. Sharing crayons, playing a board game with a nurse, or sharing dolls with two different nurses are all examples of co operative play. 28. A. Acute lymphocytic leukemia (ALL) causes leukopenia, resulting in immunosu ppression and increasing the risk of infection, a leading cause of death in chil dren with ALL. Therefore, the initial priority nursing intervention would be to institute infection control precautions to decrease the risk of infection. Ironrich foods help with anemia, but dietary iron is not an initial intervention. Th e prognosis of ALL usually is good. However, later on, the nurse may need to ass ist the child and family with coping since death and dying may still be an issue in need of discussion. Injections should be discouraged, owing to increased ris k from bleeding due to thrombocytopenia. 29. A. The pertusis component may result in fever and the tetanus component may result in injection soreness. Therefore, the mother s verbalization of information about measures to reduce fever indicates understanding. No dietary restrictions are necessary after this injection is given. A subsequent rash is more likely t o be seen 5 to 10 days after receiving the MMR vaccine, not the diphtheria, pert ussis, and tetanus vaccine. Diarrhea is not associated with this vaccine. 30. A. Multiple bruises and burns on a toddler are signs child abuse. Therefore, the nurse is responsible for reporting the case to Protective Services immediat ely to protect the child from further harm. Scheduling a follow-up visit is inap propriate because additional harm may come to the child if the nurse waits for f urther assessment data. Although the nurse should notify the physician, the goal is to initiate measures to protect the child s safety. Notifying the physician im mediately does not initiate the removal of the child from harm nor does it absol ve the nurse from responsibility. Multiple bruises and burns are not normal todd ler injuries. 31. B. The mother is using projection, the defense mechanism used when a person attributes his or her own undesirable traits to another. Displacement is the tra

nsfer of emotion onto an unrelated object, such as when the mother would kick a chair or bang the door shut. Repression is the submerging of painful ideas into the unconscious. Psychosis is a state of being out of touch with reality. 32. A. Children with congenital heart disease are more prone to respiratory infe ctions. Bleeding tendencies, frequent vomiting, and diarrhea and seizure disorde rs are not associated with congenital heart disease. 33. D. The child is exhibiting classic signs of epiglottitis, always a pediatric emergency. The physician must be notified immediately and the nurse must be pre pared for an emergency intubation or tracheostomy. Further assessment with auscu ltating lungs and placing the child in a mist tent wastes valuable time. The sit uation is a possible life-threatening emergency. Having the child lie down would cause additional distress and may result in respiratory arrest. Throat examinat ion may result in laryngospasm that could be fatal. 34. A. In females, the urethra is shorter than in males. This decreases the dist ance for organisms to travel, thereby increasing the chance of the child develop ing a urinary tract infection. Frequent emptying of the bladder would help to de crease urinary tract infections by avoiding sphincter stress. Increased fluid in take enables the bladder to be cleared more frequently, thus helping to prevent urinary tract infections. The intake of acidic juices helps to keep the urine pH acidic and thus decrease the chance of flora development. 35. B. Compartment syndrome is an emergent situation and the physician needs to be notified immediately so that interventions can be initiated to relieve the in creasing pressure and restore circulation. Acetaminophen (Tylenol) will be ineff ective since the pain is related to the increasing pressure and tissue ischemia. The cast, not traction, is being used in this situation for immobilization, so releasing the traction would be inappropriate. In this situation, specific actio n not continued monitoring is indicated. 36. D. The varicella zoster vaccine (VZV) is a live vaccine given after age 12 m onths. The first dose of hepatitis B vaccine is given at birth to 2 months, then at 1 to 4 months, and then again at 6 to 18 months. DtaP is routinely given at 2, 4, 6, and 15 to 18 months and a booster at 4 to 6 years. 37. C. Because the 8-month-old is refining his gross motor skills, being able to sit unsupported and also improving his fine motor skills, probably capable of m aking hand-to-hand transfers, large blocks would be the most appropriate toy sel ection. Push-pull toys would be more appropriate for the 10 to 12-month-old as h e or she begins to cruise the environment. Rattles and mobiles are more appropri ate for infants in the 1 to 3 month age range. Mobiles pose a danger to older in fants because of possible strangulation. 38. B. During the preschool period, the child has mastered a sense of autonomy a nd goes on to master a sense of initiative. During this period, the child common ly experiences more fears than at any other time. One common fear is fear of the body mutilation, especially associated with painful experiences. The preschool child uses simple, not complex, reasoning, engages in associative, not competiti ve, play (interactive and cooperative play with sharing), and is able to tolerat e longer periods of delayed gratification. 39. A. Mild mental retardation 50 to 70. Typically, the child ness in performing tasks, such o speech, marked motor delays, e forms mental retardation. refers to development disability involving an IQ is not noted as being retarded, but exhibits slow as self-feeding, walking, and taking. Little or n and gait disabilities would be seen in more sever

40. B. Down syndrome is characterized by the following a transverse palmar creas

e (simian crease), separated sagittal suture, oblique palpebral fissures, small nose, depressed nasal bridge, high-arched palate, excess and lax skin, wide spac ing and plantar crease between the second and big toes, hyperextensible and lax joints, large protruding tongue, and muscle weakness. 41. A. Because of the defect, the child will be unable to from the mouth adequat ely around nipple, thereby requiring special devices to allow for feeding and su cking gratification. Respiratory status may be compromised if the child is fed i mproperly or during postoperative period, Locomotion would be a problem for the older infant because of the use of restraints. GI functioning is not compromised in the child with a cleft lip. 42. B. Postoperatively children with cleft palate should be placed on their abdo mens to facilitate drainage. If the child is placed in the supine position, he o r she may aspirate. Using an infant seat does not facilitate drainage. Side-lyin g does not facilitate drainage as well as the prone position. 43. C. Projectile vomiting is a key symptom of pyloric stenosis. Regurgitation i s seen more commonly with GER. Steatorrhea occurs in malabsorption disorders suc h as celiac disease. Currant jelly stools are characteristic of intussusception. 44. D. GER is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac) sphincter. No alte ration in the oral mucous membranes occurs with this disorder. Fluid volume defi cit, risk for aspiration, and altered nutrition are appropriate nursing diagnose s. 45. A. Thickened feedings are used with GER to stop the vomiting. Therefore, the nurse would monitor the child s vomiting to evaluate the effectiveness of using t he thickened feedings. No relationship exists between feedings and characteristi cs of stools and uterine. If feedings are ineffective, this should be noted befo re there is any change in the child s weight. 46. C. Children with celiac disease cannot tolerate or digest gluten. Therefore, because of its gluten content, wheat and wheat-containing products must be avoi ded. Rice, milk, and chicken do not contain gluten and need not be avoided. 47. C. Episodes of celiac crises are precipitated by infections, ingestion of gl uten, prolonged fasting, or exposure to anticholinergic drugs. Celiac crisis is typically characterized by severe watery diarrhea. Respiratory distress is unlik ely in a routine upper respiratory infection. Irritability, rather than lethargy , is more likely. Because of the fluid loss associated with the severe watery di arrhea, the child s weight is more likely to be decreased. 48. A. For the child with Hirschsprung disease, fever and explosive diarrhea ind icate enterocolitis, a life-threatening situation. Therefore, the physician shou ld be notified immediately. Generally, because of the intestinal obstruction and inadequate propulsive intestinal movement, antidiarrheals are not used to treat Hirschsprung disease. The child is acutely ill and requires intervention, with monitoring more frequently than every 30 minutes. Hirschsprung disease typically presents with chronic constipation. 49. A. Failure to pass meconium within the first 24 hours after birth may be an indication of Hirschsprung disease, a congenital anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment. Failure to pas s meconium is not associated with celiac disease, intussusception, or abdominal wall defect. 50. C. Because intussusception is not believed to have a familial tendency, obta ining a family history would provide the least amount of information. Stool insp

ection, pain pattern, and abdominal palpation would reveal possible indicators o f intussusception. Current, jelly-like stools containing blood and mucus are an indication of intussusception. Acute, episodic abdominal pain is characteristics of intussusception. A sausage-shaped mass may be palpated in the right upper qu adrant. 1. Marco approached Nurse Trish asking for advice on how to deal with his alcoho l addiction. Nurse Trish should tell the client that the only effective treatmen t for alcoholism is: A. B. C. D. Psychotherapy Alcoholics anonymous (A.A.) Total abstinence Aversion Therapy

2.Nurse Hazel is caring for a male client who experience false sensory perceptio ns with no basis in reality. This perception is known as: A. B. C. D. Hallucinations Delusions Loose associations Neologisms

3. Nurse Monet is caring for a female client who has suicidal tendency. When acc ompanying the client to the restroom, Nurse Monet should A. B. C. D. Give her privacy Allow her to urinate Open the window and allow her to get some fresh air Observe her

4. Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action should the nurse include in the plan? A. B. C. D. Provide privacy during meals Set-up a strict eating plan for the client Encourage client to exercise to reduce anxiety Restrict visits with the family

5. A client is experiencing anxiety attack. The most appropriate nursing interve ntion should include? A. B. C. D. Turning Leaving Staying Ask the on the television the client alone with the client and speaking in short sentences client to play with other clients

6. A female client is admitted with a diagnosis of delusions of GRANDEUR. This d iagnosis reflects a belief that one is: A. B. C. D. Being Killed Highly famous and important Responsible for evil world Connected to client unrelated to oneself

7.A 20 year old client was diagnosed with dependent personality disorder. Which behavior is not most likely to be evidence of ineffective individual coping? A. Recurrent self-destructive behavior B. Avoiding relationship

C. Showing interest in solitary activities D. Inability to make choices and decision without advise 8. A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit during social situation? A. B. C. D. Paranoid thoughts Emotional affect Independence need Aggressive behavior

9. Nurse Claire is caring for a client diagnosed with bulimia. The most appropri ate initial goal for a client diagnosed with bulimia is? A. B. C. D. Encourage to avoid foods Identify anxiety causing situations Eat only three meals a day Avoid shopping plenty of groceries

10. Nurse Tony was caring for a 41 year old female client. Which behavior by the client indicates adult cognitive development? A. B. C. D. Generates new levels of awareness Assumes responsibility for her actions Has maximum ability to solve problems and learn new skills Her perception are based on reality

11. A neuromuscular blocking agent is administered to a client before ECT therap y. The Nurse should carefully observe the client for? A. B. C. D. Respiratory difficulties Nausea and vomiting Dizziness Seizures

12. A 75 year old client is admitted to the hospital with the diagnosis of demen tia of the Alzheimer s type and depression. The symptom that is unrelated to depre ssion would be? A. B. C. D. Apathetic response to the environment I don t know answer to questions Shallow of labile effect Neglect of personal hygiene

13. Nurse Trish is working in a mental health facility; the nurse priority nursi ng intervention for a newly admitted client with bulimia nervosa would be to? A. B. C. D. Teach client to measure I & O Involve client in planning daily meal Observe client during meals Monitor client continuously

14. Nurse Patricia is aware that the major health complication associated with i ntractable anorexia nervosa would be? A. B. C. D. Cardiac dysrhythmias resulting to cardiac arrest Glucose intolerance resulting in protracted hypoglycemia Endocrine imbalance causing cold amenorrhea Decreased metabolism causing cold intolerance

15. Nurse Anna can minimize agitation in a disturbed client by? A. B. C. D. Increasing stimulation limiting unnecessary interaction increasing appropriate sensory perception ensuring constant client and staff contact

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. B. C. D. Problems with being too conscientious Problems with anger and remorse Feelings of guilt and inadequacy Feeling of unworthiness and hopelessness

17. Mario is complaining to other clients about not being allowed by staff to ke ep food in his room. Which of the following interventions would be most appropri ate? A. B. C. D. Allowing a snack to be kept in his room Reprimanding the client Ignoring the clients behavior Setting limits on the behavior

18. Conney with borderline personality disorder who is to be discharge soon thre atens to do something to herself if discharged. Which of the following actions by the nurse would be most important? A. B. C. D. Ask a family member to stay with the client at home temporarily Discuss the meaning of the client s statement with her Request an immediate extension for the client Ignore the clients statement because it s a sign of manipulation

19. Joey a client with antisocial personality disorder belches loudly. A staff m ember asks Joey, Do you know why people find you repulsive? this statement most li kely would elicit which of the following client reaction? A. B. C. D. Depensiveness Embarrassment Shame Remorsefulness

20. Which of the following approaches would be most appropriate to use with a cl ient suffering from narcissistic personality disorder when discrepancies exist b etween what the client states and what actually exist? A. B. C. D. Rationalization Supportive confrontation Limit setting Consistency

21. Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis and hy peractivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Which of the med ications would the nurse expect to administer? A. B. C. D. Naloxone (Narcan) Benzlropine (Cogentin) Lorazepam (Ativan) Haloperidol (Haldol)

22. Which of the following foods would the nurse Trish eliminate from the diet o f a client in alcohol withdrawal? A. B. C. D. Milk Orange Juice Soda Regular Coffee

23. Which of the following would Nurse Hazel expect to assess for a client who i s exhibiting late signs of heroin withdrawal? A. B. C. D. Yawning & diaphoresis Restlessness & Irritability Constipation & steatorrhea Vomiting and Diarrhea

24. To establish open and trusting relationship with a female client who has bee n hospitalized with severe anxiety, the nurse in charge should? A. B. C. D. Encourage the staff to have frequent interaction with the client Share an activity with the client Give client feedback about behavior Respect 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 about 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 individual needs D. Use natural remedies rather than drugs to control behavior 26. Nurse Trish would expect a child with a diagnosis of reactive attachment dis order to: A. B. C. D. Have more positive relation with the father than the mother Cling to mother & cry on separation Be able to develop only superficial relation with the others Have been physically abuse

27. When teaching parents about childhood depression Nurse Trina should say? A. B. C. D. It may appear acting out behavior Does not respond to conventional treatment Is short in duration & resolves easily Looks almost identical to adult depression

28. Nurse Perry is aware that language development in autistic child resembles: A. B. C. D. Scanning speech Speech lag Shuttering Echolalia

29. A 60 year old female client who lives alone tells 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 defense mechanism known as?

A. B. C. D.

Displacement Projection Sublimation Denial

30. When working with a male client suffering phobia about black cats, Nurse Tri sh should anticipate that a problem for this client would be? A. B. C. D. Anxiety when discussing phobia Anger toward the feared object Denying that the phobia exist Distortion of reality when completing daily routines

31. Linda is pacing the floor and appears extremely anxious. The duty nurse appr oaches in an attempt to alleviate Linda s anxiety. The most therapeutic question b y the nurse would be? A. B. C. D. Would you like to watch TV? Would you like me to talk with you? Are you feeling upset now? Ignore the client

32. Nurse Penny is aware that the symptoms that distinguish post traumatic stres s disorder from other anxiety disorder would be: A. B. C. D. Avoidance of situation & certain activities that resemble the stress Depression and a blunted affect when discussing the traumatic situation Lack of interest in family & others Re-experiencing the trauma in dreams or flashback

33. Nurse Benjie is communicating with a male client with substance-induced pers isting dementia; the client cannot remember facts and fills in the gaps with ima ginary information. Nurse Benjie is aware that this is typical of? A. B. C. D. Flight of ideas Associative looseness Confabulation Concretism

34. Nurse Joey is aware that the signs & symptoms that would be most specific fo r diagnosis anorexia are? A. B. C. D. Excessive weight loss, amenorrhea & abdominal distension Slow pulse, 10% weight loss & alopecia Compulsive behavior, excessive fears & nausea Excessive activity, memory lapses & an increased pulse

35. A characteristic that would suggest to Nurse Anne that an adolescent may hav e bulimia would be: A. B. C. D. Frequent regurgitation & re-swallowing of food Previous history of gastritis Badly stained teeth Positive body image

36. Nurse Monette is aware that extremely depressed clients seem to do best in s ettings where they have: A. Multiple stimuli B. Routine Activities

C. Minimal decision making D. Varied Activities 37. To further assess a client s suicidal potential. Nurse Katrina should be espec ially alert to the client expression of: A. B. C. D. Frustration & fear of death Anger & resentment Anxiety & loneliness Helplessness & hopelessness

38. A nursing care plan for a male client with bipolar I disorder should include : A. Providing a structured environment B. Designing activities that will require the client to maintain contact with re ality C. Engaging the client in conversing about current affairs D. Touching the client provide assurance 39. When planning care for a female client using ritualistic behavior, Nurse Gin a must recognize that the ritual: A. B. C. D. Helps the client focus on the inability to deal with reality Helps the client control the anxiety Is under the client s conscious control Is used by the client primarily for secondary gains old male graduate student, who has become increasingly withdrawn a of his work and personal hygiene, is brought to the psychiatric ho parents. After detailed assessment, a diagnosis of schizophrenia i unlikely that the client will demonstrate:

40. A 32 year nd neglectful spital by his s made. It is A. B. C. D.

Low self esteem Concrete thinking Effective self boundaries Weak ego

41. A 23 year old client has been admitted with a diagnosis of schizophrenia say s to the nurse Yes, its march, March is little woman . That s literal you know . These statement illustrate: A. B. C. D. Neologisms Echolalia Flight of ideas Loosening of association

42. A long term goal for a paranoid male client who has unjustifiably accused hi s wife of having many extramarital affairs would be to help the client develop: A. B. C. D. Insight into his behavior Better self control Feeling of self worth Faith in his wife

43. A male client who is experiencing disordered thinking about food being poiso ned is admitted to the mental health unit. The nurse uses which communication te chnique to encourage the client to eat dinner? A. Focusing on self-disclosure of own food preference

B. Using open ended question and silence C. Offering opinion about the need to eat D. Verbalizing reasons that the client may not choose to eat 44. Nurse Nina is 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 wi th a body pulled into a fetal position. Nurse Nina should? A. B. C. D. Ask the client direct questions to encourage talking Rake the client into the dayroom to be with other clients Sit beside the client in silence and occasionally ask open-ended question Leave the client alone and continue with providing care to the other clients look at the s

45. Nurse Tina is caring for a client with delirium and states that piders on the wall . What should the nurse respond to the client? A. B. C. D.

