SET 1 Check circulation every 15-30 minutes.

Socialize with other patients once a shift.

PNLE I for Foundation of Professional Nursing Practice 7. A male client who has severe burns is receiving H2
1. The nurse In-charge in labor and delivery unit administered receptor antagonist therapy. The nurse In-charge knows the
a dose of terbutaline to a client without checking the client’s purpose of this therapy is to:
pulse. The standard that would be used to determine if the
nurse was negligent is: Prevent stress ulcer
Block prostaglandin synthesis
The physician’s orders. Facilitate protein synthesis.
The action of a clinical nurse specialist who is recognized Enhance gas exchange
expert in the field. 8. The doctor orders hourly urine output measurement for a
The statement in the drug literature about administration of postoperative male client. The nurse Trish records the
terbutaline. following amounts of output for 2 consecutive hours: 8 a.m.:
The actions of a reasonably prudent nurse with similar 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action
education and experience. should the nurse take?
2. Nurse Trish is caring for a female client with a history of GI
bleeding, sickle cell disease, and a platelet count of Increase the I.V. fluid infusion rate
22,000/μl. The female client is dehydrated and receiving Irrigate the indwelling urinary catheter
dextrose 5% in half-normal saline solution at 150 ml/hr. The Notify the physician
client complains of severe bone pain and is scheduled to Continue to monitor and record hourly urine output
receive a dose of morphine sulfate. In administering the 9. Tony, a basketball player twist his right ankle while playing
medication, Nurse Trish should avoid which route? on the court and seeks care for ankle pain and swelling. After
the nurse applies ice to the ankle for 30 minutes, which
I.V statement by Tony suggests that ice application has been
I.M effective?
Oral
S.C “My ankle looks less swollen now”.
3. Dr. Garcia writes the following order for the client who has “My ankle feels warm”.
been recently admitted “Digoxin .125 mg P.O. once daily.” To “My ankle appears redder now”.
prevent a dosage error, how should the nurse document this “I need something stronger for pain relief”
order onto the medication administration record? 10.The physician prescribes a loop diuretic for a client. When
administering this drug, the nurse anticipates that the client
“Digoxin .1250 mg P.O. once daily” may develop which electrolyte imbalance?
“Digoxin 0.1250 mg P.O. once daily”
“Digoxin 0.125 mg P.O. once daily” Hypernatremia
“Digoxin .125 mg P.O. once daily” Hyperkalemia
4. A newly admitted female client was diagnosed with deep Hypokalemia
vein thrombosis. Which nursing diagnosis should receive the Hypervolemia
highest priority? 11.She finds out that some managers have benevolent-
authoritative style of management. Which of the following
Ineffective peripheral tissue perfusion related to venous behaviors will she exhibit most likely?
congestion.
Risk for injury related to edema. Have condescending trust and confidence in their
Excess fluid volume related to peripheral vascular disease. subordinates.
Impaired gas exchange related to increased blood flow. Gives economic and ego awards.
5. Nurse Betty is assigned to the following clients. The client Communicates downward to staffs.
that the nurse would see first after endorsement? Allows decision making among subordinates.
12. Nurse Amy is aware that the following is true about
A 34 year-old post operative appendectomy client of five functional nursing
hours who is complaining of pain.
A 44 year-old myocardial infarction (MI) client who is Provides continuous, coordinated and comprehensive
complaining of nausea. nursing services.
A 26 year-old client admitted for dehydration whose One-to-one nurse patient ratio.
intravenous (IV) has infiltrated. Emphasize the use of group collaboration.
A 63 year-old post operative’s abdominal hysterectomy client Concentrates on tasks and activities.
of three days whose incisional dressing is saturated with 13.Which type of medication order might read “Vitamin K 10
serosanguinous fluid. mg I.M. daily × 3 days?”
6. Nurse Gail places a client in a four-point restraint following
orders from the physician. The client care plan should Single order
include: Standard written order
Standing order
Assess temperature frequently. Stat order
Provide diversional activities.
14.A female client with a fecal impaction frequently exhibits cancer. The nurse in-charge would take which priority action
which clinical manifestation? in the care of this client?

Increased appetite Place client on reverse isolation.

Loss of urge to defecate Admit the client into a private room.
Hard, brown, formed stools Encourage the client to take frequent rest periods.
Liquid or semi-liquid stools Encourage family and friends to visit.
15.Nurse Linda prepares to perform an otoscopic 23.A newly admitted female client was diagnosed with
examination on a female client. For proper visualization, the agranulocytosis. The nurse formulates which priority nursing
nurse should position the client’s ear by: diagnosis?

Pulling the lobule down and back Constipation

Pulling the helix up and forward Diarrhea
Pulling the helix up and back Risk for infection
Pulling the lobule down and forward Deficient knowledge
16. Which instruction should nurse Tom give to a male client 24.A male client is receiving total parenteral nutrition
who is having external radiation therapy: suddenly demonstrates signs and symptoms of an air
embolism. What is the priority action by the nurse?
Protect the irritated skin from sunlight.
Eat 3 to 4 hours before treatment. Notify the physician.
Wash the skin over regularly. Place the client on the left side in the Trendelenburg position.
Apply lotion or oil to the radiated area when it is red or sore. Place the client in high-Fowlers position.
17.In assisting a female client for immediate surgery, the Stop the total parenteral nutrition.
nurse In-charge is aware that she should: 25.Nurse May attends an educational conference on
leadership styles. The nurse is sitting with a nurse employed
Encourage the client to void following preoperative at a large trauma center who states that the leadership style
medication. at the trauma center is task-oriented and directive. The nurse
Explore the client’s fears and anxieties about the surgery. determines that the leadership style used at the trauma
Assist the client in removing dentures and nail polish. center is:
Encourage the client to drink water prior to surgery.
18. A male client is admitted and diagnosed with acute Autocratic.
pancreatitis after a holiday celebration of excessive food and Laissez-faire.
alcohol. Which assessment finding reflects this diagnosis? Democratic.
Situational
Blood pressure above normal range. 26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30
Presence of crackles in both lung fields. cc/hr. The nurse in-charge is going to hang a 500 cc bag. KCl is
Hyperactive bowel sounds supplied 20 mEq/10 cc. How many cc’s of KCl will be added to
Sudden onset of continuous epigastric and back pain. the IV solution?
19. Which dietary guidelines are important for nurse Oliver to
implement in caring for the client with burns? .5 cc
5 cc
Provide high-fiber, high-fat diet 1.5 cc
Provide high-protein, high-carbohydrate diet. 2.5 cc
Monitor intake to prevent weight gain. 27.A child of 10 years old is to receive 400 cc of IV fluid in an
Provide ice chips or water intake. 8 hour shift. The IV drip factor is 60. The IV rate that will
20.Nurse Hazel will administer a unit of whole blood, which deliver this amount is:
priority information should the nurse have about the client?
50 cc/ hour
Blood pressure and pulse rate. 55 cc/ hour
Height and weight. 24 cc/ hour
Calcium and potassium levels 66 cc/ hour
Hgb and Hct levels. 28.The nurse is aware that the most important nursing action
21. Nurse Michelle witnesses a female client sustain a fall and when a client returns from surgery is:
suspects that the leg may be broken. The nurse takes which
priority action? Assess the IV for type of fluid and rate of flow.
Assess the client for presence of pain.
Takes a set of vital signs. Assess the Foley catheter for patency and urine output
Call the radiology department for X-ray. Assess the dressing for drainage.
Reassure the client that everything will be alright. 29. Which of the following vital sign assessments that may
Immobilize the leg before moving the client. indicate cardiogenic shock after myocardial infarction?
22.A male client is being transferred to the nursing unit for
admission after receiving a radium implant for bladder BP – 80/60, Pulse – 110 irregular
BP – 90/50, Pulse – 50 regular
BP – 130/80, Pulse – 100 regular Hypertension
BP – 180/100, Pulse – 90 irregular Distended neck veins
30.Which is the most appropriate nursing action in obtaining Tachycardia
a blood pressure measurement? 37.The physician prescribes meperidine (Demerol), 75 mg
I.M. every 4 hours as needed, to control a client’s
Take the proper equipment, place the client in a comfortable postoperative pain. The package insert is “Meperidine, 100
position, and record the appropriate information in the mg/ml.” How many milliliters of meperidine should the
client’s chart. client receive?