You re having hallucination, there are no spiders in this room at all I can see the spiders on the wall, but they are not going to hurt you Would you like me to kill the spiders 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. Which statement by a group member would indicate a need to provide a dditional information? A. B. C. D. Abuse occurs more in low-income families Abuser Are often jealous or self-centered Abuser use fear and intimidation Abuser usually have poor self-esteem

47. During electroconvulsive therapy (ECT) the client receives oxygen by mask vi a positive pressure ventilation. The nurse assisting with this procedure knows t hat positive pressure ventilation is necessary because? A. Anesthesia is administered during the procedure B. Decrease oxygen to the brain increases confusion and disorientation C. Grand mal seizure activity depresses respirations D. Muscle relaxations given to prevent injury during seizure activity depress re spirations. 48. When planning the discharge of a client with chronic anxiety, Nurse Chris ev aluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation? A. B. C. D. The The The The client client client client eliminates all anxiety from daily situations ignores feelings of anxiety identifies anxiety producing situations maintains contact with a crisis counselor

49. Nurse Tina is caring for a client with depression who has not responded to a ntidepressant medication. The nurse anticipates that what treatment procedure ma y be prescribed? A. B. C. D. Neuroleptic medication Short term seclusion Psychosurgery Electroconvulsive therapy

50. Mario is admitted to the emergency room with drug-included anxiety related t o over ingestion of prescribed antipsychotic medication. The most important piec

e of information the nurse in charge should obtain initially is the: A. B. C. D. Length of time on the med. Name of the ingested medication & the amount ingested Reason for the suicide attempt Name of the nearest relative & their phone number

1. C. Total abstinence is the only effective treatment for alcoholism. 2. A. Hallucinations are visual, auditory, gustatory, tactile or olfactory perce ptions that have no basis in reality. 3. D. The Nurse has a responsibility to observe continuously the acutely suicida l client. The Nurse should watch for clues, such as communicating suicidal thoug hts, and messages; hoarding medications and talking about death. 4. B. Establishing a consistent eating plan and monitoring client s weight are imp ortant 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 highly famous and impor tant. 7. D. Individual with dependent personality disorder typically shows indecisiven ess submissiveness and clinging behavior so that others will make decisions with them. 8. A. Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts. 9. B. Bulimia disorder generally is a maladaptive coping response to stress and underlying issues. The client should identify anxiety causing situation that sti mulate 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 Blocker, such as SUCCINYLCHOLINE (Anectine) produces respir atory depression because it inhibits contractions of respiratory muscles. 12. C. With depression, there is little or no emotional involvement therefore li ttle alteration in affect. 13. D. These clients often hide food or force vomiting; therefore they must be c arefully monitored. 14. A. These clients have severely depleted levels of sodium and potassium becau se of their starvation diet and energy expenditure, these electrolytes are neces sary for cardiac functioning. 15. B. Limiting unnecessary interaction will decrease stimulation and agitation. 16. C. Ritualistic behavior seen 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 i s necessary to decrease manipulation.

18. B. Any suicidal statement must be assessed by the nurse. The nurse should di scuss 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 re pulsive, the client is likely to feel defensive because the question is belittli ng. The natural tendency is to counterattack the threat to self image. 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 administer benzodiazepine, such as lorazepan (ativan) to the client who is experiencing symptom: The client s experiences sympt oms of withdrawal because of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease. 22. D. Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. Serving coffee top the client may a dd to tremors or wakefulness. 23. D. Vomiting and diarrhea are usually the late signs of heroin withdrawal, al ong with muscle spasm, fever, nausea, repetitive, abdominal cramps and backache. 24. D. Moving to a client s personal space increases the feeling of threat, which increases anxiety. 25. A. Environmental (MILIEU) therapy aims at having everything in the client s su rrounding area toward helping the client. 26. C. Children who have experienced attachment difficulties with primary caregi ver are not able to trust others and therefore relate superficially 27. A. Children have difficulty verbally expressing their feelings, acting out b ehavior, such as temper tantrums, may indicate underlying depression. 28. D. The autistic child repeat sounds or words spoken by others. 29. D. The client statement is an example of the use of denial, a defense that b locks problem by unconscious refusing to admit they exist. 30. A. Discussion of the feared object triggers an emotional response to the obj ect. 31. B. The nurse presence may provide the client with support & feeling of contr ol. 32. D. Experiencing the actual trauma in dreams or flashback is the major sympto m that distinguishes post traumatic stress disorder from other anxiety disorder. 33. C. Confabulation or the filling in of memory gaps with imaginary facts is a defense mechanism used by people experiencing memory deficits. 34. A. These are the major signs of anorexia nervosa. Weight loss is excessive ( 15% of expected weight). 35. C. Dental enamel erosion occurs from repeated self-induced vomiting. 36. B. Depression usually is both emotional & physical. A simple daily routine i

s the best, least stressful and least anxiety producing. 37. D. The expression of these feeling may indicate that this client is unable t o continue the struggle of life. 38. A. Structure tends to decrease agitation and anxiety and to increase the cli ent s feeling of security. 39. B. The rituals used by a client with obsessive compulsive disorder help cont rol the anxiety level by maintaining a set pattern of action. 40. C. A person with this disorder would not have adequate self-boundaries. 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. Helping the client to develop feeling of self worth would reduce the clie nt s need to use pathologic defenses. 43. B. Open ended questions and silence are strategies used to encourage clients to discuss their problem in descriptive manner. 44. C. Clients who are withdrawn may be immobile and mute, and require consisten t, repeated interventions. Communication with withdrawn clients requires much pa tience from the nurse. The nurse facilitates communication with the client by si tting in silence, asking open-ended question and pausing to provide opportunitie s for the client to respond. 45. D. When hallucination is present, the nurse should reinforce reality with th e client. 46. A. Personal characteristics of abuser include low self-esteem, immaturity, d ependence, insecurity and jealousy. 47. D. A short acting skeletal muscle relaxant such as succinylcholine (Anectine ) is administered during this procedure to prevent injuries during seizure. 48. C. Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus. 49. D. Electroconvulsive therapy is an effective treatment for depression that h as not responded to medication. 50. B. In an emergency, lives saving facts are obtained first. The name and the amount of medication ingested are of outmost important in treating this potentia lly life threatening situation. 1. Nurse Tony should first discuss terminating the nurse-client relationship wit h a client during the: a. Termination phase when discharge plans are being made. b. Working phase when the client shows some progress. c. Orientation phase when a contract is established. d. Working phase when the client brings it up. 2. Malou is diagnosed with major depression spends majority of the day lying in bed with the sheet pulled over his head. Which of the following approaches by th

e nurse would be the most therapeutic? a. Question the client until he responds b. Initiate contact with the client frequently c. Sit outside the clients room d. Wait for the client to begin the conversation 3. Joe who is very depressed exhibits psychomotor retardation, a flat affect and apathy. The nurse in charge observes Joe to be in need of grooming and hygiene. Which of the following nursing actions would be most appropriate? a. Waiting until the client s family can participate in the client s care b. Asking the client if he is ready to take shower c. Explaining the importance of hygiene to the client d. Stating to the client that it s time for him to take a shower 4. When teaching Mario with a typical depression about foods to avoid while taki ng phenelzine(Nardil), which of the following would the nurse in charge include? a. Roasted chicken b. Fresh fish c. Salami d. Hamburger 5. When assessing a female client who is receiving tricyclic antidepressant ther apy, which of the following would alert the nurse to the possibility that the cl ient is experiencing anticholinergic effects? a. Urine retention and blurred vision b. Respiratory depression and convulsion c. Delirium and Sedation d. Tremors and cardiac arrhythmias 6. For a male client with dysthymic disorder, which of the following approaches would the nurse expect to implement? a. ECT b. Psychotherapeutic approach c. Psychoanalysis d. Antidepressant therapy 7. Danny who is diagnosed with bipolar disorder and acute mania, states the nurs e, Where is my daughter? I love Louis. Rain, rain go away. Dogs eat dirt. The nurs e interprets these statements as indicating which of the following?

a. Echolalia b. Neologism c. Clang associations d. Flight of ideas 8. Terry with mania is skipping up and down the hallway practically running into other clients. Which of the following activities would the nurse in charge expe ct to include in Terry s plan of care? a. Watching TV b. Cleaning dayroom tables c. Leading group activity d. Reading a book 9. When assessing a male client for suicidal risk, which of the following method s of suicide would the nurse identify as most lethal? a. Wrist cutting b. Head banging c. Use of gun d. Aspirin overdose 10. Jun has been hospitalized for major depression and suicidal ideation. Which of the following statements indicates to the nurse that the client is improving? a. b. c. d. I m of no use to anyone anymore. I know my kids don t need me anymore since they re grown. I couldn t kill myself because I don t want to go to hell. I don t think about killing myself as much as I used to.

11. Which of the following activities would Nurse Trish recommend to the client who becomes very anxious when thoughts of suicide occur? a. Using exercise bicycle b. Meditating c. Watching TV d. Reading comics 12. When developing the plan of care for a client receiving haloperidol, which o f the following medications would nurse Monet anticipate administering if the cl ient developed extra pyramidal side effects? a. Olanzapine (Zyprexa) b. Paroxetine (Paxil)

c. Benztropine mesylate (Cogentin) d. Lorazepam (Ativan) 13. Jon a suspicious client states that I know you nurses are spraying my food wi th poison as you take it out of the cart. Which of the following would be the bes t response of the nurse? a. Giving the client canned supplements until the delusion subsides b. Asking what kind of poison the client suspects is being used c. Serving foods that come in sealed packages d. Allowing the client to be the first to open the cart and get a tray 14. A client is suffering from catatonic behaviors. Which of the following would the nurse use to determine that the medication administered PRN have been most effective? a. The client responds to verbal directions to eat b. The client initiates simple activities without direction c. The client walks with the nurse to her room d. The client is able to move all extremities occasionally 15. Nurse Hazel invites new client s parents to attend the psycho educational prog ram for families of the chronically mentally ill. The program would be most like ly to help the family with which of the following issues? a. Developing a support network with other families b. Feeling more guilty about the client s illness c. Recognizing the client s weakness d. Managing their financial concern and problems 16. When planning care for Dory with schizotypal personality disorder, which of the following would help the client become involved with others? a. Attending an activity with the nurse b. Leading a sing a long in the afternoon c. Participating solely in group activities d. Being involved with primarily one to one activities 17. Which statement about an individual with a personality disorder is true? a. Psychotic behavior is common during acute episodes b. Prognosis for recovery is good with therapeutic intervention c. The individual typically remains in the mainstream of society, although he ha s problems in social and occupational roles

d. The individual usually seeks treatment willingly for symptoms that are person ally distressful. 18. Nurse John is talking with a client who has been diagnosed with antisocial p ersonality about how to socialize during activities without being seductive. Nur se John would focus the discussion on which of the following areas? a. Discussing his relationship with his mother b. Asking him to explain reasons for his seductive behavior c. Suggesting to apologize to others for his behavior d. Explaining the negative reactions of others toward his behavior 19. Tina with a histrionic personality disorder is melodramatic and responds to others and situations in an exaggerated manner. Nurse Trish would recommend whic h of the following activities for Tina? a. Baking class b. Role playing c. Scrap book making d. Music group 20. Joy has entered the chemical dependency unit for treatment of alcohol depend ency. Which of the following client s possession will the nurse most likely place in a locked area? a. Toothpaste b. Shampoo c. Antiseptic wash d. Moisturizer 21. Which of the following assessment would provide the best information about t he client s physiologic response and the effectiveness of the medication prescribe d specifically for alcohol withdrawal? a. Sleeping pattern b. Mental alertness c. Nutritional status d. Vital signs 22. After administering naloxone (Narcan), an opioid antagonist, Nurse Ronald sh ould monitor the female client carefully for which of the following? a. Respiratory depression b. Epilepsy c. Kidney failure

d. Cerebral edema 23. Which of the following would nurse Ronald use as the best measure to determi ne a client s progress in rehabilitation? a. The way he gets along with his parents b. The number of drug-free days he has c. The kinds of friends he makes d. The amount of responsibility his job entails 24. A female client is brought by ambulance to the hospital emergency room after taking an overdose of barbiturates is comatose. Nurse Trish would be especially alert for which of the following? a. Epilepsy b. Myocardial Infarction c. Renal failure d. Respiratory failure 25. Joey who has a chronic user of cocaine reports that he feels like he has coc kroaches crawling under his skin. His arms are red because of scratching. The nu rse in charge interprets these findings as possibly indicating which of the foll owing? a. Delusion b. Formication c. Flash back d. Confusion 26. Jose is diagnosed with amphetamine psychosis and was admitted in the emergen cy room. Nurse Ronald would most likely prepare to administer which of the follo wing medication? a. Librium b. Valium c. Ativan d. Haldol 27. Which of the following liquids would nurse Leng administer to a female clien t who is intoxicated with phencyclidine (PCP) to hasten excretion of the chemica l? a. Shake b. Tea c. Cranberry Juice

d. Grape juice 28. When developing a plan of care for a female client with acute stress disorde r who lost her sister in a car accident. Which of the following would the nurse expect to initiate? a. Facilitating progressive review of the accident and its consequences b. Postponing discussion of the accident until the client brings it up c. Telling the client to avoid details of the accident d. Helping the client to evaluate her sister s behavior 29. The nursing assistant tells nurse Ronald that the client is not in the dinin g room for lunch. Nurse Ronald would direct the nursing assistant to do which of the following? a. Tell the client he ll need to wait until supper to eat if he misses lunch b. Invite the client to lunch and accompany him to the dining room c. Inform the client that he has 10 minutes to get to the dining room for lunch d. Take the client a lunch tray and let the client eat in his room 30. The initial nursing intervention for the significant-others during shock pha se of a grief reaction should be focused on: a. Presenting full reality of the loss of the individuals b. Directing the individual s activities at this time c. Staying with the individuals involved d. Mobilizing the individual s support system 31. Joy s stream of consciousness is occupied exclusively with thoughts of her fat her s death. Nurse Ronald should plan to help Joy through this stage of grieving, which is known as: a. Shock and disbelief b. Developing awareness c. Resolving the loss d. Restitution 32. When taking a health history from a female client who has a moderate level o f cognitive impairment due to dementia, the nurse would expect to note the prese nce of: a. Accentuated premorbid traits b. Enhance intelligence c. Increased inhibitions

d. Hyper vigilance 33. What is the priority care for a client with a dementia resulting from AIDS? a. Planning for remotivational therapy b. Arranging for long term custodial care c. Providing basic intellectual stimulation d. Assessing pain frequently 34. Jerome who has eating disorder often exhibits similar symptoms. Nurse Lhey w ould expect an adolescent client with anorexia to exhibit: a. Affective instability b. Dishered, unkempt physical appearance c. Depersonalization and derealization d. Repetitive motor mechanisms 35. The primary nursing diagnosis for a female client with a medical diagnosis o f major depression would be: a. Situational low self-esteem related to altered role b. Powerlessness related to the loss of idealized self c. Spiritual distress related to depression d. Impaired verbal communication related to depression 36. When developing an initial nursing care plan for a male client with a Bipola r I disorder (manic episode) nurse Ron should plan to? a. Isolate his gym time b. Encourage his active participation in unit programs c. Provide foods, fluids and rest d. Encourage his participation in programs 37. Grace is exhibiting withdrawn patterns of behavior. Nurse Johnny is aware th at this type of behavior eventually produces feeling of: a. Repression b. Loneliness c. Anger d. Paranoia 38. One morning a female client on the inpatient psychiatric service complains t o nurse Hazel that she has been waiting for over an hour for someone to accompan y her to activities. Nurse Hazel replies to the client We re doing the best we can. There are a lot of other people on the unit who needs attention too. This statem

ent shows that the nurse s use of: a. Defensive behavior b. Reality reinforcement c. Limit-setting behavior d. Impulse control 39. A nursing diagnosis for a male client with a diagnosed multiple personality disorder is chronic low self-esteem probably related to childhood abuse. The mos t appropriate short term client outcome would be: a. Verbalizing the need for anxiety medications b. Recognizing each existing personality c. Engaging in object-oriented activities d. Eliminating defense mechanisms and phobia 40. A 25 year old male is admitted to a mental health facility because of inappr opriate behavior. The client has been hearing voices, responding to imaginary co mpanions and withdrawing to his room for several days at a time. Nurse Monette u nderstands that the withdrawal is a defense against the client s fear of: a. Phobia b. Powerlessness c. Punishment d. Rejection 41. When asking the parents about the onset of problems in young client with the diagnosis of schizophrenia, Nurse Linda would expect that they would relate the client s difficulties began in: a. Early childhood b. Late childhood c. Adolescence d. Puberty 42. Jose who has been hospitalized with schizophrenia tells Nurse Ron, My heart h as stopped and my veins have turned to glass! Nurse Ron is aware that this is an example of: a. Somatic delusions b. Depersonalization c. Hypochondriasis d. Echolalia 43. In recognizing common behaviors exhibited by male client who has a diagnosis

of schizophrenia, nurse Josie can anticipate: a. Slumped posture, pessimistic out look and flight of ideas b. Grandiosity, arrogance and distractibility c. Withdrawal, regressed behavior and lack of social skills d. Disorientation, forgetfulness and anxiety 44. One morning, nurse Diane finds a disturbed client curled up in the fetal pos ition in the corner of the dayroom. The most accurate initial evaluation of the behavior would be that the client is: a. Physically ill and experiencing abdominal discomfort b. Tired and probably did not sleep well last night c. Attempting to hide from the nurse d. Feeling more anxious today 45. Nurse Bea notices a female client sitting alone in the corner smiling and ta lking to herself. Realizing that the client is hallucinating. Nurse Bea should: a. Invite the client to help decorate the dayroom b. Leave the client alone until he stops talking c. Ask the client why he is smiling and talking d. Tell the client it is not good for him to talk to himself 46. When being admitted to a mental health facility, a young female adult tells Nurse Mylene that the voices she hears frighten her. Nurse Mylene understands th at the client tends to hallucinate more vividly: a. While watching TV b. During meal time c. During group activities d. After going to bed 47. Nurse John recognizes that paranoid delusions usually are related to the def ense mechanism of: a. Projection b. Identification c. Repression d. Regression 48. When planning care for a male client using paranoid ideation, nurse Jasmin s hould realize the importance of: a. Giving the client difficult tasks to provide stimulation

b. Providing the client with activities in which success can be achieved c. Removing stress so that the client can relax d. Not placing any demands on the client 49. Nurse Gerry is aware that the defense mechanism commonly used by clients who are alcoholics is: a. Displacement b. Denial c. Projection d. Compensation 50. Within a few hours of alcohol withdrawal, nurse John should assess the male client for the presence of: a. Disorientation, paranoia, tachycardia b. Tremors, fever, profuse diaphoresis c. Irritability, heightened alertness, jerky movements d. Yawning, anxiety, convulsions Answers & Rationale C. When the nurse and client agree to work together, a contract should be establ ished, the length of the relationship should be discussed in terms of its ultima te termination. B. The nurse should initiate brief, frequent contacts throughout the day to let the client know that he is important to the nurse. This will positively affect t he client s self-esteem. D. The client with depression is preoccupied, has decreased energy, and is unabl e to make decisions. The nurse presents the situation, It s time for a shower , and a ssists the client with personal hygiene to preserve his dignity and self-esteem. C. Foods high in tyramine, those that are fermented, pickled, aged, or smoked mu st be avoided because when they are ingested in combination with MAOIs a hyperte nsive crisis will occur. A. Anticholinergic effects, which result from blockage of the parasympathetic (c raniosacral) nervous system including urine retention, blurred vision, dry mouth & constipation. B. Dysthymia is a less severe, chronic depression diagnosed when a client has ha d a depressed mood for more days than not over a period of at least 2 years. Cli ent with dysthymic disorder benefit from psychotherapeutic approaches that assis t the client in reversing the negative self image, negative feelings about the f uture. D. Flight of ideas is speech pattern of rapid transition from topic to topic, of ten without finishing one idea. It is common in mania. B. The client with mania is very active & needs to have this energy channeled in a constructive task such as cleaning or tidying the room. C. A crucial factor is determining the lethality of a method is the amount of ti me that occurs between initiating the method & the delivery of the lethal impact of the method. D. The statement I don t think about killing myself as much as I used to. Indicates a lessening of suicidal ideation and improvement in the client s condition. A. Using exercise bicycle is appropriate for the client who becomes very anxious

when thoughts of suicidal occur. C. The drug of choice for a client experiencing extra pyramidal side effects fro m haloperidol (Haldol) is benztropine mesylate (cogentin) because of its anti ch olinergic properties. D. Allowing the client to be the first to open the cart & take a tray presents t he client with the reality that the nurses are not touching the food & tray, the reby dispelling the delusion. B. Although all the actions indicate improvement, the ability to initiate simple activities without directions indicates the most improvement in the catatonic b ehaviors. A. Psychoeducational groups for families develop a support network. They provide education about the biochemical etiology of psychiatric disease to reduce, not increase family guilt. C. Attending activity with the nurse assists the client to become involved with others slowly. The client with schizotypal personality disorder needs support, k indness & gentle suggestion to improve social skills & interpersonal relationshi p. C. An individual with personality disorder usually is not hospitalized unless a coexisting Axis I psychiatric disorder is present. Generally, these individuals make marginal adjustments and remain in society, although they typically experie nce relationship and occupational problems related to their inflexible behaviors . Personality disorders are chronic lifelong patterns of behavior; acute episode s do not occur. Psychotic behavior is usually not common, although it can occur in either schizotypal personality disorder or borderline personality disorder. B ecause these disorders are enduring and evasive and the individual is inflexible , prognosis for recovery is unfavorable. Generally, the individual does not seek treatment because he does not perceive problems with his own behavior. Distress can occur based on other people s reaction to the individual s behavior. D. The nurse would explain the negative reactions of others towards the client s b ehaviors to make the clients aware of the impact of his seductive behaviors on o thers. B. The nurse would use role-playing to teach the client appropriate responses to others and in various situations. This client dramatizes events, drawn attentio n to self, and is unaware of and does not deal with feelings. The nurse works to help the client clarify true feelings & learn to express them appropriately. C. Antiseptic mouthwash often contains alcohol & should be kept in locked area, unless labeling clearly indicates that the product does not contain alcohol. D. Monitoring of vital signs provides the best information about the client s over all physiologic status during alcohol withdrawal & the physiologic response to t he medication used. A. After administering naloxone (Narcan) the nurse should monitor the client s res piratory status carefully, because the drug is short acting & respiratory depres sion may recur after its effects wear off. B. The best measure to determine a client s progress in rehabilitation is the numb er of drug- free days he has. The longer the client is free of drugs, the better the prognosis is. D. Barbiturates are CNS depressants; the nurse would be especially alert for the possibility of respiratory failure. Respiratory failure is the most likely caus e of death from barbiturate over dose. B. The feeling of bugs crawling under the skin is termed as formication, and is associated with cocaine use. D. The nurse would prepare to administer an antipsychotic medication such as Hal dol to a client experiencing amphetamine psychosis to decrease agitation & psych otic symptoms, including delusions, hallucinations & cognitive impairment. C. An acid environment aids in the excretion of PCP. The nurse will definitely g ive the client with PCP intoxication cranberry juice to acidify the urine to a p h of 5.5 & accelerate excretion. A. The nurse would facilitate progressive review of the accident and its consequ ence to help the client integrate feelings & memories and to begin the grieving process.

B. The nurse instructs the nursing assistant to invite the client to lunch & acc ompany him to the dinning room to decrease manipulation, secondary gain, depende ncy and reinforcement of negative behavior while maintaining the client s worth. C. This provides support until the individuals coping mechanisms and personal su pport systems can be immobilized. C. Resolving a loss is a slow, painful, continuous process until a mental image of the dead person, almost devoid of negative or undesirable features emerges. A. A moderate level of cognitive impairment due to dementia is characterized by increasing dependence on environment & social structure and by increasing psycho logic rigidity with accentuated previous traits & behaviors. C. This action maintains for as long as possible, the clients intellectual funct ions by providing an opportunity to use them. A. Individuals with anorexia often display irritability, hospitality, and a depr essed mood. D. Depressed clients demonstrate decreased communication because of lack of psyc hic or physical energy. C. The client in a manic episode of the illness often neglects basic needs, thes e needs are a priority to ensure adequate nutrition, fluid, and rest. B. The withdrawn pattern of behavior presents the individual from reaching out t o others for sharing the isolation produces feeling of loneliness. A. The nurse s response is not therapeutic because it does not recognize the clien t s needs but tries to make the client feel guilty for being demanding. B. The client must recognize the existence of the sub personalities so that inte rpretation can occur. D. An aloof, detached, withdrawn posture is a means of protecting the self by wi thdrawing and maintaining a safe, emotional distance. C. The usual age of onset of schizophrenia is adolescence or early childhood. A. Somatic delusion is a fixed false belief about one s body. C. These are the classic behaviors exhibited by clients with a diagnosis of schi zophrenia. D. The fetal position represents regressed behavior. Regression is a way of resp onding to overwhelming anxiety. B. This provides a stimulus that competes with and reduces hallucination. D. Auditory hallucinations are most troublesome when environmental stimuli are d iminished and there are few competing distractions. A. Projection is a mechanism in which inner thoughts and feelings are projected onto the environment, seeming to come from outside the self rather than from wit hin. B. This will help the client develop self-esteem and reduce the use of paranoid ideation. B. Denial is a method of resolving conflict or escaping unpleasant realities by ignoring their existence. C. Alcohol is a central nervous system depressant. These symptoms are the body s n eurologic adaptation to the withdrawal of alcohol. 1. Flumazenil (Romazicon) has been ordered for a client who has overdosed on oxa zepam (Serax). Before administering the medication, the nurse should be prepared for which common adverse effect? A. B. C. D. Seizures Shivering Anxiety Chest pain

2. The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to: A. avoid shopping for large amounts of food. B. control eating impulses. C. identify anxiety-causing situations.

D. eat only three meals per day. 3. A client who s at high risk for suicide needs close supervision. To best ensure the client s safety, the nurse should: A. check the client frequently at irregular intervals throughout the night. B. assure the client that the nurse will hold in confidence anything the client says. C. repeatedly discuss previous suicide attempts with the client. D. disregard decreased communication by the client because this is common in sui cidal clients. 4. Which of the following drugs should the nurse prepare to administer to a clie nt with a toxic acetaminophen (Tylenol) level? A. B. C. D. deferoxamine mesylate (Desferal) succimer (Chemet) flumazenil (Romazicon) acetylcysteine (Mucomyst)

5. A client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is the nurse most likely to administer to red uce the symptoms of alcohol withdrawal? A. B. C. D. naloxone (Narcan) haloperidol (Haldol) magnesium sulfate chlordiazepoxide (Librium)

6. During postprandial monitoring, a client with bulimia nervosa tells the nurse , You can sit with me, but you re just wasting your time. After you sat with me yes terday, I was still able to purge. Today, my goal is to do it twice. What is the nurse s best response? A. B. C. D. tes I trust you not to purge. How are you purging and when do you do it? Don t worry. I won t allow you to purge today. I know it s important for you to feel in control, but I ll monitor you for 90 minu after you eat.

7. A client admitted to the psychiatric unit for treatment of substance abuse sa ys to the nurse, It felt so wonderful to get high. Which of the following is the m ost appropriate response? A. If you continue to talk like that, I m going to stop speaking to you. B. You told me you got fired from your last job for missing too many days after t aking drugs all night. C. Tell me more about how it felt to get high. D. Don t you know it s illegal to use drugs? 8. For a client with anorexia nervosa, which goal takes the highest priority? A. The client B. The client C. The client D. The client rvation. will will will will establish adequate daily nutritional intake. make a contract with the nurse that sets a target weight. identify self-perceptions about body size as unrealistic. verbalize the possible physiological consequences of self-sta

9. When interviewing the parents of an injured child, which of the following is the strongest indicator that child abuse may be a problem?

A. The B. The C. The D. The el.

injury isn t consistent with the history or the child s age. mother and father tell different stories regarding what happened. family is poor. parents are argumentative and demanding with emergency department personn

10. For a client with anorexia nervosa, the nurse plans to include the parents i n therapy sessions along with the client. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa? A. B. C. D. They They They They tend to overprotect their children. usually have a history of substance abuse. maintain emotional distance from their children. alternate between loving and rejecting their children.

11. In the emergency department, a client with facial lacerations states that he r husband beat her with a shoe. After the health care team repairs her laceratio ns, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client s h usband arrives, shouting that he wants to finish the job. What is the first priori ty of the health care worker who witnesses this scene? A. B. C. D. Remaining with the client and staying calm Calling a security guard and another staff member for assistance Telling the client s husband that he must leave at once Determining why the husband feels so angry

12. The nurse is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important? A. Fill out the client s menu and make sure she eats at least half of what is on h er tray. B. Let the client eat her meals in private. Then engage her in social activities for at least 2 hours after each meal. C. Let the client choose her own food. If she eats everything she orders, then s tay with her for 1 hour after each meal. D. Let the client eat food brought in by the family if she chooses, but she shou ld keep a strict calorie count. 13. The nurse is assigned to care for a suicidal client. Initially, which is the nurse s highest care priority? A. Assessing the client s home environment and relationships outside the hospital B. Exploring the nurse s own feelings about suicide C. Discussing the future with the client D. Referring the client to a clergyperson to discuss the moral implications of s uicide 14. A client with anorexia nervosa tells the nurse, When I look in the mirror, I hate what I see. I look so fat and ugly. Which strategy should the nurse use to d eal with the client s distorted perceptions and feelings? A. Avoid discussing the client s perceptions and feelings. B. Focus discussions on food and weight. C. Avoid discussing unrealistic cultural standards regarding weight. D. Provide objective data and feedback regarding the client s weight and attractiv eness.

15. The nurse is caring for a client being treated for alcoholism. Before initia ting therapy with disulfiram (Antabuse), the nurse teaches the client that he mu st read labels carefully on which of the following products? A. B. C. D. Carbonated beverages Aftershave lotion Toothpaste Cheese

16. The nurse is developing a plan of care for a client with anorexia nervosa. W hich action should the nurse include in the plan? A. B. C. D. Restrict visits with the family until the client begins to eat. Provide privacy during meals. Set up a strict eating plan for the client. Encourage the client to exercise, which will reduce her anxiety.

17. Victims of domestic violence should be assessed for what important informati on? A. Reasons they stay in the abusive relationship (for example, lack of financial autonomy and isolation) B. Readiness to leave the perpetrator and knowledge of resources C. Use of drugs or alcohol D. History of previous victimization 18. A client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated a t the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2 % (200 mg/dl). The client later admits to drinking heavily for years. During hos pitalization, the client periodically complains of tingling and numbness in the hands and feet. The nurse realizes that these symptoms probably result from: A. B. C. D. acetate accumulation. thiamine deficiency. triglyceride buildup. a below-normal serum potassium level

19. A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stai rs. Which action should make the nurse suspect that the child was abused? A. B. C. D. The The The The child child child child cries pulls doesn doesn uncontrollably throughout the examination. away from contact with the physician. t cry when the shoulder is examined. t make eye contact with the nurse.

20. When planning care for a client who has ingested phencyclidine (PCP), which of the following is the highest priority? A. B. C. D. Client Client Client Client s s s s physical needs safety needs psychosocial needs medical needs

21. Which outcome criteria would be appropriate for a child diagnosed with oppos itional defiant disorder?

A. B. C. D.

Accept responsibility for own behaviors. Be able to verbalize own needs and assert rights. Set firm and consistent limits with the client. Allow the child to establish his own limits and boundaries.

22. A client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. How should the nurse approach her initially ? A. Enter the room quietly and move beside her to assess her injuries. B. Call for staff back-up before entering the room and restraining her. C. Move as much glass away from her as possible and sit next to her quietly. D. Approach her slowly while speaking in a calm voice, calling her name, and tel ling her that the nurse is here to help her. 23. A client with anorexia nervosa describes herself as a whale. However, the nurs e s assessment reveals that the client is 5' 8? (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client s unrealistic body image, which intervention should be included in the plan of car e? A. Asking the client to compare her figure with magazine photographs of women he r age B. Assigning the client to group therapy in which participants provide realistic feedback about her weight C. Confronting the client about her actual appearance during one-on-one sessions , scheduled during each shift D. Telling the client of the nurse s concern for her health and desire to help her make decisions to keep her healthy 24. Eighteen hours after undergoing an emergency appendectomy, a client with a r eported history of social drinking displays these vital signs: temperature, 101. 6 F (38.7 C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The clien t exhibits gross hand tremors and is screaming for someone to kill the bugs in t he bed. The nurse should suspect: A. B. C. D. a postoperative infection. alcohol withdrawal. acute sepsis. pneumonia.

25. Clonidine (Catapres) can be used to treat conditions other than hypertension . For which of the following conditions might the drug be administered? A. B. C. D. Phencyclidine (PCP) intoxication Alcohol withdrawal Opiate withdrawal Cocaine withdrawal

26. One of the goals for a client with anorexia nervosa is that the client will demonstrate increased individual coping by responding to stress in constructive ways. Which of the following actions is the best indicator that the client is working toward meeting the goal? A. The client drinks 4 L of fluid per day. B. The client paces around the unit most of the day.

C. The client keeps a journal and discusses it with the nurse. D. The client talks almost constantly with friends by telephone. 27. The nurse in the substance abuse unit is trying to encourage a client to att end Alcoholics Anonymous meetings. When the client asks the nurse what he must d o to become a member, the nurse should respond: A. B. C. D. You must first stop drinking. Your physician must refer you to this program. Admit you re powerless over alcohol and that you need help. You must bring along a friend who will support you.

28. An attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm s employee assistance pr ogram. The nurse knows that the client s behavior most likely represents the use o f which defense mechanism? A. B. C. D. Regression Projection Reaction-formation Intellectualization

29. After completing chemical detoxification and a 12-step program to treat crac k addiction, a client is being prepared for discharge. Which remark by the clien t indicates a realistic view of the future? A. B. C. D. I I I I m never going to use crack again. know what I have to do. I have to limit my crack use. m going to take 1 day at a time. I m not making any promises. will substitue crack for something else

30. The nurse is assessing a client on admission to the chemical dependency unit for alcohol detoxification. When the nurse asks about alcohol use, this client is most likely to: A. B. C. D. accurately describe the amount consumed. underestimate the amount consumed. overestimate the amount consumed. deny any consumption of alcohol.

31. The nurse is assessing a 15-year-old female who s being admitted for treatment of anorexia nervosa. Which clinical manifestation is the nurse most likely to f ind? A. B. C. D. Tachycardia Warm, flushed extremities Parotid gland tenderness Coarse hair growth

32. A 38-year-old client is admitted for alcohol withdrawal. The most common ear ly sign or symptom that this client is likely to experience is: A. B. C. D. impending coma. manipulating behavior. suppression. perceptual disorders.

33. The nurse is caring for an adolescent female who reports amenorrhea, weight loss, and depression. Which additional assessment finding would suggest that the

woman has an eating disorder? A. B. C. D. Wearing tight-fitting clothing Increased blood pressure Oily skin Excessive and ritualized exercise

34. A client with a history of polysubstance abuse is admitted to the facility. She complains of nausea and vomiting 24 hours after admission. The nurse assesse s the client and notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through which of the following withdrawals? A. B. C. D. Alcohol withdrawal Cannibis withdrawal Cocaine withdrawal Opioid withdrawal

35. A client is admitted to the psychiatric unit with a diagnosis of anorexia ne rvosa. Although she is 5' 8? (1.7 m) tall and weighs only 103 lb (46.7 kg), she talks incessantly about how fat she is. Which measure should the nurse take first when caring for this client? A. B. C. D. Teach the client about nutrition, calories, and a balanced diet. Establish a trusting relationship with the client. Discuss cultural stereotypes regarding thinness and attractiveness. Explore the reasons why the client doesn t eat.

36. A client is admitted for an overdose of amphetamines. When assessing this cl ient, the nurse should expect to see: A. B. C. D. tension and irritability. slow pulse. hypotension. constipation.

37. Which of the following drugs may be abused because of tolerance and physiolo gic dependence. A. B. C. D. lithium (Lithobid) and divalproex (Depakote). verapamil (Calan) and chlorpromazine (Thorazine) alprazolam (Xanax) and phenobarbital (Luminal) clozapine (Clozaril) and amitriptyline (Elavil)

38. Which of the following groups are considered to be at highest risk for suici de? A. Adolescents, men over age 45, and persons who have made previous suicide atte mpts B. Teachers, divorced persons, and substance abusers C. Alcohol abusers, widows, and young married men D. Depressed persons, physicians, and persons living in rural areas 39. Tourette syndrome is characterized by the presence of multiple motor and voc al tics. A vocal tic that involves repeating one s own sounds or words is known as : A. echolalia. B. palilalia. C. apraxia.