Measure the client’s arm, if you are not sure of the size of
cuff to use. 0.75
Have the client recline or sit comfortably in a chair with the 0.6
forearm at the level of the heart. 0.5
Document the measurement, which extremity was used, and 0.25
the position that the client was in during the measurement. 38. A male client with diabetes mellitus is receiving insulin.
31.Asking the questions to determine if the person Which statement correctly describes an insulin unit?
understands the health teaching provided by the nurse would
be included during which step of the nursing process? It’s a common measurement in the metric system.
It’s the basis for solids in the avoirdupois system.
Assessment It’s the smallest measurement in the apothecary system.
Evaluation It’s a measure of effect, not a standard measure of weight or
Implementation quantity.
Planning and goals 39.Nurse Oliver measures a client’s temperature at 102° F.
32.Which of the following item is considered the single most What is the equivalent Centigrade temperature?
important factor in assisting the health professional in
arriving at a diagnosis or determining the person’s needs? 40.1 °C
38.9 °C
Diagnostic test results 48 °C
Biographical date 38 °C
History of present illness 40.The nurse is assessing a 48-year-old client who has come
Physical examination to the physician’s office for his annual physical exam. One of
33.In preventing the development of an external rotation the first physical signs of aging is:
deformity of the hip in a client who must remain in bed for
any period of time, the most appropriate nursing action Accepting limitations while developing assets.
would be to use: Increasing loss of muscle tone.
Failing eyesight, especially close vision.
Trochanter roll extending from the crest of the ileum to the Having more frequent aches and pains.
midthigh. 41.The physician inserts a chest tube into a female client to
Pillows under the lower legs. treat a pneumothorax. The tube is connected to water-seal
Footboard drainage. The nurse in-charge can prevent chest tube air
Hip-abductor pillow leaks by:
34.Which stage of pressure ulcer development does the ulcer
extend into the subcutaneous tissue? Checking and taping all connections.
Checking patency of the chest tube.
Stage I Keeping the head of the bed slightly elevated.
Stage II Keeping the chest drainage system below the level of the
Stage III chest.
Stage IV 42.Nurse Trish must verify the client’s identity before
35.When the method of wound healing is one in which administering medication. She is aware that the safest way to
wound edges are not surgically approximated and verify identity is to:
integumentary continuity is restored by granulations, the
wound healing is termed Check the client’s identification band.
Ask the client to state his name.
Second intention healing State the client’s name out loud and wait a client to repeat it.
Primary intention healing Check the room number and the client’s name on the bed.
Third intention healing 43.The physician orders dextrose 5 % in water, 1,000 ml to be
First intention healing infused over 8 hours. The I.V. tubing delivers 15 drops/ml.
36.An 80-year-old male client is admitted to the hospital with Nurse John should run the I.V. infusion at a rate of:
a diagnosis of pneumonia. Nurse Oliver learns that the client
lives alone and hasn’t been eating or drinking. When 30 drops/minute
assessing him for dehydration, nurse Oliver would expect to 32 drops/minute
find: 20 drops/minute
18 drops/minute
Hypothermia
44.If a central venous catheter becomes disconnected Massaging the area with an astringent every 2 hours.
accidentally, what should the nurse in-charge do Applying an antibiotic cream to the area three times per day.
immediately? Using normal saline solution to clean the ulcer and applying a
protective dressing as necessary.
Clamp the catheter Using a povidone-iodine wash on the ulceration three times
Call another nurse per day.
Call the physician 52.Nurse Oliver must apply an elastic bandage to a client’s
Apply a dry sterile dressing to the site. ankle and calf. He should apply the bandage beginning at the
45.A female client was recently admitted. She has fever, client’s:
weight loss, and watery diarrhea is being admitted to the
facility. While assessing the client, Nurse Hazel inspects the Knee
client’s abdomen and notice that it is slightly concave. Ankle
Additional assessment should proceed in which order: Lower thigh
Foot
Palpation, auscultation, and percussion. 53.A 10 year old child with type 1 diabetes develops diabetic
Percussion, palpation, and auscultation. ketoacidosis and receives a continuous insulin infusion.
Palpation, percussion, and auscultation. Which condition represents the greatest risk to this child?
Auscultation, percussion, and palpation.
46. Nurse Betty is assessing tactile fremitus in a client with Hypernatremia
pneumonia. For this examination, nurse Betty should use the: Hypokalemia
Hyperphosphatemia
Fingertips Hypercalcemia
Finger pads 54.Nurse Len is administering sublingual nitrglycerin
Dorsal surface of the hand (Nitrostat) to the newly admitted client. Immediately
Ulnar surface of the hand afterward, the client may experience:
47. Which type of evaluation occurs continuously throughout
the teaching and learning process? Throbbing headache or dizziness
Nervousness or paresthesia.
Summative Drowsiness or blurred vision.
Informative Tinnitus or diplopia.
Formative 55.Nurse Michelle hears the alarm sound on the telemetry
Retrospective monitor. The nurse quickly looks at the monitor and notes
48.A 45 year old client, has no family history of breast cancer that a client is in a ventricular tachycardia. The nurse rushes
or other risk factors for this disease. Nurse John should to the client’s room. Upon reaching the client’s bedside, the
instruct her to have mammogram how often? nurse would take which action first?

Twice per year Prepare for cardioversion

Once per year Prepare to defibrillate the client
Every 2 years Call a code
Once, to establish baseline Check the client’s level of consciousness
49.A male client has the following arterial blood gas values: 56.Nurse Hazel is preparing to ambulate a female client. The
pH 7.30; Pao2 89 mmHg; Paco2 50 mmHg; and HCO3 best and the safest position for the nurse in assisting the
26mEq/L. Based on these values, Nurse Patricia should client is to stand:
expect which condition?
On the unaffected side of the client.
Respiratory acidosis On the affected side of the client.
Respiratory alkalosis In front of the client.
Metabolic acidosis Behind the client.
Metabolic alkalosis 57.Nurse Janah is monitoring the ongoing care given to the
50.Nurse Len refers a female client with terminal cancer to a potential organ donor who has been diagnosed with brain
local hospice. What is the goal of this referral? death. The nurse determines that the standard of care had
been maintained if which of the following data is observed?
To help the client find appropriate treatment options.
To provide support for the client and family in coping with Urine output: 45 ml/hr
terminal illness. Capillary refill: 5 seconds
To ensure that the client gets counseling regarding health Serum pH: 7.32
care costs. Blood pressure: 90/48 mmHg
To teach the client and family about cancer and its 58. Nurse Amy has an order to obtain a urinalysis from a male
treatment. client with an indwelling urinary catheter. The nurse avoids
51.When caring for a male client with a 3-cm stage I pressure which of the following, which contaminate the specimen?
ulcer on the coccyx, which of the following actions can the
nurse institute independently? Wiping the port with an alcohol swab before inserting the
syringe.
Aspirating a sample from the port on the drainage bag. contact precautions. Nurse Myrna instructs the nursing
Clamping the tubing of the drainage bag. assistant to use which of the following protective items when
Obtaining the specimen from the urinary drainage bag. giving bed bath?
59.Nurse Meredith is in the process of giving a client a bed
bath. In the middle of the procedure, the unit secretary calls Gown and goggles
the nurse on the intercom to tell the nurse that there is an Gown and gloves
emergency phone call. The appropriate nursing action is to: Gloves and shoe protectors
Gloves and goggles
Immediately walk out of the client’s room and answer the 65. Nurse Oliver is caring for a client with impaired mobility
phone call. that occurred as a result of a stroke. The client has right sided
Cover the client, place the call light within reach, and answer arm and leg weakness. The nurse would suggest that the
the phone call. client use which of the following assistive devices that would
Finish the bed bath before answering the phone call. provide the best stability for ambulating?
Leave the client’s door open so the client can be monitored
and the nurse can answer the phone call. Crutches
60. Nurse Janah is collecting a sputum specimen for culture Single straight-legged cane
and sensitivity testing from a client who has a productive Quad cane
cough. Nurse Janah plans to implement which intervention to Walker
obtain the specimen? 66.A male client with a right pleural effusion noted on a chest
X-ray is being prepared for thoracentesis. The client
Ask the client to expectorate a small amount of sputum into experiences severe dizziness when sitting upright. To provide
the emesis basin. a safe environment, the nurse assists the client to which
Ask the client to obtain the specimen after breakfast. position for the procedure?
Use a sterile plastic container for obtaining the specimen.
Provide tissues for expectoration and obtaining the Prone with head turned toward the side supported by a
specimen. pillow.