D. aphonia. 40. A client is admitted to the psychiatric unit with a diagnosis of borderline personality disorder. The nurse expects the assessment to reveal: A. B. C. D. unpredictable behavior and intense interpersonal relationships. inability to function as a responsible parent. somatic symptoms. coldness, detachment, and lack of tender feelings.

41. A client with disorganized type schizophrenia has been hospitalized for the past 2 years on a unit for chronic mentally ill clients. The client s behavior is labile and fluctuates from childishness and incoherence to loud yelling to slow but appropriate interaction. The client needs assistance with all activities of daily living. Which behavior is characte ristic of disorganized type schizophrenia? A. B. C. D. Extreme social impairment Suspicious delusions Waxy flexibility Elevated affect

42. The nurse is providing care for a female client with a history of schizophre nia who s experiencing hallucinations. The physician orders 200 mg of haloperidol (Haldol) orally or I.M. every 4 hours as needed. What is the nurse s best action? A. B. or C. D. Administer the haloperidol orally if the client agrees to take it. Call the physician to clarify whether the haloperidol should be given orally I.M. Call the physician to clarify the order because the dosage is too high. Withhold haloperidol because it may worsen hallucinations.

43. A client receiving haloperidol (Haldol) complains of a stiff jaw and difficu lty swallowing. The nurse s first action is to: A. B. C. D. reassure the client and administer as needed lorazepam (Ativan) I.M. administer as needed dose of benztropine (Cogentin) I.M. as ordered. administer as needed dose of benztropine (Cogentin) by mouth as ordered. administer as needed dose of haloperidol (Haldol) by mouth.

44. A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse s best response at th is time would be to: A. B. C. D. take the client s vital signs. explore the content of the hallucinations. tell him his fear is unrealistic. engage the client in reality-oriented activities.

45. Which medication can control the extrapyramidal effects associated with anti psychotic agents? A. B. C. D. perphenazine (Trilafon) doxepin (Sinequan) amantadine (Symmetrel) clorazepate (Tranxene)

46. A client with paranoid schizophrenia has been experiencing auditory hallucin

ations for many years. One approach that has proven to be effective for hallucin ating clients is to: A. B. C. D. take an as-needed dose of psychotropic medication whenever they hear voices. practice saying Go away or Stop when they hear voices. sing loudly to drown out the voices and provide a distraction. go to their room until the voices go away.

47. A dystonic reaction can be caused by which of the following medications? A. B. C. D. diazepam (Valium) haloperidol (Haldol) amitriptyline (Elavil) clonazepam (Klonopin)

48. While pacing in the hall, a client with paranoid schizophrenia runs to the n urse and says, Why are you poisoning me? I know you work for central thought cont rol! You can keep my thoughts. Give me back my soul! How should the nurse respond during the early stage of the therapeutic process? A. B. C. D. I I I I m a nurse. I m not poisoning you. It s against the nursing code of ethics. m a nurse, and you re a client in the hospital. I m not going to harm you. m not poisoning you. And how could I possibly steal your soul? sense anger. Are you feeling angry today?

49. A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He s shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate? A. I think you re wrong. France is a friendly country and an ally of the United Sta tes. Their government wouldn t try to kill you. B. I find it hard to believe that a foreign government or anyone else is trying t o hurt you. You must feel frightened by this. C. You re wrong. Nobody is trying to kill you. D. A foreign government is trying to kill you? Please tell me more about it. 1. A. Seizures Rationale: Seizures are the most common serious adverse effect of using flumazen il to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common ad verse effects include shivering, anxiety, and chest pain. 2. C. identify anxiety-causing situations. Rationale: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxie ty. Controlling shopping for large amounts of food isn t a goal early in treatment . Managing eating impulses and replacing them with adaptive coping mechanisms ca n be integrated into the plan of care after initially addressing stress and unde rlying issues. Eating three meals per day isn t a realistic goal early in treatmen t. 3. A. check the client frequently at irregular intervals throughout the night. Rationale: Checking the client frequently but at irregular intervals prevents th e client from predicting when observation will take place and altering behavior in a misleading way at these times. Option B may encourage the client to try to manipulate the nurse or seek attention for having a secret suicide plan. Option C may reinforce suicidal ideas. Decreased communication is a sign of withdrawal that may indicate the client has decided to commit suicide; the nurse

shouldn t disregard it (option D 4.D. acetylcysteine (Mucomyst) Rationale: The antidote for acetaminophen toxicity is acetylcysteine. It enhance s conversion of toxic metabolites to nontoxic metabolites. Deferoxamine mesylate is the antidote for iron intoxication. Succimer is an antidote for lead poisoni ng. Flumazenil reverses the sedative effects of benzodiazepines. 5. D. chlordiazepoxide (Librium) Rationale: Chlordiazepoxide (Librium) and other tranquilizers help reduce the sy mptoms of alcohol withdrawal. Haloperidol (Haldol) may be given to treat clients with psychosis, severe agitation, or delirium. Naloxone (Narcan) is administere d for narcotic overdose. Magnesium sulfate and other anticonvulsant medications are only administered to treat seizures if they occur during withdrawal. 6. D. I know it s important for you to feel in control, but I ll monitor you for 90 m inutes after you eat. Rationale: This response acknowledges that the client is testing limits and that the nurse is setting them by performing postprandial monitoring to prevent self -induced emesis. Clients with bulimia nervosa need to feel in control of the die t because they feel they lack control over all other aspects of their lives. Bec ause their therapeutic relationships with caregivers are less important than the ir need to purge, they don t fear betraying the nurse s trust by engaging in the act ivity. They commonly plot purging and rarely share their secrets about it. An au thoritarian or challenging response may trigger a power struggle between the nur se and client. 7. B. You told me you got fired from your last job for missing too many days afte r taking drugs all night. Rationale: Confronting the client with the consequences of substance abuse helps to break through denial. Making threats (option A) isn t an effective way to prom ote self-disclosure or establish a rapport with the client. Although the nurse s hould encourage the client to discuss feelings, the discussion should focus on h ow the client felt before, not during, an episode of substance abuse (option C). Encouraging elaboration about his experience while getting high may reinforce t he abusive behavior. The client undoubtedly is aware that drug use is illegal; a reminder to this effect (option D) is unlikely to alter behavior. 8. A. The client will establish adequate daily nutritional intake. Rationale: According to Maslow s hierarchy of needs, all humans need to meet basic physiological needs first. Because a client with anorexia nervosa eats little o r nothing, the nurse must first plan to help the client meet this basic, immedia te physiological need. The nurse may give lesser priority to goals that address long-term plans (as in option B), self-perception (as in option C), and potentia l complications (as in option D). 9. A. The injury isn t consistent with the history or the child s age. Rationale: When the child s injuries are inconsistent with the history given or im possible because of the child s age and developmental stage, the emergency departm ent nurse should be suspicious that child abuse is occurring. The parents may te ll different stories because their perception may be different regarding what ha ppened. If they change their story when different health care workers ask the sa me question, this is a clue that child abuse may be a problem. Child abuse occur s in all socioeconomic groups. Parents may argue and be demanding because of the stress of having an injured child. 10.A. They tend to overprotect their children. Rationale: Clients with anorexia nervosa typically come from a family with paren ts who are controlling and overprotective. These clients use eating to gain cont rol of an aspect of their lives. The characteristics described in options B, C,

and D aren t typical of parents of children with anorexia. 11. B. Calling a security guard and another staff member for assistance Rationale: The health care worker who witnesses this scene must take precautions to ensure personal as well as client safety, but shouldn t attempt to manage a ph ysically aggressive person alone. Therefore, the first priority is to call a sec urity guard and another staff member. After doing this, the health care worker s hould inform the husband what is expected, speaking in concise statements and ma intaining a firm but calm demeanor. This approach makes it clear that the health care worker is in control and may diffuse the situation until the security guar d arrives. Telling the husband to leave would probably be ineffective because of his agitated and irrational state. Exploring his anger do esn t take precedence over safeguarding the client and staff. 12. C. Let the client choose her own food. If she eats everything she orders, th en stay with her for 1 hour after each meal. Rationale: Allowing the client to select her own food from the menu will help he r feel some sense of control. She must then eat 100% of what she selected. Remai ning with the client for at least 1 hour after eating will prevent purging. Buli mic clients should only be allowed to eat food provided by the dietary departmen t. 13. B. Exploring the nurse s own feelings about suicide Rationale: The nurse s values, beliefs, and attitudes toward self-destructive beha vior influence responses to a suicidal client; such responses set the overall mo od for the nurse-client relationship. Therefore, the nurse initially must explor e personal feelings about suicide to avoid conveying negative feelings to the cl ient. Assessment of the client s home environment and relationships may reveal the need for family therapy; however, conducting such an assessment isn t a nursing priority. Discussing the future and providing anticipatory guidance ca n help the client prepare for future stress, but this isn t a priority. Referring the client to a clergyperson may increase the client s trust or alleviate guilt; h owever, it isn t the highest priority. 14. D. Provide objective data and feedback regarding the client s weight and attra ctiveness. Rationale: By focusing on reality, this strategy may help the client develop a m ore realistic body image and gain self-esteem. Option A is inappropriate because discussing the client s perceptions and feeling wouldn t help her to identify, acce pt, and work through them. Focusing discussions on food and weight would give th e client attention for not eating, making option B incorrect. Option C is inappr opriate because recognizing unrealistic cultural standards wouldn t help the clien t establish more realistic weight goals. 15. B. Aftershave lotion Rationale: Disulfiram may be given to clients with chronic alcohol abuse who wis h to curb impulse drinking. Disulfiram works by blocking the oxidation of alcoho l, inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can produce a reaction. The client receiving disul firam must be taught to read ingredient labels carefully to avoid products conta ining alcohol such as aftershave lotions. Carbonated beverages, toothpaste, and cheese don t contain alcohol and don t need to be avoided by the client. 16. C. Set up a strict eating plan for the client. Rationale: Establishing a consistent eating plan and monitoring the client s weigh t are important for this disorder. The family should be included in the client s c are. The client should be monitored during meals not given privacy. Exercise mus t be limited and supervised.

17. B. Readiness to leave the perpetrator and knowledge of resources Rationale: Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nu rses can then provide the victims with information and options to enable them to leave when they are ready. The reasons they stay in the relationship are comple x and can be explored at a later time. The use of drugs or alcohol is irrelevant . There is no evidence to suggest that previous victimization results in a person s seeking or causing abusive relationships. 18.B. thiamine deficiency. Rationale: Numbness and tingling in the hands and feet are symptoms of periphera l polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) se condary to prolonged and excessive alcohol intake. Treatment includes reducing a lcohol intake, correcting nutritional deficiencies through diet and vitamin supp lements, and preventing such residual disabilities as foot and wrist drop. Aceta te accumulation, triglyceride buildup, and a below-normal serum potassium level are unrelated to the client s symptoms. 19. C. The child doesn t cry when the shoulder is examined. Rationale: A characteristic behavior of abused children is lack of crying when t hey undergo a painful procedure or are examined by a health care professional. T herefore, the nurse should suspect child abuse. Crying throughout the examinatio n, pulling away from the physician, and not making eye contact with the nurse ar e normal behaviors for preschoolers. 20. B. Client s safety needs Rationale: The highest priority for a client who has ingested PCP is meeting saf ety needs of the client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose control easily. After safety needs have been met, the client s physical, psychosocial, and medical needs can be met. 21. A. Accept responsibility for own behaviors. Rationale: Children with oppositional defiant disorder frequently violate the ri ghts of others. They are defiant, disobedient, and blame others for their action s. Accountability for their actions would demonstrate progress for the oppositio nal child. Options C and D aren t outcome criteria but interventions. Option B is incorrect as the oppositional child usually focuses on his own needs. 22. D. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her. Rationale: Ensuring the safety of the client and the nurse is the priority at th is time. Therefore, the nurse should approach the client cautiously while callin g her name and talking to her in a calm, confident manner. The nurse should keep in mind that the client shouldn t be startled or overwhelmed. After explaining th at the nurse is there to help, the nurse should observe the client s response care fully. If the client shows signs of agitation or confusion or poses a threat, th e nurse should retreat and request assistance. The nurse shouldn t attempt to sit next to the client or examine injuries without first announcing the nurse s presence and assessing the dangers of the situation. 23. D. Telling the client of the nurse s concern for her health and desire to help her make decisions to keep her healthy Rationale: A client with anorexia nervosa has an unrealistic body image that cau ses consumption of little or no food. Therefore, the client needs assistance wit h making decisions about health. Instead of protecting the client s health, option s A, B, and C may serve to make the client defensive and more entrenched in her unrealistic body image. 24. B. alcohol withdrawal.

Rationale: The client s vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome. Although infection, acute sepsis, and pneumonia ma y arise as postoperative complications, they wouldn t cause this client s signs and symptoms and typically would occur later in the postoperative course. 25. C. Opiate withdrawal Rationale: Clonidine is used as adjunctive therapy in opiate withdrawal. Benzodi azepines, such as chlordiazepoxide (Librium), and neuropleptic agents, such as h aloperidol, are used to treat alcohol withdrawal. Benzodiazepines and neuroplept ic agents are typically used to treat PCP intoxication. Antidepressants and medi cations with dopaminergic activity in the brain, such as fluoxotine (Prozac), ar e used to treat cocaine withdrawal. 26.C. The client keeps a journal and discusses it with the nurse. Rationale: The client is moving toward meeting the goal because recording and di scussing feelings is a constructive way to manage stress. Although physical acti vity can reduce stress, the anorexic client is more likely to use pacing to burn calories and lose weight. Although talks with friends can decrease stress, cons tant talking is more likely a way of avoiding dealing with problems. Increased f luid intake may be an attempt by the client to curb her appetite and artificiall y increase her weight. 27. C. Admit you re powerless over alcohol and that you need help. Rationale: The first of the Twelve Steps of Alcoholics Anonymous is admitting that an individual is powerless over alcohol and that life has become unmanageable. Although Alcoholics Anonymous promotes total abstinence, a client will still be accepted if he drinks. A physician referral isn t necessary to join. New members a re assigned a support person who may be called upon when the client has the urge to drink. 28. A. Regression Rationale: An adult who throws temper tantrums, such as this one, is displaying regressive behavior, or behavior that is appropriate at a younger age. In projec tion, the client blames someone or something other than the source. In reaction formation, the client acts in opposition to his feelings. In intellectualization , the client overuses rational explanations or abstract thinking to decrease the significance of a feeling or event. 29. C. I m going to take 1 day at a time. I m not making any promises. Rationale: Twelve-step programs focus on recovery 1 day at a time.Such programs discourage people from claiming that they will never again use a substance, beca use relapse is common. The belief that one may use a limited amount of an abused substance indicates denial. Substituting one abused substance for another predi sposes the client to cross-addiction. 30. B. underestimate the amount consumed. Rationale: Most people who abuse substances underestimate their consumption in a n attempt to conform to social norms or protect themselves. Few accurately descr ibe or overestimate consumption; some may deny it. Therefore, on admission, quan titative and qualitative toxicology screens are done to validate information obt ained from the client. 31. C. Parotid gland tenderness Rationale: Frequent vomiting causes tenderness and swelling of the parotid gland s. The reduced metabolism that occurs with severe weight loss produces bradycard ia and cold extremities. Soft, downlike hair (called lanugo) may cover the extre mities, shoulders, and face of an anorexic client. 32. D. perceptual disorders. Rationale: Perceptual disorders, especially frightening visual hallucinations, a

re very common with alcohol withdrawal. Coma isn t an immediate consequence. Manip ulative behaviors are part of the alcoholic client s personality but aren t signs of alcohol withdrawal. Suppression is a conscious effort to conceal unacceptable t houghts, feelings, impulses, or acts and serves as a coping mechanism for most a lcoholics. 33.D. Excessive and ritualized exercise Rationale: A client with an eating disorder will normally exercise to excess in an effort to burn as many calories as possible. The client will usually wear loo se-fitting clothing to hide what she considers to be a fat body. Skin and nails become dry and brittle and blood pressure and body temperature drop from excessi ve weight loss. 34. D. Opioid withdrawal Rationale: The symptoms listed are specific to opioid withdrawal. Alcohol withdr awal would show elevated vital signs. There is no real withdrawal from cannibis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation. 35. B. Establish a trusting relationship with the client. Rationale: A client with an eating disorder may be secretive and unwilling to ad mit that a problem exists. Therefore, the nurse first must establish a trusting relationship to elicit the client s feelings and thoughts. The anorexic client may spend long hours discussing nutrition or handling and preparing food in an effo rt to stall or avoid eating food; the nurse shouldn t reinforce her preoccupation with food, as in option A. Although cultural stereotypes may play a prominent role in anorexia nervosa, discussing these factors isn t the first action the nurs e should take. Exploring the reasons why the client doesn t eat would increase her emotional investment in food and eating. 36. A. tension and irritability. Rationale: An amphetamine is a nervous system stimulant that is subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increas es tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhe a is a common adverse effect, so option D is incorrect. 37. C. alprazolam (Xanax) and phenobarbital (Luminal) Rationale: Both benzodiazepines, such as alprazolam, and barbiturates, such as p henobarbital, are addictive, controlled substances. All the other drugs listed a ren t addictive substances. 38. A. Adolescents, men over age 45, and persons who have made previous suicide attempts Rationale: Studies of those who commit suicide reveal the following high-risk gr oups: adolescents; men over age 45; persons who have made previous suicide attem pts; divorced, widowed, and separated persons; professionals, such as physicians , dentists, and attorneys; students; unemployed persons; persons who are depress ed, delusional, or hallucinating; alcohol or substance abusers; and persons who live in urban areas. Although more women attempt suicide than men, they typically choose less lethal means and therefore are less likely to su cceed in their attempts. 39. B. palilalia. Rationale: Palilalia is defined as the repetition of sounds and words. Echolalia is the act of repeating the words of others. Apraxia is the inability to carry out motor activities, and aphonia is the inability to speak 40. A. unpredictable behavior and intense interpersonal relationships. Rationale: A client with borderline personality disorder displays a pervasive pa ttern of unpredictable behavior, mood, and self-image. Interpersonal relationshi

ps may be intense and unstable and behavior may be inappropriate and impulsive. Although the client s impaired ability to form relationships may affect parenting skills, inability to function as a responsible parent is more typical of antisoc ial personality disorder. Somatic symptoms characterize avoidant personality dis order. Coldness, detachment, and lack of tender feelings typify schizoid and sch izotypal personality disorders. 41. A. Extreme social impairment Rationale: Disorganized type schizophrenia (formerly called hebephrenia) is char acterized by extreme social impairment, marked inappropriate affect, silliness, grimacing, posturing, and fragmented delusions and hallucinations. A client with a paranoid disorder typically exhibits suspicious delusions, such as a belief t hat evil forces are after him. Waxy flexibility, a condition in which the client s limbs remain fixed in uncomfortable positions for long periods, characterizes catatonic schizophrenia. Elevated affect is associated withschizoaffective disor der. 42. C. Call the physician to clarify the order because the dosage is too high. Rationale: The dosage is too high (normal dosage ranges from 5 to 10 mg daily). Options A and B may lead to an overdose. Option D is incorrect because haloperid ol helps with symptoms of hallucinations. 43. B. administer as needed dose of benztropine (Cogentin) I.M. as ordered. Rationale: The client is most likely suffering from muscle rigidity due to halop eridol. I.M. benztropine should be administered to prevent asphyxia or aspiratio n. Lorazepam treats anxiety, not extrapyramidal effects. Another dose of haloper idol would increase the severity of the reaction. 44. B. explore the content of the hallucinations. Rationale: Exploring the content of the hallucinations will help the nurse under stand the client s perspective on the situation. The client shouldn t be touched, su ch as in taking vital signs, without telling him exactly what is going to happen . Debating with the client about his emotions isn t therapeutic. When the client i s calm, engage him in reality-based activities. 45. C. amantadine (Symmetrel) Rationale: Amantadine is an anticholinergic drug used to relieve drug-induced ex trapyramidal adverse effects, such as muscle weakness, involuntary muscle moveme nt, pseudoparkinsonism, and tardive dyskinesia. Other anticholinergic agents use d to control extrapyramidal reactions include benztropine mesylate (Cogentin), t rihexyphenidyl (Artane), biperiden (Akineton), and diphenhydramine (Benadryl). P erphenazine is an antipsychotic agent; doxepin, an antidepressant; and chlorazep ate, an antianxiety agent. Because these medications have no anticholinergic or neurotransmitter effects, they don t alleviate extrapyramidal reactions. 46. B. practice saying Go away or Stop when they hear voices. Rationale: Researchers have found that some clients can learn to control bothers ome hallucinations by telling the voices to go away or stop. Taking an as needed dose of psychotropic medication whenever the voices arise may lead to overmedic ation and put the client at risk for adverse effects. Because the voices aren t li kely to go away permanently, the client must learn to deal with the hallucinatio ns without relying on drugs. Although distraction is helpful, singing loudly may upset other clients and would be socially unacceptable after the client is disc harged. Hallucinations are most bothersome in a quiet environment when the client is alone, so sending the client to his room would in crease, rather than decrease, the hallucinations. 47. B. haloperidol (Haldol) Rationale: Haloperidol is a phenothiazine and is capable of causing dystonic rea

ctions. Diazepam and clonazepam are benzodiazepines, and amitriptyline is a tric yclic antidepressant. Benzodiazepines don t cause dystonic reactions; however, the y can cause drowsiness, lethargy, and hypotension. Tricyclic antidepressants rar ely cause severe dystonic reactions; however, they can cause a decreased level o f consciousness, tachycardia, dry mouth, and dilated pupils. 48. B. I m a nurse, and you re a client in the hospital. I m not going to harm you. Rationale: The nurse should directly orient a delusional client to reality, espe cially to place and person. Options A and C may encourage further delusions by d enying poisoning and offering information related to the delusion. Validating th e client s feelings, as in option D, occurs during a later stage in the therapeuti c process. 49. B. I find it hard to believe that a foreign government or anyone else is tryi ng to hurt you. You must feel frightened by this. Rationale: Responses should focus on reality while acknowledging the client s feel ings. Arguing with the client or denying his belief isn t therapeutic. Arguing can also inhibit development of a trusting relationship. Continuing to talk about d elusions may aggravate the psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delus ions. 1. An unemployed woman, age 24, seeks help because she feels depressed and aband oned and doesn t know what to do with her life. She says she has quit her last fiv e jobs because her coworkers didn t like her and didn t train her adequately. Last w eek, her boyfriend broke up with her after she drove his car into a tree after a n argument. The client s initial diagnosis is borderline personality disorder. Whi ch nursing observations support this diagnosis? A. B. C. D. Flat affect, social withdrawal, and unusual dress Suspiciousness, hypervigilance, and emotional coldness Lack of self-esteem, strong dependency needs, and impulsive behavior Insensitivity to others, sexual acting out, and violence

2.In a toddler, which of the following injuries is most likely the result of chi ld abuse? A. B. C. D. A hematoma on the occipital region of the head A 1-inch forehead laceration Several small, dime-sized circular burns on the child s back A small isolated bruise on the right lower extremity

3. A client is admitted to the emergency department after being found unconsciou s. Her blood pressure is 82/50 mm Hg. She is 5' 4? (1.6 m) tall, weighs 79 lb (3 5.8 kg), and appears dehydrated and emaciated. After regaining consciousness, sh e reports that she has had trouble eating lately and can t remember what she ate i n the last 24 hours. She also states that she has had amenorrhea for the past ye ar. She is convinced she is fat and refuses food. The nurse suspects that she ha s: A. B. C. D. bulimia nervosa. anorexia nervosa. depression. schizophrenia.

4. A 15-year-old girl with anorexia has been admitted to a mental health unit. S he refuses to eat. Which of the following statements is the best response from t he nurse? A. You don t have to eat. It s your choice.

B. I hope you ll eat your food by mouth. Tube feedings and I.V. lines can be uncomf ortable. C. Why do you think you re fat? You re underweight. Here look in the mirror. D. You really look terrible at this weight. I hope you ll eat. 5. A client with a history of substance abuse has been attending Alcoholics Anon ymous meetings regularly in the psychiatric unit. One afternoon, the client tell s the nurse, I m not going to those meetings anymore. I m not like the rest of those people. I m not a drunk. What is the most appropriate response? A. al? B. C. D. If you aren t an alcoholic, why do you keep drinking and ending up in the hospit It s your decision. If you don t want to go, you don t have to. You seem upset about the meetings. You have to go to the meetings. It s part of your treatment plan.

6. A client is admitted to the inpatient adolescent unit after being arrested fo r attempting to sell cocaine to an undercover police officer. The nurse plans to write a behavioral contract. To best promote compliance, the contract should be written: A. B. C. D. abstractly. by the client alone. jointly by the client and nurse. jointly by the physician and nurse.

7. During which phase of alcoholism is loss of control and physiologic dependenc e evident? A. B. C. D. Prealcoholic phase Early alcoholic phase Crucial phase Chronic phase

8. Which of the following is important when restraining a violent client? A. Have three staff members present, one for each side of the body and one for t he head. B. Always tie restraints to side rails. C. Have an organized, efficient team approach after the decision is made to rest rain the client. D. Secure restraints to the gurney with knots to prevent escape. 9. A client who s actively hallucinating is brought to the hospital by friends. Th ey say that the client used either lysergic acid diethylamide (LSD) or angel dus t (phencyclidine [PCP]) at a concert. Which of the following common assessment f indings indicates that the client may have ingested PCP? A. B. C. D. Dilated pupils Nystagmus Paranoia Altered mood

10. A severely dehydrated teenager admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. Her history incl udes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the last month. She is 5' 7? (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority? A. Initiating caloric and nutritional therapy as ordered

B. Instituting behavioral modification therapy as ordered C. Addressing the client s low self-esteem D. Regularly monitoring vital signs and weight 11. A client tells the nurse that he is having suicidal thoughts every day. In c onferring with the treatment team, the nurse should make which of the following recommendations? A. B. C. D. A no-suicide contract Weekly outpatient therapy A second psychiatric opinion Intensive inpatient treatment

12. Which of the following etiologic factors predispose a client to Tourette syn drome? A. No known etiology B. Abnormalities in brain neurotransmitters, structural changes in basal ganglia and caudate nucleus, and genetics C. Abnormalities in the structure and function of the ventricles D. Environmental factors and birth-related trauma 13. A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but he can control his use if h e chooses. Which coping mechanism is he using? A. B. C. D. Withdrawal Logical thinking Repression Denial

14. An 16-year-old boy is admitted to the facility after acting out his aggressi ons inappropriately at school. Predisposing factors to the expression of aggress ion include: A. B. C. D. violence on television. passive parents. an internal locus of control. a single-parent family

15. A client is brought to the emergency department after being beaten by her hu sband, a prominent attorney. The nurse caring for this client understands that: A. B. C. D. open boundaries are common in violent families. violence usually results from a power struggle. domestic violence and abuse span all socioeconomic classes. violent behavior is a genetic trait passed from one generation to the next.

16. On discharge after treatment for alcoholism, a client plans to take disulfir am (Antabuse) as prescribed. When teaching the client about this drug, the nurse emphasizes the need to: A. B. C. D. avoid all products containing alcohol. adhere to concomitant vitamin B therapy. return for monthly blood drug level monitoring. limit alcohol consumption to a moderate level.

17. During a private conversation, a client with borderline personality disorder asks the nurse to keep his secret and then displays multiple, self-inflicted, s uperficial lacerations on the forearms. What is the nurse s best response?

A. That s it! You re B. I m going to tell C. Tell me what type D. The team needs to tell the others, but

on suicide precautions. your physician. Do you want to tell me why you did that? of instrument you used. I m concerned about infection. know when something important occurs in treatment. I need to let s talk about it first.

18. The nurse is providing care for a client undergoing opiate withdrawal. Opiat e withdrawal causes severe physical discomfort and can be life-threatening. To m inimize these effects, opiate users are commonly detoxified with: A. B. C. D. barbiturates. amphetamines. methadone. benzodiazepines.

19. The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates such as morphine include: A. B. C. D. dilated pupils and slurred speech. rapid speech and agitation. dilated pupils and agitation. euphoria and constricted pupils.

20. Which of the following signs should the nurse expect in a client with known amphetamine overdose? A. B. C. D. Hypotension Tachycardia Hot, dry skin Constricted pupils

21. A client is admitted to the psychiatric unit with a diagnosis of alcohol int oxication and suspected alcohol dependence. Other assessment findings include an enlarged liver, jaundice, lethargy, and rambling, incoherent speech. No other i nformation about the client is available. After the nurse completes the initial assessment, what is the first priority? A. Instituting seizure precautions, obtaining frequent vital signs, and recordin g fluid intake and output B. Checking the client s medical records for health history information C. Attempting to contact the client s family to obtain more information about the client D. Restricting fluids and leaving the client alone to sleep off the episode 22. Which nursing action is best when trying to diffuse a client s impending viole nt behavior? A. B. C. D. Helping the client identify and express feelings of anxiety and anger Involving the client in a quiet activity to divert attention Leaving the client alone until the client can talk about feelings Placing the client in seclusion

23. The nurse is working with a client who abuses alcohol. Which of the followin g facts should the nurse communicate to the client? A. B. C. D. Abstinence is Attendance at For treatment An occasional the basis for successful treatment. Alcoholics Anonymous meetings every day will cure alcoholism. to be successful, family members must participate. social drink is acceptable behavior for the alcoholic

24. Which psychosocial influence has been causally related to the development of aggressive behavior and conduct disorder? A. B. C. D. An overbearing mother Rejection by peers A history of schizophrenia in the family Low socioeconomic status

25. In group therapy, a client who has used I.V. heroin every day for the past 1 4 years says, I don t have a drug problem. I can quit whenever I want. I ve done it b efore. Which defense mechanism is the client using? A. B. C. D. Denial Obsession Compensation Rationalization

26. A client with a history of cocaine addiction is admitted to the coronary car e unit for evaluation of substernal chest pain. The electrocardiogram (ECG) show s a 1-mm ST-segment elevation the anteroseptal leads and T-wave inversion in lea ds V3 to V5. Considering the client s history of drug abuse, the nurse expects the physician to prescribe: A. B. C. D. lidocaine (Xylocaine). procainamide (Pronestyl). nitroglycerin (Nitro-Bid IV). epinephrine.

27. A 15-year-old client is brought to the clinic by her mother. Her mother expr esses concern about her daughter s weight loss and constant dieting. The nurse con ducts a health history interview. Which of the following comments indicates that the client may be suffering from anorexia nervosa? A. I like the way I look. I just need to keep my weight down because I m a cheerlea der. B. I don t like the food my mother cooks. I eat plenty of fast food when I m out with my friends. C. I just can t seem to get down to the weight I want to be. I m so fat compared to o ther girls. D. I do diet around my periods; otherwise, I just get so bloated. 28. Which is the drug of choice for treating Tourette syndrome? A. B. C. D. fluoxetine (Prozac) fluvoxamine (Luvox) haloperidol (Haldol) paroxetine (Paxil)

29. The client tells the nurse he was involved in a car accident while he was in toxicated. What would be the most therapeutic response from the nurse? A. B. C. D. Why didn t you get someone else to drive you? Tell me how you feel about the accident. You should know better than to drink and drive. I recommend that you attend an Alcoholics Anonymous meeting.

30. A client voluntarily admits himself to the substance abuse unit. He confesse s that he drinks 1 qt or more of vodka each day and uses cocaine occasionally. L ater that afternoon, he begins to show signs of alcohol withdrawal. What are som

e early signs of this condition? A. B. C. D. Vomiting, diarrhea, and bradycardia Dehydration, temperature above 101 F (38.3 C), and pruritus Hypertension, diaphoresis, and seizures Diaphoresis, tremors, and nervousness

31. When monitoring a client recently admitted for treatment of cocaine addictio n, the nurse notes sudden increases in the arterial blood pressure and heart rat e. To correct these problems, the nurse expects the physician to prescribe: A. B. C. D. norepinephrine (Levophed) and lidocaine (Xylocaine). nifedipine (Procardia) and lidocaine. nitroglycerin (Nitro-Bid IV) and esmolol (Brevibloc). nifedipine and esmolol

32. A client experiencing alcohol withdrawal is upset about going through detoxi fication. Which of the following goals is a priority? A. B. C. D. The The The The client client client client will will will will commit to a drug-free lifestyle. work with the nurse to remain safe. drink plenty of fluids daily. make a personal inventory of strengths

33. A client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiati ng fights and abusing animals and recently was arrested for setting a neighbor s d og on fire. When evaluating this client for the potential for violence, the nurs e should assess for which behavioral clues? A. B. C. D. A rigid posture, restlessness, and glaring Depression and physical withdrawal Silence and noncompliance Hypervigilance and talk of past violent acts

34. A client is brought to the psychiatric clinic by family members, who tell th e admitting nurse that the client repeatedly drives while intoxicated despite th eir pleas to stop. During an interview with the nurse, which statement by the cl ient most strongly supports a diagnosis of psychoactive substance abuse? A. I m not addicted to alcohol. In fact, I can drink more than I used to without be ing affected. B. I only spend half of my paycheck at the bar. C. I just drink to relax after work. D. I know I ve been arrested three times for drinking and driving, but the police a re just trying to hassle me. 35. A client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client s wrists are scratched f rom a recent suicide attempt. Based on this finding, the nurse should formulate a nursing diagnosis of: A. B. C. D. Ineffective individual coping related to feelings of guilt. Situational low self-esteem related to feelings of loss of control. Risk for violence: Self-directed related to impulsive mutilating acts. Risk for violence: Directed toward others related to verbal threats.

36. A client recently admitted to the hospital with sharp, substernal chest pain suddenly complains of palpitations. The nurse notes a rise in the client s arteri al blood pressure and a heart rate of 144 beats/minute. On further questioning,

the client admits to having used cocaine recently after previously denying use o f the drug. The nurse concludes that the client is at high risk for which compli cation of cocaine use? A. B. C. D. Coronary artery spasm Bradyarrhythmias Neurobehavioral deficits Panic disorder

37. A client is being admitted to the substance abuse unit for alcohol detoxific ation. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Ba sed on this response, the nurse should expect early withdrawal symptoms to: A. B. C. D. begin after 7 days. not occur at all because the time period for their occurrence has passed. begin anytime within the next 1 to 2 days. begin within 2 to 7 days.

38. The nurse is assigned to care for a client with anorexia nervosa. Initially, which nursing intervention is most appropriate for this client? A. Providing one-on-one supervision during meals and for 1 hour afterward B. Letting the client eat with other clients to create a normal mealtime atmosph ere C. Trying to persuade the client to eat and thus restore nutritional balance D. Giving the client as much time to eat as desired 39. A client begins to experience alcoholic hallucinosis. What is the best nursi ng intervention at this time? A. Keeping the client restrained in bed B. Checking the client s blood pressure every 15 minutes and offering juices C. Providing a quiet environment and administering medication as needed and pres cribed D. Restraining the client and measuring blood pressure every 30 minutes 40. Which assessment finding is most consistent with early alcohol withdrawal? A. B. C. D. Heart Heart Blood Blood rate of 120 to 140 beats/minute rate of 50 to 60 beats/minute pressure of 100/70 mm Hg pressure of 140/80 mm Hg

41. Which client is at highest risk for suicide? A. One who appears depressed, frequently thinks of dying, and gives away all per sonal possessions B. One who plans a violent death and has the means readily available C. One who tells others that he or she might do something if life doesn t get bett er soon D. One who talks about wanting to die 42. Which of the following medical conditions is commonly found in clients with bulimia nervosa? A. B. C. D. Allergies Cancer Diabetes mellitus Hepatitis A

43. A high school student is referred to the school nurse for suspected substanc e abuse. Following the nurse s assessment and interventions, what would be the mos t desirable outcome? A. B. C. D. The The The The student student student student discusses conflicts over drug use. accepts a referral to a substance abuse counselor. agrees to inform his parents of the problem. reports increased comfort with making choices.

44. A client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, the physician is most likely to prescribe which drug? A. B. C. D. clozapine (Clozaril) thiothixene (Navane) lorazepam (Ativan) lithium carbonate (Eskalith)

45. A client is being treated for alcoholism. After a family meeting, the client s spouse asks the nurse about ways to help the family deal with the effects of al coholism. The nurse should suggest that the family join which organization? A. B. C. D. Al-Anon Make Today Count Emotions Anonymous Alcoholics Anonymous

46. A client is admitted to the psychiatric clinic for treatment of anorexia ner vosa. To promote the client s physical health, the nurse should plan to: A. B. C. D. severely restrict the client s physical activities. weigh the client daily, after the evening meal. monitor vital signs, serum electrolyte levels, and acid-base balance. instruct the client to keep an accurate record of food and fluid intake.