61. Nurse Ron is observing a male client using a walker. The Sims’ position with the head of the bed flat.
nurse determines that the client is using the walker correctly Right side-lying with the head of the bed elevated 45
if the client: degrees.
Left side-lying with the head of the bed elevated 45 degrees.
Puts all the four points of the walker flat on the floor, puts 67.Nurse John develops methods for data gathering. Which
weight on the hand pieces, and then walks into it. of the following criteria of a good instrument refers to the
Puts weight on the hand pieces, moves the walker forward, ability of the instrument to yield the same results upon its
and then walks into it. repeated administration?
Puts weight on the hand pieces, slides the walker forward,
and then walks into it. Validity
Walks into the walker, puts weight on the hand pieces, and Specificity
then puts all four points of the walker flat on the floor. Sensitivity
62.Nurse Amy has documented an entry regarding client care Reliability
in the client’s medical record. When checking the entry, the 68.Harry knows that he has to protect the rights of human
nurse realizes that incorrect information was documented. research subjects. Which of the following actions of Harry
How does the nurse correct this error? ensures anonymity?

Erases the error and writes in the correct information. Keep the identities of the subject secret
Uses correction fluid to cover up the incorrect information Obtain informed consent
and writes in the correct information. Provide equal treatment to all the subjects of the study.
Draws one line to cross out the incorrect information and Release findings only to the participants of the study
then initials the change. 69.Patient’s refusal to divulge information is a limitation
Covers up the incorrect information completely using a black because it is beyond the control of Tifanny”. What type of
pen and writes in the correct information research is appropriate for this study?
63.Nurse Ron is assisting with transferring a client from the
operating room table to a stretcher. To provide safety to the Descriptive- correlational
client, the nurse should: Experiment
Quasi-experiment
Moves the client rapidly from the table to the stretcher. Historical
Uncovers the client completely before transferring to the 70.Nurse Ronald is aware that the best tool for data
stretcher. gathering is?
Secures the client safety belts after transferring to the
stretcher. Interview schedule
Instructs the client to move self from the table to the Questionnaire
stretcher. Use of laboratory data
64.Nurse Myrna is providing instructions to a nursing Observation
assistant assigned to give a bed bath to a client who is on
71.Monica is aware that there are times when only Design the theoretical and conceptual framework
manipulation of study variables is possible and the elements 78. The leader of the study knows that certain patients who
of control or randomization are not attendant. Which type of are in a specialized research setting tend to respond
research is referred to this? psychologically to the conditions of the study. This referred
to as :
Field study
Quasi-experiment Cause and effect
Solomon-Four group design Hawthorne effect
Post-test only design Halo effect
72.Cherry notes down ideas that were derived from the Horns effect
description of an investigation written by the person who 79.Mary finally decides to use judgment sampling on her
conducted it. Which type of reference source refers to this? research. Which of the following actions of is correct?

Footnote Plans to include whoever is there during his study.

Bibliography Determines the different nationality of patients frequently
Primary source admitted and decides to get representations samples from
Endnotes each.
73.When Nurse Trish is providing care to his patient, she Assigns numbers for each of the patients, place these in a
must remember that her duty is bound not to do doing any fishbowl and draw 10 from it.
action that will cause the patient harm. This is the meaning of Decides to get 20 samples from the admitted patients
the bioethical principle: 80. The nursing theorist who developed transcultural nursing
theory is:
Non-maleficence
Beneficence Florence Nightingale
Justice Madeleine Leininger
Solidarity Albert Moore
74.When a nurse in-charge causes an injury to a female Sr. Callista Roy
patient and the injury caused becomes the proof of the 81.Marion is aware that the sampling method that gives
negligent act, the presence of the injury is said to exemplify equal chance to all units in the population to get picked is:
the principle of:
Random
Force majeure Accidental
Respondeat superior Quota
Res ipsa loquitor Judgment
Holdover doctrine 82.John plans to use a Likert Scale to his study to determine
75.Nurse Myrna is aware that the Board of Nursing has quasi- the:
judicial power. An example of this power is:
Degree of agreement and disagreement
The Board can issue rules and regulations that will govern the Compliance to expected standards
practice of nursing Level of satisfaction
The Board can investigate violations of the nursing law and Degree of acceptance
code of ethics 83.Which of the following theory addresses the four modes
The Board can visit a school applying for a permit in of adaptation?
collaboration with CHED
The Board prepares the board examinations Madeleine Leininger
76. When the license of nurse Krina is revoked, it means that Sr. Callista Roy
she: Florence Nightingale
Jean Watson
Is no longer allowed to practice the profession for the rest of 84.Ms. Garcia is responsible to the number of personnel
her life reporting to her. This principle refers to:
Will never have her/his license re-issued since it has been
revoked Span of control
May apply for re-issuance of his/her license based on certain Unity of command
conditions stipulated in RA 9173 Downward communication
Will remain unable to practice professional nursing Leader
77.Ronald plans to conduct a research on the use of a new 85.Ensuring that there is an informed consent on the part of
method of pain assessment scale. Which of the following is the patient before a surgery is done, illustrates the bioethical
the second step in the conceptualizing phase of the research principle of:
process?
Beneficence
Formulating the research hypothesis Autonomy
Review related literature Veracity
Formulating and delimiting the research problem Non-maleficence
86.Nurse Reese is teaching a female client with peripheral Informing the client that the transfusion usually take 1 ½ to 2
vascular disease about foot care; Nurse Reese should include hours.
which instruction? Documenting blood administration in the client care record.
Assessing the client’s vital signs when the transfusion ends.
Avoid wearing cotton socks. 94.A male client complains of abdominal discomfort and
Avoid using a nail clipper to cut toenails. nausea while receiving tube feedings. Which intervention is
Avoid wearing canvas shoes. most appropriate for this problem?
Avoid using cornstarch on feet.
87.A client is admitted with multiple pressure ulcers. When Give the feedings at room temperature.
developing the client’s diet plan, the nurse should include: Decrease the rate of feedings and the concentration of the
formula.
Fresh orange slices Place the client in semi-Fowler’s position while feeding.
Steamed broccoli Change the feeding container every 12 hours.
Ice cream 95.Nurse Patricia is reconstituting a powdered medication in
Ground beef patties a vial. After adding the solution to the powder, she nurse
88.The nurse prepares to administer a cleansing enema. should:
What is the most common client position used for this
procedure? Do nothing.
Invert the vial and let it stand for 3 to 5 minutes.
Lithotomy Shake the vial vigorously.
Supine Roll the vial gently between the palms.
Prone 96.Which intervention should the nurse Trish use when
Sims’ left lateral administering oxygen by face mask to a female client?
89.Nurse Marian is preparing to administer a blood
transfusion. Which action should the nurse take first? Secure the elastic band tightly around the client’s head.
Assist the client to the semi-Fowler position if possible.
Arrange for typing and cross matching of the client’s blood. Apply the face mask from the client’s chin up over the nose.
Compare the client’s identification wristband with the tag on Loosen the connectors between the oxygen equipment and
the unit of blood. humidifier.
Start an I.V. infusion of normal saline solution. 97.The maximum transfusion time for a unit of packed red
Measure the client’s vital signs. blood cells (RBCs) is:
90.A 65 years old male client requests his medication at 9
p.m. instead of 10 p.m. so that he can go to sleep earlier. 6 hours
Which type of nursing intervention is required? 4 hours
3 hours
Independent 2 hours
Dependent 98.Nurse Monique is monitoring the effectiveness of a
Interdependent client’s drug therapy. When should the nurse Monique obtain
Intradependent a blood sample to measure the trough drug level?
91.A female client is to be discharged from an acute care
facility after treatment for right leg thrombophlebitis. The 1 hour before administering the next dose.
Nurse Betty notes that the client’s leg is pain-free, without Immediately before administering the next dose.
redness or edema. The nurse’s actions reflect which step of Immediately after administering the next dose.
the nursing process? 30 minutes after administering the next dose.
99.Nurse May is aware that the main advantage of using a
Assessment floor stock system is:
Diagnosis
Implementation The nurse can implement medication orders quickly.
Evaluation The nurse receives input from the pharmacist.
92.Nursing care for a female client includes removing elastic The system minimizes transcription errors.
stockings once per day. The Nurse Betty is aware that the The system reinforces accurate calculations.
rationale for this intervention? 100. Nurse Oliver is assessing a client’s abdomen. Which
finding should the nurse report as abnormal?
To increase blood flow to the heart
To observe the lower extremities Dullness over the liver.
To allow the leg muscles to stretch and relax Bowel sounds occurring every 10 seconds.
To permit veins in the legs to fill with blood. Shifting dullness over the abdomen.
93.Which nursing intervention takes highest priority when Vascular sounds heard over the renal arteries.
caring for a newly admitted client who’s receiving a blood
transfusion? Answers and Rationales
1. Answer: (D) The actions of a reasonably prudent nurse
Instructing the client to report any itching, swelling, or with similar education and experience. The standard of
dyspnea.
 care is determined by the average degree of skill, care, medications given only once. A stat order is written for
and diligence by nurses in similar circumstances. medications given immediately for an urgent client
2. Answer: (B) I.M. With a platelet count of 22,000/μl, the problem. A standing order, also known as a protocol,
clients tends to bleed easily. Therefore, the nurse establishes guidelines for treating a particular disease
should avoid using the I.M. route because the area is a or set of symptoms in special care areas such as the
highly vascular and can bleed readily when penetrated coronary care unit. Facilities also may institute
by a needle. The bleeding can be difficult to stop. medication protocols that specifically designate drugs
3. Answer: (C) “Digoxin 0.125 mg P.O. once daily” The that a nurse may not give.
nurse should always place a zero before a decimal 14. Answer: (D) Liquid or semi-liquid stools. Passage of
point so that no one misreads the figure, which could liquid or semi-liquid stools results from seepage of
result in a dosage error. The nurse should never insert unformed bowel contents around the impacted stool
a zero at the end of a dosage that includes a decimal in the rectum. Clients with fecal impaction don’t pass
point because this could be misread, possibly leading hard, brown, formed stools because the feces can’t
to a tenfold increase in the dosage. move past the impaction. These clients typically report
4. Answer: (A) Ineffective peripheral tissue perfusion the urge to defecate (although they can’t pass stool)
related to venous congestion. Ineffective peripheral and a decreased appetite.
tissue perfusion related to venous congestion takes the 15. Answer: (C) Pulling the helix up and back. To perform
highest priority because venous inflammation and clot an otoscopic examination on an adult, the nurse grasps
formation impede blood flow in a client with deep the helix of the ear and pulls it up and back to
vein thrombosis. straighten the ear canal. For a child, the nurse grasps
5. Answer: (B) A 44 year-old myocardial infarction (MI) the helix and pulls it down to straighten the ear canal.
client who is complaining of nausea. Nausea is a Pulling the lobule in any direction wouldn’t straighten
symptom of impending myocardial infarction (MI) and the ear canal for visualization.
should be assessed immediately so that treatment can 16. Answer: (A) Protect the irritated skin from sunlight.
be instituted and further damage to the heart is Irradiated skin is very sensitive and must be protected
avoided. with clothing or sunblock. The priority approach is the
6. Answer: (C) Check circulation every 15-30 minutes. avoidance of strong sunlight.
Restraints encircle the limbs, which place the client at 17. Answer: (C) Assist the client in removing dentures and
risk for circulation being restricted to the distal areas nail polish. Dentures, hairpins, and combs must be
of the extremities. Checking the client’s circulation removed. Nail polish must be removed so that cyanosis
every 15-30 minutes will allow the nurse to adjust the can be easily monitored by observing the nail beds.
restraints before injury from decreased blood flow 18. Answer: (D) Sudden onset of continuous epigastric and
occurs. back pain. The autodigestion of tissue by the
7. Answer: (A) Prevent stress ulcer. Curling’s ulcer occurs pancreatic enzymes results in pain from inflammation,
as a generalized stress response in burn patients. This edema, and possible hemorrhage. Continuous,
results in a decreased production of mucus and unrelieved epigastric or back pain reflects the
increased secretion of gastric acid. The best treatment inflammatory process in the pancreas.
for this prophylactic use of antacids and H2 receptor 19. Answer: (B) Provide high-protein, high-carbohydrate
blockers. diet. A positive nitrogen balance is important for
8. Answer: (D) Continue to monitor and record hourly meeting metabolic needs, tissue repair, and resistance
urine output. Normal urine output for an adult is to infection. Caloric goals may be as high as 5000
approximately 1 ml/minute (60 ml/hour). Therefore, calories per day.
this client’s output is normal. Beyond continued 20. Answer: (A) Blood pressure and pulse rate. The
evaluation, no nursing action is warranted. baseline must be established to recognize the signs of
9. Answer: (A) “My ankle looks less swollen now”. Ice an anaphylactic or hemolytic reaction to the
application decreases pain and swelling. Continued or transfusion.
increased pain, redness, and increased warmth are 21. Answer: (D) Immobilize the leg before moving the
signs of inflammation that shouldn’t occur after ice client. If the nurse suspects a fracture, splinting the
application area before moving the client is imperative. The nurse
10. Answer: (B) Hyperkalemia. A loop diuretic removes should call for emergency help if the client is not
water and, along with it, sodium and potassium. This hospitalized and call for a physician for the
may result in hypokalemia, hypovolemia, and hospitalized client.
hyponatremia. 22. Answer: (B) Admit the client into a private room. The
11. Answer:(A) Have condescending trust and confidence client who has a radiation implant is placed in a private
in their subordinates. Benevolent-authoritative room and has a limited number of visitors. This
managers pretentiously show their trust and reduces the exposure of others to the radiation.
confidence to their followers. 23. Answer: (C) Risk for infection. Agranulocytosis is
12. Answer: (A) Provides continuous, coordinated and characterized by a reduced number of leukocytes
comprehensive nursing services. Functional nursing is (leucopenia) and neutrophils (neutropenia) in the
focused on tasks and activities and not on the care of blood. The client is at high risk for infection because of
the patients. the decreased body defenses against microorganisms.
13. Answer: (B) Standard written order. This is a standard Deficient knowledge related to the nature of the
written order. Prescribers write a single order for
 disorder may be appropriate diagnosis but is not the quantity. Different drugs measured in units may have
priority. no relationship to one another in quality or quantity.
24. Answer: (B) Place the client on the left side in the 39. Answer: (B) 38.9 °C. To convert Fahrenheit degreed to
Trendelenburg position. Lying on the left side may Centigrade, use this formula
prevent air from flowing into the pulmonary veins. The °C = (°F – 32) ÷ 1.8
Trendelenburg position increases intrathoracic °C = (102 – 32) ÷ 1.8
pressure, which decreases the amount of blood pulled °C = 70 ÷ 1.8
into the vena cava during aspiration. °C = 38.9
25. Answer: (A) Autocratic. The autocratic style of 40. Answer: (C) Failing eyesight, especially close vision.
leadership is a task-oriented and directive. Failing eyesight, especially close vision, is one of the
26. Answer: (D) 2.5 cc. 2.5 cc is to be added, because only first signs of aging in middle life (ages 46 to 64). More
a 500 cc bag of solution is being medicated instead of a frequent aches and pains begin in the early late years
1 liter. (ages 65 to 79). Increase in loss of muscle tone occurs
27. Answer: (A) 50 cc/ hour. A rate of 50 cc/hr. The child is in later years (age 80 and older).
to receive 400 cc over a period of 8 hours = 50 cc/hr. 41. Answer: (A) Checking and taping all connections. Air
28. Answer: (B) Assess the client for presence of pain. leaks commonly occur if the system isn’t secure.
Assessing the client for pain is a very important Checking all connections and taping them will prevent
measure. Postoperative pain is an indication of air leaks. The chest drainage system is kept lower to
complication. The nurse should also assess the client promote drainage – not to prevent leaks.
for pain to provide for the client’s comfort. 42. Answer: (A) Check the client’s identification band.