47. A young man is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running aw ay, auto theft, and vandalism. He dropped out of school at age 16 and has been l iving on his own since then. His history suggests maladaptive coping, which is a ssociated with: A. B. C. D. antisocial personality disorder. borderline personality disorder. obsessive-compulsive personality disorder. narcissistic personality disorder.

48. A husband and wife seek emergency crisis intervention because he slapped her repeatedly the night before. The husband indicates that his childhood was marre d by an abusive relationship with his father. When intervening with this couple, the nurse knows they are at risk for repeated violence because the husband: A. B. C. D. has only moderate impulse control. denies feelings of jealousy or possessiveness. has learned violence as an acceptable behavior. feels secure in his relationship with his wife.

49. A client whose husband just left her has a recurrence of anorexia nervosa. T he nurse caring for her realizes that this exacerbation of anorexia nervosa resu lts from the client s effort to:

A. B. C. D.

manipulate her husband. gain control of one part of her life. commit suicide. live up to her mother s expectations.

50. A client has approached the nurse asking for advice on how to deal with his alcohol addiction. The nurse should tell the client that the only effective trea tment for alcoholism is: A. B. C. D. psychotherapy. total abstinence. Alcoholics Anonymous (AA). aversion therapy.

Answers & Rationale 1. C. Lack of self-esteem, strong dependency needs, and impulsive behavior Rationale: Borderline personality disorder is characterized by lack of self-este em, strong dependency needs, and impulsive behavior. Instability in interpersona l relationships, mood, and poor self-image also is common. Typically, the client can t tolerate being alone and expresses fee lings of emptiness or boredom. Flat affect, social withdrawal, and unusual dress are characteristic of schizoid personality disorder. Suspiciousness, hypervigil ance, and emotional coldness are seen in paranoid personality disorders. In anti social personality disorder, clients are usually insensitive to others and act o ut sexually; they may also be violent 2.C. Several small, dime-sized circular burns on the child s back Rationale: Small circular burns on a child s back are no accident and may be from cigarettes. Toddlers are injury prone because of their developmental stage, and falls are frequent because of their unsteady gait; head injuries aren t uncommon. A small area of ecchymosis isn t suspicious in this age-group. 3.B. anorexia nervosa. Rationale: Anorexia nervosa is an eating disorder characterized by self-imposed starvation with subsequent emaciation, nutritional deficiencies, and atrophic an d metabolic changes. Typically, the client is hypotensive and dehydrated. Depending on the severity of the disorder, anorex ic clients are at risk for circulatory collapse (indicated by hypotension), dehy dration, and death. Bulimia nervosa is an eating disorder characterized by binge eating followed by self-induced vomiting. Although depression may be accompanie d by weight loss, it isn t characterized by a body image disturbance or the intens e fear of obesity seen in anorexia nervosa. Schizophrenia may cause bizarre eati ng patterns, but it rarely causes the full syndrome of anorexia nervosa. 4. B. I hope you ll eat your food by mouth. Tube feedings and I.V. lines can be unc omfortable. Rationale: Clients with anorexia can refuse food to the point of cardiac damage. Tube feedings and I.V. infusions are ordered to prevent such damage. The nurse is informing her of her treatment options. Option A doesn t tell the client about the consequences of choosing not to eat. Telling clients that they are too thin won t change their self-image. 5. C. You seem upset about the meetings. Rationale: The substance abuser uses the substance to cope with feelings and may deny the abuse. Asking if the client is upset about the meetings encourages the client to identify and deal with feelings instead of covering them up. Arguing with the client about the substance abuse (option A) or insisting that the clien t attend the meetings (option D) wouldn t help the client identify resistance to t reatment. Option B isn t therapeutic behavior because it plays down the importance

of attending meetings. 6. C. jointly by the client and nurse. Rationale: A contract written jointly by the client and nurse most successfully promotes cooperation and consistent behavior. The most effective contract and th e type least likely to allow for manipulation and misinterpretation states the b ehavioral terms as concretely as possible. A contract written solely by the clie nt may not be agreeable to staff members; one written by the physician and nurse may not be agreeable to the client. 7. C. Crucial phase Rationale: The crucial phase is marked by physical dependence. The prealcoholic phase is characterized by drinking to medicate feelings and for relief from stre ss. The early phase is characterized by sneaking drinks, blackouts, rapidly gulp ing drinks, and preoccupation with alcohol. The chronic phase is characterized b y emotional and physical deterioration. 8. C. Have an organized, efficient team approach after the decision is made to r estrain the client. Rationale: Emergency department personnel should use an organized, team approach when restraining violent clients so that no one is injured in the process. The leader, located at the client s head, should take charge; four staff members are r equired to hold and restrain the limbs. For safety reasons, restraints should be fastened to the bed frame instead of the side rails. For quick release, loops s hould be used instead of knots 9. B. Nystagmus Rationale: Phencyclidine is an anesthetic with severe psychological effects. It blocks the reuptake of dopamine and directly affects the midbrain and thalamus. Nystagmus and ataxia are common physical findings of PCP use. Dilated pupils are evidence of LSD ingestion. Paranoia and altered mood occur with both PCP and LS D ingestion. 10. A. Initiating caloric and nutritional therapy as ordered Rationale: The client with anorexia nervosa is at risk for death from self-starv ation. Therefore, initiating caloric and nutritional therapy takes highest prior ity. Behavioral modification (in which client privileges depend on weight gain) and psychoanalysis (which addresses the client s low self-esteem, guilt, anxiety, and feelings of hopelessness and depression) are important aspects of care but a re secondary to stabilizing the client s physical condition. Monitoring vital sign s and weight is important in evaluating nutritional therapy but doesn t take prece dence over providing adequate caloric intake to ensure survival 11. D. Intensive inpatient treatment Rationale: Inpatient care is the best intervention for a client who is thinking about suicide every day. Implementing a no-suicide contract is an important stra tegy, but this client requires additional care. Weekly therapy wouldn t provide th e intensity of care that this case warrants. Obtaining a second opinion would ta ke time; this client requires immediate intervention. 12. B. Abnormalities in brain neurotransmitters, structural changes in basal gan glia and caudate nucleus, and genetics Rationale: The etiology of Tourette syndrome includes genetics, abnormalities in neurotransmission, and structural changes in the basal ganglia and caudate nucl eus. The ventricles in the brain, environmental factors, and birth trauma aren t i nvolved. 13. D. Denial Rationale: Denial is an unconscious defense mechanism in which emotional conflic t and anxiety are avoided by refusing to acknowledge feelings, desires, impulses

, or external facts that are consciously intolerable. Withdrawal is a common response to stress, characterized by apathy. Logical thinking IS the ability to think rationally and make responsible decisi ons, which would lead the client to admitting the problem and seeking help. Repr ession is suppressing past events from the consciousness because of guilty assoc iation. 14. A. violence on television. Rationale: Violence on television has been correlated with an increase in aggres sive behavior. Passive parents contribute to acting-out behaviors but not specif ically to violence. An internal locus of control leads to a positive sense of se lf-esteem and isn t related to violence or aggression. There is no direct correlat ion between single-parent families and violence. 15. C. domestic violence and abuse span all socioeconomic classes. Rationale: Domestic violence and abuse affect all socioeconomic classes. Closed boundaries and an imbalance of power, with one member having control over the ot hers, are common in violent families. Although violent behavior may be passed fr om one generation to the next, it s a learned behavior, not a genetic trait. 16. A. avoid all products containing alcohol. Rationale: To avoid severe adverse effects, the client taking disulfiram must st rictly avoid alcohol and all products that contain alcohol. Vitamin B therapy an d blood monitoring aren t necessary during disulfiram therapy. 17. D. The team needs to know when something important occurs in treatment. I nee d to tell the others, but let s talk about it first. Rationale: This response informs the client of the nurse s planned actions and all ows time to discuss the client s actions. Options A and B put the client on the de fensive and may lead to a power struggle. Option C ignores the psychological imp lications of the client s actions. 18. C. methadone. Rationale: Methadone is used to detoxify opiate users because it binds with opio id receptors at many sites in the central nervous system but doesn t have the same deleterious effects as other opiates, such as cocaine, heroin, and morphine. Ba rbiturates, amphetamines, and benzodiazepines are highly addictive and would req uire detoxification treatment. 19. D. euphoria and constricted pupils. Rationale: Assessment findings in a client abusing opiates include agitation, sl urred speech, euphoria, and constricted pupils. 20. B. Tachycardia Rationale: Amphetamines are central nervous system stimulants. They cause sympat hetic stimulation, including hypertension, tachycardia, vasoconstriction, and hy perthermia. Hot, dry skin is seen with anticholinergic agents such as jimsonweed. Pupils will be dilated, not constrict ed. 21. A. Instituting seizure precautions, obtaining frequent vital signs, and reco rding fluid intake and output Rationale: A nurse who lacks adequate information to determine which level of ca re a client requires must take all possible precautions to ensure the client s phy sical safety and prevent complications. To do otherwise could place the client a t risk for potential complications. After taking all possible precautions, the n urse can begin seeking health history information and, as needed, modify the pla n of care. Fluids are typically increased unless contraindicated by a preexistin g medical condition.

22. A. Helping the client identify and express feelings of anxiety and anger Rationale: In many instances, the nurse can diffuse impending violence by helpin g the client identify and express feelings of anger and anxiety. Such statements as What happened to get you this angry? may help the client verbalize feelings rather than act on them. Close inte raction with the client in a quiet activity may place the nurse at risk for inju ry should the client suddenly become violent. An agitated and potentially violen t client shouldn t be left alone or unsupervised because the danger of the client acting out is too great. The client should be placed in seclusion only if other interventions fail or the client requests this. Unlocked seclusion can be helpfu l for some clients because it reduces environmental stimulation and provides a f eeling of security. 23. A. Abstinence is the basis for successful treatment. Rationale: The foundation of any treatment for alcoholism is abstinence. Attenda nce at Alcoholics Anonymous is helpful to some individuals to maintain strict ab stinence. Participation in treatment by the family is beneficial to both the client and the family but isn t essential. Ab stinence requires refraining from social drinking. 24. B. Rejection by peers Rationale: Studies indicate that children who are rejected by their peers are mo re likely to behave aggressively. Aggression and conduct disorder are represente d in all socioeconomic groups. Schizophrenia and an overbearing mother haven t bee n associated with aggression or conduct disorder 25. A. Denial Rationale: A client who states that he or she doesn t have a drug problem and can quit using drugs at any time despite evidence to the contrary is denying the dru g addiction. Obsession isn t a defense mechanism. In compensation, the client emph asizes positive attributes to compensate for negative ones. In rationalization, the client justifies behaviors by faulty logic. 26. C. nitroglycerin (Nitro-Bid IV). Rationale: The elevated ST segments in this client s ECG indicate myocardial ische mia. To reverse this problem, the physician is mostlikely to prescribe an infusi on of nitroglycerin to dilate the coronary arteries. Lidocaine and procainamide are cardiac drugs that may be indicated for this client at some point but aren t used for coronary artery dilation. If a coca ine user experiences ventricular fibrillation or asystole, the physician may pre scribe epinephrine. However, this drug must be used with caution because cocaine may potentiate its adrenergic effects. 27. C. I just can t seem to get down to the weight I want to be. I m so fat compared to other girls. Rationale: Low self-esteem is the highest risk factor for anorexia nervosa. Cons tant dieting to get down to a desirable weight is characteristic of the disorder. Feeling inadequate when compared to peers indicates poor self-esteem. Most clients with anorexia nervosa don t like th e way they look, and their self-perception may be distorted. A girl with cachexi a may perceive herself to be overweight when she looks in the mirror. Preferring fast food over healthy food is common i n this age-group. Because of the absence of body fat necessary for proper hormon e production, amenorrhea is common in a client with anorexia nervosa. 28. C. haloperidol (Haldol) Rationale: Haloperidol is the drug of choice for treating Tourette syndrome. Pro zac, Luvox, and Paxil are antidepressants and aren t used to treat Tourette syndro me

29. B. Tell me how you feel about the accident. Rationale: An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in his feelings. Asking the cl ient why he drove while intoxicated can make him feel defensive and intimidated. A judgmental approach isn t therapeutic. By giving advice, the nurse suggests tha t the client isn t capable of making decisions, thus fostering dependency. 30. D. Diaphoresis, tremors, and nervousness Rationale: Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic ha llucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs o f alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pu lse rate, sleep disturbance, and irritability. Although diarrhea may be an early sign of alcohol withdrawal, tachycardia not bradycardia is associated with alco hol withdrawal. Dehydration and an elevated temperature may be expected, but a t emperature above 101 F indicates an infection rather than alcohol withdrawal. Pru ritus rarely occurs in alcohol withdrawal. If withdrawal symptoms remain untreat ed, seizures may arise later. 31. D. nifedipine and esmolol Rationale: This client requires a vasodilator, such as nifedipine, to treat hype rtension, and a beta-adrenergic blocker, such as esmolol, to reduce the heart ra te. Lidocaine, an antiarrhythmic, isn t indicated because the client doesn t have an arrhythmia. Although nitroglycerin may be used to treat coronary vasospasm, it isn t the drug of choice in hypertension. 32. B. The client will work with the nurse to remain safe. Rationale: The priority goal in alcohol withdrawal is maintaining the client s saf ety. Committing to a drug-free lifestyle, drinking plenty of fluids, and identif ying personal strengths are important goals, but ensuring the client s safety is t he nurse s top priority. 33. A. A rigid posture, restlessness, and glaring Rationale: Behavioral clues that suggest the potential for violence include a ri gid posture, restlessness, glaring, a change in usual behavior, clenched hands, overtly aggressive actions, physical withdrawal, noncompliance, overreaction, ho stile threats, recent alcohol ingestion or drug use, talk of past violent acts, inability to express feelings, repetitive demands and complaints, argumentativen ess, profanity, disorientation, inability to focus attention, hallucinations or delusions, paranoid ideas or suspicions, and somatic complaints. Violent clients rarely exhibit depression, silence, or hypervigilance. 34. D. I know I ve been arrested three times for drinking and driving, but the poli ce are just trying to hassle me. Rationale: According to the Diagnostic and Statistical Manual of Mental Disorder s, 4th edition, diagnostic criteria for psychoactive substance abuse include a m aladaptive pattern of such use, indicated either by continued use despite knowle dge of having a persistent or recurrent social, occupational, psychological, or physical problem caused or exacerbated by substance abuse or recurrent use in da ngerous situations (for example, while driving). For this client, psychoactive s ubstance dependence must be ruled out; criteria for this disorder include a need for increasing amounts of the substance to achieve intoxication (option A), inc reased time and money spent on the substance (option B), inability to fulfill ro le obligations (option C), and typical withdrawal symptoms. 35. C. Risk for violence: Self-directed related to impulsive mutilating acts. Rationale: The predominant behavioral characteristic of the client with borderli

ne personality disorder is impulsiveness, especially of a physically self-destru ctive sort. The observation that the client has scratched wrists doesn t substanti ate the other options. 36.A. Coronary artery spasm Rationale: Cocaine use may cause such cardiac complications as coronary artery s pasm, myocardial infarction, dilated cardiomyopathy, acute heart failure, endoca rditis, and sudden death. Cocaine blocks reuptake of norepinephrine, epinephrine , and dopamine, causing an excess of these neurotransmitters at postsynaptic rec eptor sites. Consequently, the drug is more likely to cause tachyarrhythmias tha n bradyarrhythmias. Although neurobehavioral deficits are common in neonates bor n to cocaine users, they are rare in adults. As craving for the drug increases, a person who s addicted to cocaine typically experiences euphoria followed by depr ession, not panic disorder. 37. C. begin anytime within the next 1 to 2 days. Rationale: Acute withdrawal symptoms from alcohol may begin 6 hours after the cl ient has stopped drinking and peak 1 to 2 days later. Delirium tremens may occur 2 to 4 days even up to 7 days after the last drink. 38. A. Providing one-on-one supervision during meals and for 1 hour afterward Rationale: Because the client with anorexia nervosa may discard food or induce v omiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 hour afterward. Option B wouldn t be therapeutic because other cli ents may urge the client to eat and give attention for not eating. Option C woul d reinforce control issues, which are central to this client s underlying psycholo gical problem. Instead of giving the client unlimited time to eat, as in option D, the nurse should set limits and let the client know what is expected. 39. C. Providing a quiet environment and administering medication as needed and prescribed Rationale: Manifestations of alcoholic hallucinosis are best treated by providin g a quiet environment to reduce stimulation and administering prescribed central nervous system depressants in dosages that control symptoms without causing ove rsedation. Although bed rest is indicated, restraints are unnecessary unless the client poses a danger to himself or others. Also, restraints may increase agita tion and make the client feel trapped and helpless when hallucinating. Offering juice is appropriate, but measuring blood pressure every 15 minutes would interr upt the client s rest. To avoid overstimulating the client, the nurse should check blood pressure every 2 hours. 40. A. Heart rate of 120 to 140 beats/minute Rationale: Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sig n of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, flu ctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in lat er stages. Hypotension is associated with cardiovascular collapse and most commo nly occurs in clients who don t receive treatment. The nurse should monitor the cl ient s vital signs carefully throughout the entire alcohol withdrawal process. 41. B. One who plans a violent death and has the means readily available Rationale: The client at highest risk for suicide is one who plans a violent dea th (for example, by gunshot, jumping off a bridge, or hanging), has a specific p lan (for example, after the spouse leaves for work), and has the means readily available (for example, a rifle hidden in the g arage). A client who gives away possessions, thinks about death, or talks about wanting to die or attempting suicide is considered at a lower risk for suicide because this behavior typically serves to alert others that the client is contemplating suicide and wishes to be helped.