29. Answer: (A) BP – 80/60, Pulse – 110 irregular. The Checking the client’s identification band is the safest
classic signs of cardiogenic shock are low blood way to verify a client’s identity because the band is
pressure, rapid and weak irregular pulse, cold, clammy assigned on admission and isn’t be removed at any
skin, decreased urinary output, and cerebral hypoxia. time. (If it is removed, it must be replaced). Asking the
30. Answer: (A) Take the proper equipment, place the client’s name or having the client repeated his name
client in a comfortable position, and record the would be appropriate only for a client who’s alert,
appropriate information in the client’s chart. It is a oriented, and able to understand what is being said,
general or comprehensive statement about the correct but isn’t the safe standard of practice. Names on bed
procedure, and it includes the basic ideas which are aren’t always reliable
found in the other options 43. Answer: (B) 32 drops/minute. Giving 1,000 ml over 8
31. Answer: (B) Evaluation. Evaluation includes observing hours is the same as giving 125 ml over 1 hour (60
the person, asking questions, and comparing the minutes). Find the number of milliliters per minute as
patient’s behavioral responses with the expected follows:
outcomes. 125/60 minutes = X/1 minute
32. Answer: (C) History of present illness. The history of 60X = 125 = 2.1 ml/minute
present illness is the single most important factor in To find the number of drops per minute:
assisting the health professional in arriving at a 2.1 ml/X gtt = 1 ml/ 15 gtt
diagnosis or determining the person’s needs. X = 32 gtt/minute, or 32 drops/minute
33. Answer: (A) Trochanter roll extending from the crest of 44. Answer: (A) Clamp the catheter. If a central venous
the ileum to the mid-thigh. A trochanter roll, properly catheter becomes disconnected, the nurse should
placed, provides resistance to the external rotation of immediately apply a catheter clamp, if available. If a
the hip. clamp isn’t available, the nurse can place a sterile
34. Answer: (C) Stage III. Clinically, a deep crater or syringe or catheter plug in the catheter hub. After
without undermining of adjacent tissue is noted. cleaning the hub with alcohol or povidone-iodine
35. Answer: (A) Second intention healing. When wounds solution, the nurse must replace the I.V. extension and
dehisce, they will allowed to heal by secondary restart the infusion.
intention 45. Answer: (D) Auscultation, percussion, and
36. Answer: (D) Tachycardia. With an extracellular fluid or palpation.The correct order of assessment for
plasma volume deficit, compensatory mechanisms examining the abdomen is inspection, auscultation,
stimulate the heart, causing an increase in heart rate. percussion, and palpation. The reason for this
37. Answer: (A) 0.75. To determine the number of approach is that the less intrusive techniques should
milliliters the client should receive, the nurse uses the be performed before the more intrusive techniques.
fraction method in the following equation. Percussion and palpation can alter natural findings
75 mg/X ml = 100 mg/1 ml during auscultation.
To solve for X, cross-multiply: 46. Answer: (D) Ulnar surface of the hand. The nurse uses
75 mg x 1 ml = X ml x 100 mg the ulnar surface, or ball, of the hand to asses tactile
75 = 100X fremitus, thrills, and vocal vibrations through the chest
75/100 = X wall. The fingertips and finger pads best distinguish
0.75 ml (or ¾ ml) = X texture and shape. The dorsal surface best feels
38. Answer: (D) It’s a measure of effect, not a standard warmth.
measure of weight or quantity. An insulin unit is a 47. Answer: (C) Formative. Formative (or concurrent)
measure of effect, not a standard measure of weight or evaluation occurs continuously throughout the
teaching and learning process. One benefit is that the
 nurse can adjust teaching strategies as necessary to instructed to look up and outward rather than at his or
enhance learning. Summative, or retrospective, her feet.
evaluation occurs at the conclusion of the teaching and 57. Answer: (A) Urine output: 45 ml/hr. Adequate
learning session. Informative is not a type of perfusion must be maintained to all vital organs in
evaluation. order for the client to remain visible as an organ
48. Answer: (B) Once per year. Yearly mammograms donor. A urine output of 45 ml per hour indicates
should begin at age 40 and continue for as long as the adequate renal perfusion. Low blood pressure and
woman is in good health. If health risks, such as family delayed capillary refill time are circulatory system
history, genetic tendency, or past breast cancer, exist, indicators of inadequate perfusion. A serum pH of 7.32
more frequent examinations may be necessary. is acidotic, which adversely affects all body tissues.
49. Answer: (A) Respiratory acidosis. The client has a 58. Answer: (D ) Obtaining the specimen from the urinary
below-normal (acidic) blood pH value and an above- drainage bag. A urine specimen is not taken from the
normal partial pressure of arterial carbon dioxide urinary drainage bag. Urine undergoes chemical
(Paco2) value, indicating respiratory acidosis. In changes while sitting in the bag and does not
respiratory alkalosis, the pH value is above normal and necessarily reflect the current client status. In addition,
in the Paco2 value is below normal. In metabolic it may become contaminated with bacteria from
acidosis, the pH and bicarbonate (Hco3) values are opening the system.
below normal. In metabolic alkalosis, the pH and Hco3 59. Answer: (B) Cover the client, place the call light within
values are above normal. reach, and answer the phone call. Because telephone
50. Answer: (B) To provide support for the client and call is an emergency, the nurse may need to answer it.
family in coping with terminal illness. Hospices provide The other appropriate action is to ask another nurse to
supportive care for terminally ill clients and their accept the call. However, is not one of the options. To
families. Hospice care doesn’t focus on counseling maintain privacy and safety, the nurse covers the client
regarding health care costs. Most client referred to and places the call light within the client’s reach.
hospices have been treated for their disease without Additionally, the client’s door should be closed or the
success and will receive only palliative care in the room curtains pulled around the bathing area.
hospice. 60. Answer: (C) Use a sterile plastic container for obtaining
51. Answer: (C) Using normal saline solution to clean the the specimen. Sputum specimens for culture and
ulcer and applying a protective dressing as necessary. sensitivity testing need to be obtained using sterile
Washing the area with normal saline solution and techniques because the test is done to determine the
applying a protective dressing are within the nurse’s presence of organisms. If the procedure for obtaining
realm of interventions and will protect the area. Using the specimen is not sterile, then the specimen is not
a povidone-iodine wash and an antibiotic cream sterile, then the specimen would be contaminated and
require a physician’s order. Massaging with an the results of the test would be invalid.
astringent can further damage the skin. 61. Answer: (A) Puts all the four points of the walker flat
52. Answer: (D) Foot. An elastic bandage should be applied on the floor, puts weight on the hand pieces, and then
form the distal area to the proximal area. This method walks into it. When the client uses a walker, the nurse
promotes venous return. In this case, the nurse should stands adjacent to the affected side. The client is
begin applying the bandage at the client’s foot. instructed to put all four points of the walker 2 feet
Beginning at the ankle, lower thigh, or knee does not forward flat on the floor before putting weight on hand
promote venous return. pieces. This will ensure client safety and prevent stress
53. Answer: (B) Hypokalemia. Insulin administration cracks in the walker. The client is then instructed to
causes glucose and potassium to move into the cells, move the walker forward and walk into it.
causing hypokalemia. 62. Answer: (C) Draws one line to cross out the incorrect
54. Answer: (A) Throbbing headache or dizziness. information and then initials the change. To correct an
Headache and dizziness often occur when nitroglycerin error documented in a medical record, the nurse draws
is taken at the beginning of therapy. However, the one line through the incorrect information and then
client usually develops tolerance initials the error. An error is never erased and
55. Answer: (D) Check the client’s level of consciousness. correction fluid is never used in the medical record.
Determining unresponsiveness is the first step 63. Answer: (C) Secures the client safety belts after
assessment action to take. When a client is in transferring to the stretcher. During the transfer of the
ventricular tachycardia, there is a significant decrease client after the surgical procedure is complete, the
in cardiac output. However, checking the nurse should avoid exposure of the client because of
unresponsiveness ensures whether the client is the risk for potential heat loss. Hurried movements
affected by the decreased cardiac output. and rapid changes in the position should be avoided
56. Answer: (B) On the affected side of the client.When because these predispose the client to hypotension. At
walking with clients, the nurse should stand on the the time of the transfer from the surgery table to the
affected side and grasp the security belt in the stretcher, the client is still affected by the effects of the
midspine area of the small of the back. The nurse anesthesia; therefore, the client should not move self.
should position the free hand at the shoulder area so Safety belts can prevent the client from falling off the
that the client can be pulled toward the nurse in the stretcher.
event that there is a forward fall. The client is 64. Answer: (B) Gown and gloves. Contact precautions
require the use of gloves and a gown if direct client
 contact is anticipated. Goggles are not necessary following conditions are met: a) the cause for
unless the nurse anticipates the splashes of blood, revocation of license has already been corrected or
body fluids, secretions, or excretions may occur. Shoe removed; and, b) at least four years has elapsed since
protectors are not necessary. the license has been revoked.