42. C. Diabetes mellitus Rationale: Bulimia nervosa can lead to many complications, including diabetes, h eart disease, and hypertension. The eating disorder isn t typically associated wit h allergies, cancer, or hepatitis A. 43. B. The student accepts a referral to a substance abuse counselor. Rationale: All of the outcomes stated are desirable; however, the best outcome i s that the student would agree to seek the assistance of a professional substanc e abuse counselor. 44. C. lorazepam (Ativan) Rationale: The best choice for preventing or treating alcohol withdrawal symptom s is lorazepam, a benzodiazepine. Clozapine and thiothixene are antipsychotic ag ents, and lithium carbonate is an antimanic agent; these drugs aren t used to mana ge alcohol withdrawal syndrome. 45. A. Al-Anon Rationale: Al-Anon is an organization that assists family members to share commo n experiences and increase their understanding of alcoholism. Make Today Count i s a support group for people with lifethreatening or chronic illnesses. Emotions Anonymous is a support group for peop le experiencing depression, anxiety, or similar conditions. Alcoholics Anonymous is an organization that helps alcoholics recover by using a twelve-step program . 46. C. monitor vital signs, serum electrolyte levels, and acid-base balance. Rationale: An anorexic client who requires hospitalization is in poor physical c ondition from starvation and may die as a result of arrhythmias, hypothermia, ma lnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalan ces. Therefore, 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 ob tained after the evening meal. Option D would reward the client with attention f or not eating and reinforce the control issues that are central to the underlyin g psychological problem; also, the client may record food and fluid intake inacc urately. 47. A. antisocial personality disorder. Rationale: The client s history of delinquency, running away from home, vandalism, and dropping out of school are characteristic of antisocial personality disorde r. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to rel ate meaningfully to others. In borderline personality disorder, the client exhib its mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive personality disorder is cha racterized by a preoccupation with impulses and thoughts that the client realize s are senseless but can t control. Narcissistic personality disorder is marked by a pattern of self-involvement, grandiosity, and demand for constant attention. 48. C. has learned violence as an acceptable behavior. Rationale: Family violence usually is a learned behavior, and violence typically leads to further violence, putting this couple at risk. Repeated slapping may i ndicate poor, not moderate, impulse control. Violent people commonly are jealous and possessive and feel insecure in their relationships. 49. B. gain control of one part of her life. Rationale: By refusing to eat, a client with anorexia nervosa is unconsciously a ttempting to gain control over the only part of her life she feels she can contr ol. This eating disorder doesn t represent an attempt to manipulate others or live up to their expectations (although anorexia

nervosa has a high incidence in families that emphasize achievement). The clien t isn t attempting to commit suicide through starvation; rather, by refusing to ea t, she is expressing feelings of despair, worthlessness, and hopelessness. 50. B. total abstinence. Rationale: Total abstinence is the only effective treatment for alcoholism. Psyc hotherapy, attendance at AA meetings, and aversion therapy are all adjunctive th erapies that can support the client in his efforts to abstain. 1. The nurse is caring for a client with schizophrenia. Which of the following o utcomes is the least desirable? A. B. C. D. The The The The client client client client spends more time by himself. doesn t engage in delusional thinking. doesn t harm himself or others. demonstrates the ability to meet his own self-care needs.

2. The nurse formulates a nursing diagnosis of Impaired verbal communication for a client with schizotypal personality disorder. Based on this nursing diagnosis , which nursing intervention is most appropriate? A. Helping the client to participate in social interactions B. Establishing a one-on-one relationship with the client C. Establishing alternative forms of communication D. Allowing the client to decide when he wants to participate in verbal communic ation with the nurse 3. Since admission 4 days ago, a client has refused to take a shower, stating, Th ere are poison crystals hidden in the showerhead. They ll kill me if I take a show er. Which nursing action is most appropriate? A. B. C. D. Dismantling the showerhead and showing the client that there is nothing in it Explaining that other clients are complaining about the client s body odor Asking a security officer to assist in giving the client a shower Accepting these fears and allowing the client to take a sponge bath

4. Drug therapy with thioridazine (Mellaril) shouldn t exceed a daily dose of 800 mg to prevent which adverse reaction? A. B. C. D. Hypertension Respiratory arrest Tourette syndrome Retinal pigmentation

5. A client with paranoid personality disorder is admitted to a psychiatric faci lity. Which remark by the nurse would best establish rapport and encourage the c lient to confide in the nurse? A. B. C. D. I get upset once in a while, too. I know just how you feel. I d feel the same way in your situation. I worry, too, when I think people are talking about me. At times, it s normal not to trust anyone.

6. How soon after chlorpromazine (Thorazine) administration should the nurse exp ect to see a client s delusional thoughts and hallucinations eliminated? A. B. C. D. Several Several Several Several minutes hours days weeks

7. A client is about to be discharged with a prescription for the antipsychotic agent haloperidol (Haldol), 10 mg by mouth twice per day. During a discharge tea ching session, the nurse should provide which instruction to the client? A. B. C. D. e. Take the medication 1 hour before a meal. Decrease the dosage if signs of illness decrease. Apply a sunscreen before being exposed to the sun. Increase the dosage up to 50 mg twice per day if signs of illness don t decreas

8. A client with paranoid schizophrenia repeatedly uses profanity during an acti vity 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 is interrupting the activity. Take time out in your room for 10 m inutes. D. I m disappointed in you. You can t control yourself even for a few minutes. 9. Which of the following is one of the advantages of the newer antipsychotic me dication risperidone (Risperdal)? A. B. C. D. The absence of anticholinergic effects A lower incidence of extrapyramidal effects Photosensitivity and sedation No incidence of neuroleptic malignant syndrome

10. The etiology of schizophrenia is best described by: A. B. C. D. genetics due to a faulty dopamine receptor. environmental factors and poor parenting. structural and neurobiological factors. a combination of biological, psychological, and environmental factors.

11. A client with schizophrenia who receives fluphenazine (Prolixin) develops ps eudoparkinsonism and akinesia. What drug would the nurse administer to minimize extrapyramidal symptoms? A. B. C. D. benztropine (Cogentin) dantrolene (Dantrium) clonazepam (Klonopin) diazepam (Valium)

12. A client with a diagnosis of paranoid schizophrenia comments tothe nurse, How do I know what is really in those pills? Which of the following is the best resp onse? A. B. C. D. Say, You know it s your medicine. Allow him to open the individual wrappers of the medication. Say, Don t worry about what is in the pills. It s what is ordered. Ignore the comment because it s probably a joke.

13. A client tells the nurse that people from Mars are going to invade the earth . Which response by the nurse would be most therapeutic? A. B. C. D. That must be frightening to you. Can you tell me how you feel about it? There are no people living on Mars. What do you mean when you say they re going to invade the earth? I know you believe the earth is going to be invaded, but I don t believe that.

14. A client with schizophrenia tells the nurse he hears the voices of his dead parents. To help the client ignore the voices, the nurse should recommend that h e: A. B. C. D. sit in listen call a engage a quiet, dark room and concentrate on the voices. to a personal stereo through headphones and sing along with the music. friend and discuss the voices and his feelings about them. in strenuous exercise.

15. A client with schizophrenia is receiving antipsychotic medication. Which nur sing diagnosis may be appropriate for this client? A. B. C. D. Ineffective protection related to blood dyscrasias Urinary frequency related to adverse effects of antipsychotic medication Risk for injury related to a severely decreased level of consciousness Risk for injury related to electrolyte disturbances

16. A client with persistent, severe schizophrenia has been treated with phenoth iazines for the past 17 years. Now the client s speech is garbled as a result of d rug-induced rhythmic tongue protrusion. What is another name for this extrapyram idal symptom? A. B. C. D. Dystonia Akathisia Pseudoparkinsonism Tardive dyskinesia

17. The nurse is assigned to a client with catatonic schizophrenia. Which interv ention should the nurse include in the client s plan of care? A. B. C. D. Meeting all of the client s physical needs Giving the client an opportunity to express concerns Administering lithium carbonate (Lithonate) as prescribed Providing a quiet environment where the client can be alone

18. A client with a history of medication noncompliance is receiving outpatient treatment for chronic undifferentiated schizophrenia. The physician is most like ly to prescribe which medication for this client? A. B. C. D. chlorpromazine (Thorazine) imipramine (Tofranil) lithium carbonate (Lithane) fluphenazine decanoate (Prolixin Decanoate)

19. Propranolol (Inderal) is used in the mental health setting to manage which o f the following conditions? A. B. C. D. Antipsychotic-induced akathisia and anxiety The manic phase of bipolar illness as a mood stabilizer Delusions for clients suffering from schizophrenia Obsessive-compulsive disorder (OCD) to reduce ritualistic behavior

20. Every day for the past 2 weeks, a client with schizophrenia stands up during group therapy and screams, Get out of here right now! The elevator bombs are goi ng to explode in 3 minutes! The next time this happens, how should the nurse resp ond? A. Why do you think there is a bomb in the elevator? B. That is the same thing you said in yesterday s session.

C. D.

I know you think there are bombs in the elevator, but there aren t. If you have something to say, you must do it according to our group rules.

21. A 26-year-old client is admitted to the psychiatric unit with acute onset of schizophrenia. His physician prescribes the phenothiazine chlorpromazine (Thora zine), 100 mg by mouth four times per day. Before administering the drug, the nu rse reviews the client s medication history. Concomitant use of which drug is like ly to increase the risk of extrapyramidal effects? A. B. C. D. guanethidine (Ismelin) droperidol (Inapsine) lithium carbonate (Lithonate) alcohol

22. A client, age 36, with paranoid schizophrenia believes the room is bugged by the Central Intelligence Agency and that his roommate is a foreign spy. The cli ent has never had a romantic relationship, has no contact with family members, a nd hasn t been employed in the last 14 years. Based on Erikson s theories, the nurse should recognize that this client is in which stage of psychosocial development ? A. B. C. D. Autonomy versus shame and doubt Generativity versus stagnation Integrity versus despair Trust versus mistrust

23. During a group therapy session in the psychiatric unit, a client constantly interrupts with impulsive behavior and exaggerated stories that cast her as a he ro or princess. She also manipulates the group with attention-seeking behaviors, such as sexual comments and angry outbursts. The nurse realizes that these beha viors are typical of: A. B. C. D. paranoid personality disorder. avoidant personality disorder. histrionic personality disorder. borderline personality disorder.

24. The nurse is teaching a psychiatric client about her prescribed drugs, chlor promazine and benztropine. Why is benztropine administered? A. B. C. D. To To To To reduce psychotic symptoms reduce extrapyramidal symptoms control nausea and vomiting relieve anxiety

25. A client is admitted to the psychiatric unit with a tentative diagnosis of p sychosis. Her physician prescribes the phenothiazine thioridazine (Mellaril) 50 mg by mouth three times per day. Phenothiazines differ from central nervous syst em (CNS) depressants in their sedative effects by producing: A. B. C. D. deeper sleep than CNS depressants. greater sedation than CNS depressants. a calming effect from which the client is easily aroused. more prolonged sedative effects, making the client more difficult to arouse.

26. A woman is admitted to the psychiatric emergency department. Her significant other reports that she has difficulty sleeping, has poor judgment, and is incoh erent at times. The client s speech is rapid and loose. She reports being a specia l messenger from the Messiah. She has a history of depressed mood for which she has been taking an antidepressant. The nurse suspects which diagnosis?

A. B. C. D.

Schizophrenia Paranoid personality Bipolar illness Obsessive-compulsive disorder (OCD)

27. A client with paranoid schizophrenia is admitted to the psychiatric unit of a hospital. Nursing assessment should include careful observation of the client s: A. B. C. D. thinking, perceiving, and decision-making skills. verbal and nonverbal communication processes. affect and behavior. psychomotor activity.

28. Which information is most important for the nurse to include in a teaching p lan for a schizophrenic client taking clozapine (Clozaril)? A. B. C. D. Monthly blood tests will be necessary. Report a sore throat or fever to the physician immediately. Blood pressure must be monitored for hypertension. Stop the medication when symptoms subside.

29. Important teaching for clients receiving antipsychotic medication such as ha loperidol (Haldol) includes which of the following instructions? A. B. C. D. Use sunscreen because of photosensitivity. Take the antipsychotic medication with food. Have routine blood tests to determine levels of the medication. Abstain from eating aged cheese.

30. Positive symptoms of schizophrenia include which of the following? A. B. C. D. Hallucinations, delusions, and disorganized thinking Somatic delusions, echolalia, and a flat affect Waxy flexibility, alogia, and apathy Flat affect, avolition, and anhedonia

31. A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate (Prolixin Decanoate) by I.M. injection. Three days later, the client has muscle contractions that contort the neck. This client is exhibiting which extrapyrami dal reaction? A. B. C. D. Dystonia Akinesia Akathisia Tardive dyskinesia

32. Hormonal effects of the antipsychotic medications include which of the follo wing? A. B. C. D. Retrograde ejaculation and gynecomastia Dysmenorrhea and increased vaginal bleeding Polydipsia and dysmenorrhea Akinesia and dysphasia

33. A client is unable to get out of bed and get dressed unless the nurse prompt s every step. This is an example of which behavior? A. Word salad B. Tangential

C. Perseveration D. Avolition 34. An agitated and incoherent client, age 29, comes to the emergency department with complaints of visual and auditory hallucinations. The history reveals that the client was hospitalized for paranoid schizophrenia from ages 20 to 21. The physician prescribes haloperidol (Haldol), 5 mg I.M. The nurse understands that this drug is used in this client to treat: A. B. C. D. dyskinesia. dementia. psychosis. tardive dyskinesia.

35. Yesterday, a client with schizophrenia began treatment with haloperidol (Hal dol). Today, the nurse notices that the client is holding his head to one side a nd complaining of neck and jaw spasms. What should the nurse do? A. B. C. D. Assume that the client is posturing. Tell the client to lie down and relax. Evaluate the client for adverse reactions to haloperidol. Put the client on the list for the physician to see tomorrow.

36. A client receiving fluphenazine decanoate (Prolixin Decanoate) therapy devel ops pseudoparkinsonism. The physician is likely to prescribe which drug to contr ol this extrapyramidal effect? A. B. C. D. phenytoin (Dilantin) amantadine (Symmetrel) benztropine (Cogentin) diphenhydramine (Benadryl)

37. Important teaching for a client receiving risperidone (Risperdal) would incl ude advising the client to: A. B. h. C. D. double the dose if missed to maintain a therapeutic level. be sure to take the drug with a meal because it s very irritating to the stomac discontinue the drug if the client reports weight gain. notify the physician if the client notices an increase in bruising.

38. A client is admitted to the psychiatric hospital with a diagnosis of cataton ic schizophrenia. During the physical examination, the client s arm remains outstr etched after the nurse obtains the pulse and blood pressure, and the nurse must reposition the arm. This client is exhibiting: A. B. C. D. suggestibility. negativity. waxy flexibility. retardation.

39. A client with borderline personality disorder becomes angry when he is told that today s psychotherapy session with the nurse will be delayed 30 minutes becau se of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be most helpful in dealing with the client s an ger? A. If it had been your emergency, I would have made the other client wait. B. I know it s frustrating to wait. I m sorry this happened. C. You had to wait. Can we talk about how this is making you feel right now?

D.

I really care about you and I ll never let this happen again.

40. A client begins clozapine (Clozaril) therapy after several other antipsychot ic agents fail to relieve her psychotic symptoms. The nurse instructs her to ret urn for weekly white blood cell (WBC) counts to assess for which adverse reactio n? A. B. C. D. Hepatitis Infection Granulocytopenia Systemic dermatitis

41. Which nonantipsychotic medication is used to treat some clients with schizoa ffective disorder? A. B. C. D. phenelzine (Nardil) chlordiazepoxide (Librium) lithium carbonate (Lithane) imipramine (Tofranil)

42. A client diagnosed with schizoaffective disorder is suffering from schizophr enia with elements of which of the following disorders? A. B. C. D. Personality disorder Mood disorder Thought disorder Amnestic disorder

43. When teaching the family of a client with schizophrenia, the nurse should pr ovide which information? A. B. C. D. Relapse can be prevented if the client takes the medication. Support is available to help family members meet their own needs. Improvement should occur if the client has a stimulating environment. Stressful family situations can precipitate a relapse in the client.

44. A client is admitted to the psychiatric unit with active psychosis. The phys ician diagnoses schizophrenia after ruling out several other conditions. Schizophrenia is characterized by: A. B. C. D. loss of identity and self-esteem. multiple personalities and decreased self-esteem. disturbances in affect, perception, and thought content and form. persistent memory impairment and confusion.

45. The nurse is providing care to a client with a catatonic type of schizophren ia who exhibits extreme negativism. To help the client meet his basic needs, the nurse should: A. B. C. D. ask the client which activity he negotiate a time when the client tell the client specifically and prepare the client ahead of time would prefer to do first. will perform activities. concisely what needs to be done. for the activity.

46. The nurse is caring for a client who experiences false sensory perceptions w ith no basis in reality. These perceptions are known as: A. delusions. B. hallucinations. C. loose associations.

D. neologisms. 47. The nurse is aware that antipsychotic medications may cause which of the fol lowing adverse effects? A. B. C. D. Increased production of insulin Lower seizure threshold Increased coagulation time Increased risk of heart failure

48. A client is admitted with a diagnosis of delusions of grandeur. This diagnos is reflects a belief that one is: A. B. C. D. highly important or famous. being persecuted. connected to events unrelated to oneself. responsible for the evil in the world.