65. Answer: (C) Quad cane. Crutches and a walker can be 77. Answer: (B) Review related literature. After
difficult to maneuver for a client with weakness on one formulating and delimiting the research problem, the
side. A cane is better suited for client with weakness of researcher conducts a review of related literature to
the arm and leg on one side. However, the quad cane determine the extent of what has been done on the
would provide the most stability because of the study by previous researchers.
structure of the cane and because a quad cane has four 78. Answer: (B) Hawthorne effect. Hawthorne effect is
legs. based on the study of Elton Mayo and company about
66. Answer: (D) Left side-lying with the head of the bed the effect of an intervention done to improve the
elevated 45 degrees. To facilitate removal of fluid from working conditions of the workers on their
the chest wall, the client is positioned sitting at the productivity. It resulted to an increased productivity
edge of the bed leaning over the bedside table with but not due to the intervention but due to the
the feet supported on a stool. If the client is unable to psychological effects of being observed. They
sit up, the client is positioned lying in bed on the performed differently because they were under
unaffected side with the head of the bed elevated 30 observation.
to 45 degrees. 79. Answer: (B) Determines the different nationality of
67. Answer: (D) Reliability Reliability is consistency of the patients frequently admitted and decides to get
research instrument. It refers to the repeatability of representations samples from each. Judgment
the instrument in extracting the same responses upon sampling involves including samples according to the
its repeated administration. knowledge of the investigator about the participants in
68. Answer: (A) Keep the identities of the subject secret. the study.
Keeping the identities of the research subject secret 80. Answer: (B) Madeleine Leininger. Madeleine Leininger
will ensure anonymity because this will hinder developed the theory on transcultural theory based on
providing link between the information given to her observations on the behavior of selected people
whoever is its source. within a culture.
69. Answer: (A) Descriptive- correlational. Descriptive- 81. Answer: (A) Random. Random sampling gives equal
correlational study is the most appropriate for this chance for all the elements in the population to be
study because it studies the variables that could be the picked as part of the sample.
antecedents of the increased incidence of nosocomial 82. Answer: (A) Degree of agreement and disagreement.
infection. Likert scale is a 5-point summated scale used to
70. Answer: (C) Use of laboratory data. Incidence of determine the degree of agreement or disagreement
nosocomial infection is best collected through the use of the respondents to a statement in a study
of biophysiologic measures, particularly in vitro 83. Answer: (B) Sr. Callista Roy. Sr. Callista Roy developed
measurements, hence laboratory data is essential. the Adaptation Model which involves the physiologic
71. Answer: (B) Quasi-experiment. Quasi-experiment is mode, self-concept mode, role function mode and
done when randomization and control of the variables dependence mode.
are not possible. 84. Answer: (A) Span of control. Span of control refers to
72. Answer: (C) Primary source. This refers to a primary the number of workers who report directly to a
source which is a direct account of the investigation manager.
done by the investigator. In contrast to this is a 85. Answer: (B) Autonomy. Informed consent means that
secondary source, which is written by someone other the patient fully understands about the surgery,
than the original researcher. including the risks involved and the alternative
73. Answer: (A) Non-maleficence. Non-maleficence means solutions. In giving consent it is done with full
do not cause harm or do any action that will cause any knowledge and is given freely. The action of allowing
harm to the patient/client. To do good is referred as the patient to decide whether a surgery is to be done
beneficence. or not exemplifies the bioethical principle of
74. Answer: (C) Res ipsa loquitor. Res ipsa loquitor literally autonomy.
means the thing speaks for itself. This means in 86. Answer: (C) Avoid wearing canvas shoes. The client
operational terms that the injury caused is the proof should be instructed to avoid wearing canvas shoes.
that there was a negligent act. Canvas shoes cause the feet to perspire, which may, in
75. Answer: (B) The Board can investigate violations of the turn, cause skin irritation and breakdown. Both cotton
nursing law and code of ethics. Quasi-judicial power and cornstarch absorb perspiration. The client should
means that the Board of Nursing has the authority to be instructed to cut toenails straight across with nail
investigate violations of the nursing law and can issue clippers.
summons, subpoena or subpoena duces tecum as 87. Answer: (D) Ground beef patties. Meat is an excellent
needed. source of complete protein, which this client needs to
76. Answer: (C) May apply for re-issuance of his/her repair the tissue breakdown caused by pressure ulcers.
license based on certain conditions stipulated in RA Oranges and broccoli supply vitamin C but not protein.
9173. RA 9173 sec. 24 states that for equity and justice, Ice cream supplies only some incomplete protein,
a revoked license maybe re-issued provided that the making it less helpful in tissue repair.
88. Answer: (D) Sims’ left lateral. The Sims’ left lateral client’s bed should be elevated at least 30 degrees.
position is the most common position used to Also, to prevent bacterial growth, feeding containers
administer a cleansing enema because it allows gravity should be routinely changed every 8 to 12 hours.
to aid the flow of fluid along the curve of the sigmoid 95. Answer: (D) Roll the vial gently between the palms.
colon. If the client can’t assume this position nor has Rolling the vial gently between the palms produces
poor sphincter control, the dorsal recumbent or right heat, which helps dissolve the medication. Doing
lateral position may be used. The supine and prone nothing or inverting the vial wouldn’t help dissolve the
positions are inappropriate and uncomfortable for the medication. Shaking the vial vigorously could cause the
client. medication to break down, altering its action.
89. Answer: (A) Arrange for typing and cross matching of 96. Answer: (B) Assist the client to the semi-Fowler
the client’s blood. The nurse first arranges for typing position if possible. By assisting the client to the semi-
and cross matching of the client’s blood to ensure Fowler position, the nurse promotes easier chest
compatibility with donor blood. The other expansion, breathing, and oxygen intake. The nurse
options,although appropriate when preparing to should secure the elastic band so that the face mask
administer a blood transfusion, come later. fits comfortably and snugly rather than tightly, which
90. Answer: (A) Independent. Nursing interventions are could lead to irritation. The nurse should apply the
classified as independent, interdependent, or face mask from the client’s nose down to the chin —
dependent. Altering the drug schedule to coincide with not vice versa. The nurse should check the connectors
the client’s daily routine represents an independent between the oxygen equipment and humidifier to
intervention, whereas consulting with the physician ensure that they’re airtight; loosened connectors can
and pharmacist to change a client’s medication cause loss of oxygen.
because of adverse reactions represents an 97. Answer: (B) 4 hours. A unit of packed RBCs may be
interdependent intervention. Administering an given over a period of between 1 and 4 hours. It
already-prescribed drug on time is a dependent shouldn’t infuse for longer than 4 hours because the
intervention. An intradependent nursing intervention risk of contamination and sepsis increases after that
doesn’t exist. time. Discard or return to the blood bank any blood
91. Answer: (D) Evaluation. The nursing actions described not given within this time, according to facility policy.
constitute evaluation of the expected outcomes. The 98. Answer: (B) Immediately before administering the next
findings show that the expected outcomes have been dose. Measuring the blood drug concentration helps
achieved. Assessment consists of the client’s history, determine whether the dosing has achieved the
physical examination, and laboratory studies. Analysis therapeutic goal. For measurement of the trough, or
consists of considering assessment information to lowest, blood level of a drug, the nurse draws a blood
derive the appropriate nursing diagnosis. sample immediately before administering the next
Implementation is the phase of the nursing process dose. Depending on the drug’s duration of action and
where the nurse puts the plan of care into action. half-life, peak blood drug levels typically are drawn
92. Answer: (B) To observe the lower extremities. Elastic after administering the next dose.
stockings are used to promote venous return. The 99. Answer: (A) The nurse can implement medication
nurse needs to remove them once per day to observe orders quickly. A floor stock system enables the nurse
the condition of the skin underneath the stockings. to implement medication orders quickly. It doesn’t
Applying the stockings increases blood flow to the allow for pharmacist input, nor does it minimize
heart. When the stockings are in place, the leg muscles transcription errors or reinforce accurate calculations.
can still stretch and relax, and the veins can fill with 100. Answer: (C) Shifting dullness over the abdomen.
blood. Shifting dullness over the abdomen indicates ascites,
93. Answer:(A) Instructing the client to report any itching, an abnormal finding. The other options are normal
swelling, or dyspnea. Because administration of blood abdominal findings.
or blood products may cause serious adverse effects
such as allergic reactions, the nurse must monitor the PNLE II for Community Health Nursing and Care of the
client for these effects. Signs and symptoms of life- Mother and Child
threatening allergic reactions include itching, swelling,
and dyspnea. Although the nurse should inform the 1. May arrives at the health care clinic and tells the nurse that
client of the duration of the transfusion and should her last menstrual period was 9 weeks ago. She also tells the
document its administration, these actions are less nurse that a home pregnancy test was positive but she began
critical to the client’s immediate health. The nurse to have mild cramps and is now having moderate vaginal
should assess vital signs at least hourly during the bleeding. During the physical examination of the client, the
transfusion. nurse notes that May has a dilated cervix. The nurse
94. Answer: (B) Decrease the rate of feedings and the determines that May is experiencing which type of abortion?
concentration of the formula. Complaints of abdominal Inevitable
discomfort and nausea are common in clients receiving Incomplete
tube feedings. Decreasing the rate of the feeding and Threatened
the concentration of the formula should decrease the Septic
client’s discomfort. Feedings are normally given at 2. Nurse Reese is reviewing the record of a pregnant client
room temperature to minimize abdominal cramping. for her first prenatal visit. Which of the following data, if
To prevent aspiration during feeding, the head of the
noted on the client’s record, would alert the nurse that the First low transverse cesarean was for active herpes type 2
client is at risk for a spontaneous abortion? infections; vaginal culture at 39 weeks pregnancy was
Age 36 years positive.
History of syphilis First and second caesareans were for cephalopelvic
History of genital herpes disproportion.
History of diabetes mellitus First caesarean through a classic incision as a result of severe
3. Nurse Hazel is preparing to care for a client who is newly fetal distress.
admitted to the hospital with a possible diagnosis of ectopic First low transverse caesarean was for breech position. Fetus
pregnancy. Nurse Hazel develops a plan of care for the client in this pregnancy is in a vertex presentation.
and determines that which of the following nursing actions is 11.Nurse Ryan is aware that the best initial approach when
the priority? trying to take a crying toddler’s temperature is:
Monitoring weight Talk to the mother first and then to the toddler.
Assessing for edema Bring extra help so it can be done quickly.
Monitoring apical pulse Encourage the mother to hold the child.
Monitoring temperature Ignore the crying and screaming.
4. Nurse Oliver is teaching a diabetic pregnant client about 12.Baby Tina a 3 month old infant just had a cleft lip and
nutrition and insulin needs during pregnancy. The nurse palate repair. What should the nurse do to prevent trauma to
determines that the client understands dietary and insulin operative site?
needs if the client states that the second half of pregnancy Avoid touching the suture line, even when cleaning.
require: Place the baby in prone position.
Decreased caloric intake Give the baby a pacifier.
Increased caloric intake Place the infant’s arms in soft elbow restraints.
Decreased Insulin 13. Which action should nurse Marian include in the care
Increase Insulin plan for a 2 month old with heart failure?
5. Nurse Michelle is assessing a 24 year old client with a Feed the infant when he cries.
diagnosis of hydatidiform mole. She is aware that one of the Allow the infant to rest before feeding.
following is unassociated with this condition? Bathe the infant and administer medications before feeding.
Excessive fetal activity. Weigh and bathe the infant before feeding.
Larger than normal uterus for gestational age. 14.Nurse Hazel is teaching a mother who plans to discontinue
Vaginal bleeding breast feeding after 5 months. The nurse should advise her to
Elevated levels of human chorionic gonadotropin. include which foods in her infant’s diet?
6. A pregnant client is receiving magnesium sulfate for severe Skim milk and baby food.
pregnancy induced hypertension (PIH). The clinical findings Whole milk and baby food.
that would warrant use of the antidote , calcium gluconate is: Iron-rich formula only.
Urinary output 90 cc in 2 hours. Iron-rich formula and baby food.
Absent patellar reflexes. 15.Mommy Linda is playing with her infant, who is sitting
Rapid respiratory rate above 40/min. securely alone on the floor of the clinic. The mother hides a
Rapid rise in blood pressure. toy behind her back and the infant looks for it. The nurse is
7. During vaginal examination of Janah who is in labor, the aware that estimated age of the infant would be:
presenting part is at station plus two. Nurse, correctly 6 months
interprets it as: 4 months
Presenting part is 2 cm above the plane of the ischial spines. 8 months
Biparietal diameter is at the level of the ischial spines. 10 months
Presenting part in 2 cm below the plane of the ischial spines. 16.Which of the following is the most prominent feature of
Biparietal diameter is 2 cm above the ischial spines. public health nursing?
8. A pregnant client is receiving oxytocin (Pitocin) for It involves providing home care to sick people who are not
induction of labor. A condition that warrant the nurse in- confined in the hospital.
charge to discontinue I.V. infusion of Pitocin is: Services are provided free of charge to people within the
Contractions every 1 ½ minutes lasting 70-80 seconds. catchments area.
Maternal temperature 101.2 The public health nurse functions as part of a team providing
Early decelerations in the fetal heart rate. a public health nursing services.
Fetal heart rate baseline 140-160 bpm. Public health nursing focuses on preventive, not curative,
9. Calcium gluconate is being administered to a client with services.
pregnancy induced hypertension (PIH). A nursing action that 17.When the nurse determines whether resources were
must be initiated as the plan of care throughout injection of maximized in implementing Ligtas Tigdas, she is evaluating
the drug is: Effectiveness
Ventilator assistance Efficiency
CVP readings Adequacy
EKG tracings Appropriateness
Continuous CPR 18.Vangie is a new B.S.N. graduate. She wants to become a
10. A trial for vaginal delivery after an earlier caesareans, Public Health Nurse. Where should she apply?
would likely to be given to a gravida, who had: Department of Health
Provincial Health Office
Regional Health Office 27.A fullterm client is in labor. Nurse Betty is aware that the
Rural Health Unit fetal heart rate would be:
19.Tony is aware the Chairman of the Municipal Health Board 80 to 100 beats/minute
is: 100 to 120 beats/minute
Mayor 120 to 160 beats/minute
Municipal Health Officer 160 to 180 beats/minute
Public Health Nurse 28.The skin in the diaper area of a 7 month old infant is
Any qualified physician excoriated and red. Nurse Hazel should instruct the mother
20.Myra is the public health nurse in a municipality with a to:
total population of about 20,000. There are 3 rural health Change the diaper more often.
midwives among the RHU personnel. How many more Apply talc powder with diaper changes.
midwife items will the RHU need? Wash the area vigorously with each diaper change.
1 Decrease the infant’s fluid intake to decrease saturating
2 diapers.
3 29.Nurse Carla knows that the common cardiac anomalies in
The RHU does not need any more midwife item. children with Down Syndrome (tri-somy 21) is:
21.According to Freeman and Heinrich, community health Atrial septal defect
nursing is a developmental service. Which of the following Pulmonic stenosis
best illustrates this statement? Ventricular septal defect
The community health nurse continuously develops himself Endocardial cushion defect
personally and professionally. 30.Malou was diagnosed with severe preeclampsia is now
Health education and community organizing are necessary in receiving I.V. magnesium sulfate. The adverse effects
providing community health services. associated with magnesium sulfate is:
Community health nursing is intended primarily for health Anemia
promotion and prevention and treatment of disease. Decreased urine output
The goal of community health nursing is to provide nursing Hyperreflexia
services to people in their own places of residence. Increased respiratory rate
22.Nurse Tina is aware that the disease declared through 31.A 23 year old client is having her menstrual period every 2
Presidential Proclamation No. 4 as a target for eradication in weeks that last for 1 week. This type of menstrual pattern is
the Philippines is? bets defined by:
Poliomyelitis Menorrhagia
Measles Metrorrhagia
Rabies Dyspareunia
Neonatal tetanus Amenorrhea
23.May knows that the step in community organizing that 32. Jannah is admitted to the labor and delivery unit. The
involves training of potential leaders in the community is: critical laboratory result for this client would be:
Integration Oxygen saturation
Community organization Iron binding capacity
Community study Blood typing
Core group formation Serum Calcium
24.Beth a public health nurse takes an active role in 33.Nurse Gina is aware that the most common condition
community participation. What is the primary goal of found during the second-trimester of pregnancy is:
community organizing? Metabolic alkalosis
To educate the people regarding community health problems Respiratory acidosis
To mobilize the people to resolve community health Mastitis
problems Physiologic anemia
To maximize the community’s resources in dealing with 34.Nurse Lynette is working in the triage area of an
health problems. emergency department. She sees that several pediatric
To maximize the community’s resources in dealing with clients arrive simultaneously. The client who needs to be
health problems. treated first is:
25.Tertiary prevention is needed in which stage of the natural A crying 5 year old child with a laceration on his scalp.
history of disease? A 4 year old child with a barking coughs and flushed
Pre-pathogenesis appearance.