49. A man with a 5-year history of multiple psychiatric admissions is brought to the emergency department by the police. He was found wandering the streets dish eveled, shoeless, and confused. Based on his previous medical records and curren t behavior, he is diagnosed with chronic undifferentiated schizophrenia. The nur se should assign highest priority to which nursing diagnosis? A. B. C. D. Anxiety Impaired verbal communication Disturbed thought processes Self-care deficient: Dressing/grooming

50. A client s medication order reads, Thioridazine (Mellaril) 200 mg P.O. q.i.d. a nd 100 mg P.O. p.r.n. The nurse should: A. administer the medication as B. question the physician about C. administer the order for 200 D. administer the medication as verse effects. prescribed. the order. mg P.O. q.i.d. but not for 100 mg P.O. p.r.n. prescribed but observe the client closely for ad

Answers & Rationale 1. A. The client spends more time by himself. Rationale: The client with schizophrenia is commonly socially isolated and withd rawn; therefore, having the client spend more time by himself wouldn t be a desira ble outcome. Rather, a desirable outcome would specify that the client spend mor e time with other clients and staff on the unit. Delusions are false personal be liefs. Reducing or eliminating delusional thinking using talking therapy and ant ipsychotic medications would be a desirable outcome. Protecting the client and o thers from harm is a desirable client outcome achieved by close observation, rem oving any dangerous objects, and administering medications. Because the client w ith schizophrenia may have difficulty meeting his or her own self-care needs, fo stering the ability to perform self-care independently is a desirable client out come. 2. B. Establishing a one-on-one relationship with the client Rationale: By establishing a one-on-one relationship, the nurse helps the client learn how to interact with people in new situations. The other options are appr opriate but should take place only after the nurse-client relationship is establ ished. 3. D. Accepting these fears and allowing the client to take a sponge bath Rationale: By acknowledging the client s fears, the nurse can arrange to meet the

client s hygiene needs in another way. Because these fears are real to the client, providing a demonstration of reality (as in option A) wouldn t be effective at th is time. Options B and C would violate the client s rights by shaming or embarrass ing the client. 4.D. Retinal pigmentation Rationale: Retinal pigmentation may occur if the thioridazine dosage exceeds 800 mg per day. The other options don t occur as a result of exceeding this dose. 5. A. I get upset once in a while, too. Rationale: Sharing a benign, nonthreatening, personal fact or feeling helps the nurse establish rapport and encourages the client to confide in the nurse. The n urse can t know how the client feels. Telling the client otherwise, as in option B , would justify the suspicions of a paranoid client; furthermore, the client rel ies on the nurse to interpret reality. Option C is incorrect because it focuses on the nurse s feelings, not the client s. Option D wouldn t help establish rapport or encourage the client to confide in the nurse 6. D. Several weeks Rationale: Although most phenothiazines produce some effects within minutes to h ours, their antipsychotic effects may take several weeks to appear. 7. C. Apply a sunscreen before being exposed to the sun. Rationale: Because haloperidol can cause photosensitivity and precipitate severe sunburn, the nurse should instruct the client to apply a sunscreen before expos ure to the sun. The nurse also should teach the client to take haloperidol with meals not 1 hour before and should instruct the client not to decrease or increa se the dosage unless the physician orders it 8. A. Your behavior won t be tolerated. Go to your room immediately. Rationale: The nurse should set limits on client behavior to ensure a comfortabl e environment for all clients. The nurse should accept hostile or quarrelsome cl ient outbursts within limits without becoming personally offended, as in option A. Option B is incorrect because it implies that the client s actions reflect feel ings toward the staff instead of the client s own misery. Judgmental remarks, such as option D, may decrease the client s self-esteem. 9. B. A lower incidence of extrapyramidal effects Rationale: Risperdal has a lower incidence of extrapyramidal effects than the ty pical antipsychotics. Risperdal does produce anticholinergic effects and neurole ptic malignant syndrome can occur. Photosensitivity isn t an advantage. 10. D. a combination of biological, psychological, and environmental factors. Rationale: A reliable genetic marker hasn t been determined for schizophrenia. How ever, studies of twins and adopted siblings have strongly implicated a genetic p redisposition. Since the mid-19th century, excessive dopamine activity in the br ain has also been suggested as a causal factor. Communication and the family sys tem have been studied as contributing factors in the development of schizophreni a. Therefore, a combination of biological, psychological, and environmental factors are thought to cause schizophrenia. 11. A. benztropine (Cogentin) Rationale: Benztropine is an anticholinergic drug administered to reduce extrapy ramidal adverse effects in the client taking antipsychotic drugs. It works by re storing the equilibrium between the neurotransmitters acetylcholine and dopamine in the central nervous system (CNS). Dantrolene, a hydantoin drug that reduces the catabolic processes, is administered to alleviate the symptoms of neurolepti c malignant syndrome, a potentially fatal adverse effect of antipsychotic drugs. Clonazepam, a benzodiazepine drug that depresses the CNS, is administered to co ntrol seizure activity. Diazepam, a benzodiazepine

drug, is administered to reduce anxiety. 12. B. Allow him to open the individual wrappers of the medication. Rationale: Option B is correct because allowing a paranoid client to open his me dication can help reduce suspiciousness. Option A is incorrect because the clien t doesn t know that it s his medication and he s obviously suspicious. Telling the cli ent not to worry or ignoring the comment isn t supportive and doesn t offer reassura nce. 13. A. That must be frightening to you. Can you tell me how you feel about it? Rationale: This response addresses the client s underlying fears without feeding t he delusion. Refuting the client s delusion, as in option B, would increase anxiet y and reinforce the delusion. Asking the client to elaborate on the delusion, as in option C, would also reinforce it. Voicing disbelief about the delusion, as in option D, wouldn t help the client deal with underlying fears 14. B. listen to a personal stereo through headphones and sing along with the mu sic. Rationale: Increasing the amount of auditory stimulation, such as by listening t o music through headphones, may make it easier for the client to focus on extern al sounds and ignore internal sounds from auditory hallucinations. Option A woul d make it harder for the client to ignore the hallucinations. Talking about the voices, as in option C, would encourage the client to focus on them. Option D is incorrect because exercise alone wouldn t provide enough auditory stimulation to drown out the voices. 15. A. Ineffective protection related to blood dyscrasias Rationale: Antipsychotic medications may cause neutropenia and granulocytopenia, life-threatening blood dyscrasias, that warrant a nursing diagnosis of Ineffect ive protection related to blood dyscrasias. These medications also have antichol inergic effects, such as urine retention, dry mouth, and constipation. Urinary f requency isn t an approved nursing diagnosis. Although antipsychotic medications m ay cause sedation, they don t severely decrease the level of consciousness, elimin ating option C. These drugs don t cause electrolyte disturbances, eliminating opti on D. 16. D. Tardive dyskinesia Rationale: An adverse reaction to phenothiazines, tardive dyskinesia refers to c horeiform tongue movements that commonly are irreversible and may interfere with speech. Dystonia refers to involuntary contraction of a muscle group. Akathisia is restlessness or inability to sit still. Pseudoparkinsonism describes a group of symptoms that mimic those of Parkinson s disease. 17. A. Meeting all of the client s physical needs Rationale: Because a client with catatonic schizophrenia can t meet physical needs independently, the nurse must provide for all of these needs, including adequat e food and fluid intake, exercise, and elimination. This client is incapable of expressing concerns; however, the nurse should try to verbalize the message conv eyed by the client s nonverbal behavior. Lithium is used to treat mania, not catat onic schizophrenia. Despite the client s mute, unresponsive state, the nurse shoul d provide nonthreatening stimulation and should spend time with the client, not leave the client alone all the time. Although aware of the environment, the clie nt doesn t interact with it actively; the nurse s support and presence can be reassu ring. 18. D. fluphenazine decanoate (Prolixin Decanoate) Rationale: Fluphenazine decanoate is a long-acting antipsychotic agent given by injection. Because it has a 4-week duration of action, it s commonly prescribed fo r outpatients with a history of medication noncompliance. Chlorpromazine, also a n antipsychotic agent, must be administered daily to maintain adequate plasma le

vels, which necessitates compliance with the dosage schedule. Imipramine, a tric yclic antidepressant, and lithium carbonate, a mood stabilizer, are rarely used to treat clients with chronic schizophrenia. 19. A. Antipsychotic-induced akathisia and anxiety Rationale: Propranolol is a potent beta-adrenergic blocker and produces a sedati ng effect; therefore, it s used to treat antipsychotic induced akathisia and anxie ty. Lithium (Lithobid) is used to stabilize clients with bipolar illness. Antips ychotics are used to treat delusions. Some antidepressants have been effective i n treating OCD. 20. C. I know you think there are bombs in the elevator, but there aren t. Rationale: Option C is the most therapeutic response because it orients the clie nt to reality. Options A and B are condescending. Option D sounds punitive and c ould embarrass the client. 21. B. droperidol (Inapsine) Rationale: When administered with any phenothiazine, droperidol may increase the risk of extrapyramidal effects. The other options are incorrect 22. D. Trust versus mistrust Rationale: This client s paranoid ideation indicates difficulty trusting others. T he stage of autonomy versus shame and doubt deals with separation, cooperation, and self-control. Generativity versus stagnation is the normal stage for this cl ient s chronologic age. Integrity versus despair is the stage for accepting the po sitive and negative aspects of one s life, which would be difficult or impossible for this client. 23. C. histrionic personality disorder. Rationale: This client s behaviors are typical of histrionic personality disorder, which is marked by excessive emotionality and attention seeking. The client con stantly seeks and demands attention, approval, or praise; may be seductive in be havior, appearance, or conversation; and is uncomfortable except when she is the center of attention. Typically, a client with paranoid personality disorder is suspicious, cold, hostile, and argumentative. Avoidant personality disorder is c haracterized by anxiety, fear, and social isolation. Borderline personality diso rder is characterized by impulsive, unpredictable behavior and unstable, intense interpersonal relationships. 24. B. To reduce extrapyramidal symptoms Rationale: Benztropine is an anticholinergic medication, administered to reduce the extrapyramidal adverse effects of chlorpromazine and other antipsychotic med ications. Benztropine doesn t reduce psychotic symptoms, relieve anxiety, or contr ol nausea and vomiting. 25. C. a calming effect from which the client is easily aroused. Rationale: Shortly after phenothiazine administration, a quieting and calming ef fect occurs, but the client is easily aroused, alert, and responsive and has goo d motor coordination. 26. C. Bipolar illness Rationale: Bipolar illness is characterized by mood swings from profound depress ion to elation and euphoria. Delusions of grandeur along with pressured speech a re common symptoms of mania. Schizophrenia doesn t exhibit mood swings from depres sion to euphoria. Paranoia is characterized by unrealistic suspiciousness and is often accompanied by grandiosity. OCD is a preoccupation with rituals and rules . 27. A. thinking, perceiving, and decision-making skills. Rationale: Nursing assessment of a psychotic client should include careful inqui

ry about and observation of the client s thinking, perceiving, symbolizing, and de cision-making skills and abilities. Assessment of such a client typically reveal s alterations in thought content and process, perception, affect, and psychomoto r behavior; changes in personality, coping, and sense of self; lack of self-moti vation; presence of psychosocial stressors; and degeneration of adaptive functio ning. Although assessing communication processes, affect, behavior, and psychomo tor activity would reveal important information about the client s condition, the nurse should concentrate on determining whether the client is hallucinating by a ssessing thought processes and decision-making ability. 28. B. Report a sore throat or fever to the physician immediately. Rationale: A sore throat and fever are indications of an infection caused by agr anulocytosis, a potentially life-threatening complication of clozapine. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary week ly, not monthly. If the WBC count drops below 3,000/ l, the medication must be sto pped. Hypotension may occur in clients taking this medication. Warn the client t o stand up slowly to avoid dizziness from orthostatic hypotension. The medicatio n should be continued, even when symptoms have been controlled. If the medicatio n must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician. 29. A. Use sunscreen because of photosensitivity. B. Take the antipsychotic medication with food. * A and B are both correct in taking HALDOL. 30. A. Hallucinations, delusions, and disorganized thinking Rationale: The positive symptoms of schizophrenia are distortions of normal func tioning. Option A lists the positive symptoms of schizophrenia. A flat affect, a logia, apathy, avolition, and anhedonia refer to the negative symptoms. Negative symptoms list the diminution or loss of normal function 31. A. Dystonia Rationale: Dystonia, a common extrapyramidal reaction to fluphenazine decanoate, manifests as muscle spasms in the tongue, face, neck, back, and sometimes the l egs. Akinesia refers to decreased or absent movement; akathisia, to restlessness or inability to sit still; and tardive dyskinesia, to abnormal muscle movements , particularly around the mouth. 32. A. Retrograde ejaculation and gynecomastia Rationale: Decreased libido, retrograde ejaculation, and gynecomastia are all ho rmonal effects that can occur with antipsychotic medications. Reassure the clien t that the effects can be reversed or that changing medication may be possible. Polydipsia, akinesia, and dysphasia aren t hormonal effects. 33. D. Avolition Rationale: Avolition refers to impairment in the ability to initiate goal-direct ed activity. Word salad is when a group of words are put together in a random fa shion without logical connection. Tangential is where a person never gets to the point of the communication. Perseveration is when a person repeats the same wor d or idea in response to different questions. 34. C. psychosis. Rationale: By treating psychosis, haloperidol, an antipsychotic drug, decreases agitation. Haloperidol is used to treat dyskinesia in clients with Tourette synd rome and to treat dementia in elderly clients. Tardive dyskinesia may occur afte r prolonged haloperidol use; the client should be monitored for this adverse rea ction. 35. C. Evaluate the client for adverse reactions to haloperidol. Rationale: An antipsychotic agent, such as haloperidol, can cause muscle spasms

in the neck, face, tongue, back, and sometimes legs as well as torticollis (twis ted neck position). The nurse should be aware of these adverse reactions and ass ess for related reactions promptly. Although posturing may occur in clients with schizophrenia, it isn t the same as neck and jaw spasms. Having the client relax can reduce tension-induced muscle stiffness but not drug-induced muscle spasms. When a client develops a new sign or symptom, the nurse should consider an adver se drug reaction as the possible cause and obtain treatment immediately, rather than have the client wait. 36. B. amantadine (Symmetrel) Rationale: An antiparkinsonian agent, such as amantadine, may be used to control pseudoparkinsonism; diphenhydramine or benztropine may be used to control other extrapyramidal effects. Phenytoin is used to treat seizure activity. 37. D. notify the physician if the client notices an increase in bruising. Rationale: Bruising may indicate blood dyscrasias, so notifying the physician ab out increased bruising is very important. Don t double the dose. This drug doesn t i rritate the stomach, and weight gain isn t a problem. 38. C. waxy flexibility. Rationale: Waxy flexibility, the ability to assume and maintain awkward or uncom fortable positions for long periods, is characteristic of catatonic schizophreni a. Clients commonly remain in these awkward positions until someone repositions them. Clients with dependency problems may demonstrate suggestibility, a respons e pattern in which one easily agrees to the ideas and suggestions of others rath er than making independent judgments. Negativity (for example, resistance to bei ng moved or being asked to cooperate) and retardation (slowed movement) also occ ur in catatonic clients. 39. C. You had to wait. Can we talk about how this is making you feel right now? Rationale: This response may diffuse the client s anger by helping to maintain a t herapeutic relationship and addressing the client s feelings. Option A wouldn t addr ess the client s anger. Option B is incorrect because the client with a borderline personality disorder blames others for things that happen, so apologizing reinf orces the client s misconceptions. The nurse can t promise that a delay will never o ccur again, as in option D, because such matters are outside the nurse s control. 40. C. Granulocytopenia Rationale: Clozapine can cause life-threatening neutropenia or granulocytopenia. To detect this adverse reaction, a WBC count should be performed weekly. Hepati tis, infection, and systemic dermatitis aren t adverse reactions of clozapine ther apy. 41. C. lithium carbonate (Lithane) Rationale: Lithium carbonate, an antimania drug, is used to treat clients with c yclical schizoaffective disorder, a psychotic disorder once classified under sch izophrenia that causes affective symptoms, including maniclike activity. Lithium helps control the affective component of this disorder. Phenelzine is a monoami ne oxidase inhibitor prescribed for clients who don t respond to other antidepress ant drugs such as imipramine. Chlordiazepoxide, an antianxiety agent, generally is contraindicated in psychotic clients. Imipramine, primarily considered an ant idepressant agent, is also used to treat clients with agoraphobia and those unde rgoing cocaine detoxification. 42. B. Mood disorder Rationale: According to the DSM-IV, schizoaffective disorder refers to clients s uffering from schizophrenia with elements of a mood disorder, either mania or de pression. The prognosis is generally better than for the other types of schizoph renia, but it s worse than the prognosis for a mood disorder alone. Option A is in correct because personality disorders and psychotic illness aren t listed together

on the same axis. Option C is incorrect because schizophrenia is a major though t disorder and the question asks for elements of another disorder. Clients with schizoaffective disorder aren t suffering from schizophrenia and an amnestic disor der. 43. B. Support is available to help family members meet their own needs. Rationale: Because family members of a client with schizophrenia face difficult situations and great stress, the nurse should inform them of support services th at can help them cope with such problems. The nurse should also teach them that medication can t prevent relapses and that environmental stimuli may precipitate s ymptoms. Although stress can trigger symptoms, the nurse shouldn t make the family feel responsible for relapses (as in option D). 44. C. disturbances in affect, perception, and thought content and form. Rationale: The Diagnostic and Statistic Manual of Mental Disorders, 4th edition, defines schizophrenia as a disturbance in multiple psychological processes that affects thought content and form, perception, affect, sense of self, volition, relationship to the external world, and psychomotor behavior. Loss of identity s ometimes occurs but is only one characteristic of the disorder. Multiple persona lities typify multiple personality disorder, a dissociative personality disorder . Mood disorders are commonly accompanied by increased or decreased self-esteem. Schizophrenia doesn t cause a disturbance in sensorium, although the client may e xhibit confusion, disorientation, and memory impairment during the acute phase. 45. C. tell the client specifically and concisely what needs to be done. Rationale: The client needs to be informed of the activity and when it will be d one. Giving the client choices isn t desirable because he can be manipulative or r efuse to do anything. Negotiating and preparing the client ahead of time also is n t therapeutic with this type of client because he may not want to perform the ac tivity. 46. B. hallucinations. Rationale: Hallucinations are visual, auditory, gustatory, tactile, or olfactory perceptions that have no basis in reality. Delusions are false beliefs, rather than perceptions, that the client accepts as real. Loose associations are rapid shifts among unrelated ideas. Neologisms are bizarre words that have meaning onl y to the client. 47. B. Lower seizure threshold Rationale: Antipsychotic medications exert an effect on brain neurotransmitters that lowers the seizure threshold and can, therefore, increase the risk of seizu re activity. Antipsychotics don t affect insulin production or coagulation time. H eart failure isn t an adverse effect ofantipsychotic agents 48. A. highly important or famous. Rationale: A delusion of grandeur is a false belief that one is highly important or famous. A delusion of persecution is a false belief that one is being persec uted. A delusion of reference is a false belief that one is connected to events unrelated to oneself or a belief that one is responsible for the evil in the wor ld. 49. A. Anxiety Rationale: For this client, the highest-priority nursing diagnosis is Anxiety (s evere to panic-level), manifested by the client s extreme withdrawal and attempt t o protect himself from the environment. The nurse must act immediately to reduce anxiety and protect the client and others from possible injury. Impaired verbal communication, manifested by noncommunicativeness; Disturbed thought processes, evidenced by inability to understand the situation; and Self-care deficient: Dr essing/grooming, evidenced by a disheveled appearance, are appropriate nursing d iagnoses but aren t the highest priority

50. B. question the physician about the order. Rationale: The nurse must question this order immediately. Thioridazine (Mellari l) has an absolute dosage ceiling of 800 mg/day. Any dosage above this level pla ces the client at high risk for toxic pigmentary retinopathy, which can t be rever sed. As written, the order allows for administering more than the maximum 800 mg /day; it should be corrected immediately, before the client s health is jeopardize d.