Pathogenesis A 3 year old child with Down syndrome who is pale and
Prodromal asleep in his mother’s arms.
Terminal A 2 year old infant with stridorous breath sounds, sitting up in
26.The nurse is caring for a primigravid client in the labor and his mother’s arms and drooling.
delivery area. Which condition would place the client at risk 35.Maureen in her third trimester arrives at the emergency
for disseminated intravascular coagulation (DIC)? room with painless vaginal bleeding. Which of the following
Intrauterine fetal death. conditions is suspected?
Placenta accreta. Placenta previa
Dysfunctional labor. Abruptio placentae
Premature rupture of the membranes. Premature labor
Sexually transmitted disease 44.Nurse Carla should know that the most common causative
36.A young child named Richard is suspected of having factor of dermatitis in infants and younger children is:
pinworms. The community nurse collects a stool specimen to Baby oil
confirm the diagnosis. The nurse should schedule the Baby lotion
collection of this specimen for: Laundry detergent
Just before bedtime Powder with cornstarch
After the child has been bathe 45.During tube feeding, how far above an infant’s stomach
Any time during the day should the nurse hold the syringe with formula?
Early in the morning 6 inches
37.In doing a child’s admission assessment, Nurse Betty 12 inches
should be alert to note which signs or symptoms of chronic 18 inches
lead poisoning? 24 inches
Irritability and seizures 46. In a mothers’ class, Nurse Lhynnete discussed childhood
Dehydration and diarrhea diseases such as chicken pox. Which of the following
Bradycardia and hypotension statements about chicken pox is correct?
Petechiae and hematuria The older one gets, the more susceptible he becomes to the
38.To evaluate a woman’s understanding about the use of complications of chicken pox.
diaphragm for family planning, Nurse Trish asks her to A single attack of chicken pox will prevent future episodes,
explain how she will use the appliance. Which response including conditions such as shingles.
indicates a need for further health teaching? To prevent an outbreak in the community, quarantine may
“I should check the diaphragm carefully for holes every time I be imposed by health authorities.
use it” Chicken pox vaccine is best given when there is an impending
“I may need a different size of diaphragm if I gain or lose outbreak in the community.
weight more than 20 pounds” 47.Barangay Pinoy had an outbreak of German measles. To
“The diaphragm must be left in place for atleast 6 hours after prevent congenital rubella, what is the BEST advice that you
intercourse” can give to women in the first trimester of pregnancy in the
“I really need to use the diaphragm and jelly most during the barangay Pinoy?
middle of my menstrual cycle”. Advice them on the signs of German measles.
39.Hypoxia is a common complication of Avoid crowded places, such as markets and movie houses.
laryngotracheobronchitis. Nurse Oliver should frequently Consult at the health center where rubella vaccine may be
assess a child with laryngotracheobronchitis for: given.
Drooling Consult a physician who may give them rubella
Muffled voice immunoglobulin.
Restlessness 48.Myrna a public health nurse knows that to determine
Low-grade fever possible sources of sexually transmitted infections, the BEST
40.How should Nurse Michelle guide a child who is blind to method that may be undertaken is:
walk to the playroom? Contact tracing
Without touching the child, talk continuously as the child Community survey
walks down the hall. Mass screening tests
Walk one step ahead, with the child’s hand on the nurse’s Interview of suspects
elbow. 49.A 33-year old female client came for consultation at the
Walk slightly behind, gently guiding the child forward. health center with the chief complaint of fever for a week.
Walk next to the child, holding the child’s hand. Accompanying symptoms were muscle pains and body
41.When assessing a newborn diagnosed with ductus malaise. A week after the start of fever, the client noted
arteriosus, Nurse Olivia should expect that the child most yellowish discoloration of his sclera. History showed that he
likely would have an: waded in flood waters about 2 weeks before the onset of
Loud, machinery-like murmur. symptoms. Based on her history, which disease condition will
Bluish color to the lips. you suspect?
Decreased BP reading in the upper extremities Hepatitis A
Increased BP reading in the upper extremities. Hepatitis B
42.The reason nurse May keeps the neonate in a neutral Tetanus
thermal environment is that when a newborn becomes too Leptospirosis
cool, the neonate requires: 50.Mickey a 3-year old client was brought to the health
Less oxygen, and the newborn’s metabolic rate increases. center with the chief complaint of severe diarrhea and the
More oxygen, and the newborn’s metabolic rate decreases. passage of “rice water” stools. The client is most probably
More oxygen, and the newborn’s metabolic rate increases. suffering from which condition?
Less oxygen, and the newborn’s metabolic rate decreases. Giardiasis
43.Before adding potassium to an infant’s I.V. line, Nurse Ron Cholera
must be sure to assess whether this infant has: Amebiasis
Stable blood pressure Dysentery
Patant fontanelles 51.The most prevalent form of meningitis among children
Moro’s reflex aged 2 months to 3 years is caused by which microorganism?
Voided Hemophilus influenzae
Morbillivirus 60.Marie brought her 10 month old infant for consultation
Steptococcus pneumoniae because of fever, started 4 days prior to consultation. In
Neisseria meningitidis determining malaria risk, what will you do?
52.The student nurse is aware that the pathognomonic sign Perform a tourniquet test.
of measles is Koplik’s spot and you may see Koplik’s spot by Ask where the family resides.
inspecting the: Get a specimen for blood smear.
Nasal mucosa Ask if the fever is present everyday.
Buccal mucosa 61.Susie brought her 4 years old daughter to the RHU
Skin on the abdomen because of cough and colds. Following the IMCI assessment
Skin on neck guide, which of the following is a danger sign that indicates
53.Angel was diagnosed as having Dengue fever. You will say the need for urgent referral to a hospital?
that there is slow capillary refill when the color of the nailbed Inability to drink
that you pressed does not return within how many seconds? High grade fever
3 seconds Signs of severe dehydration
6 seconds Cough for more than 30 days
9 seconds 62.Jimmy a 2-year old child revealed “baggy pants”. As a
10 seconds nurse, using the IMCI guidelines, how will you manage
54.In Integrated Management of Childhood Illness, the nurse Jimmy?
is aware that the severe conditions generally require urgent Refer the child urgently to a hospital for confinement.
referral to a hospital. Which of the following severe Coordinate with the social worker to enroll the child in a
conditions DOES NOT always require urgent referral to a feeding program.
hospital? Make a teaching plan for the mother, focusing on menu
Mastoiditis planning for her child.
Severe dehydration Assess and treat the child for health problems like infections
Severe pneumonia and intestinal parasitism.
Severe febrile disease 63.Gina is using Oresol in the management of diarrhea of her
55.Myrna a public health nurse will conduct outreach 3-year old child. She asked you what to do if her child vomits.
immunization in a barangay Masay with a population of As a nurse you will tell her to:
about 1500. The estimated number of infants in the barangay Bring the child to the nearest hospital for further assessment.
would be: Bring the child to the health center for intravenous fluid
45 infants therapy.
50 infants Bring the child to the health center for assessment by the
55 infants physician.
65 infants Let the child rest for 10 minutes then continue giving Oresol
56.The community nurse is aware that the biological used in more slowly.
Expanded Program on Immunization (EPI) should NOT be 64.Nikki a 5-month old infant was brought by his mother to
stored in the freezer? the health center because of diarrhea for 4 to 5 times a day.
DPT Her skin goes back slowly after a skin pinch and her eyes are
Oral polio vaccine sunken. Using the IMCI guidelines, you will classify this infant
Measles vaccine in which category?
MMR No signs of dehydration
57.It is the most effective way of controlling schistosomiasis Some dehydration
in an endemic area? Severe dehydration
Use of molluscicides The data is insufficient.
Building of foot bridges 65.Chris a 4-month old infant was brought by her mother to
Proper use of sanitary toilets the health center because of cough. His respiratory rate is
Use of protective footwear, such as rubber boots 42/minute. Using the Integrated Management of Child Illness
58.Several clients is newly admitted and diagnosed with (IMCI) guidelines of assessment, his breathing is considered
leprosy. Which of the following clients should be classified as as:
a case of multibacillary leprosy? Fast
3 skin lesions, negative slit skin smear Slow
3 skin lesions, positive slit skin smear Normal
5 skin lesions, negative slit skin smear Insignificant
5 skin lesions, positive slit skin smear 66.Maylene had just received her 4th dose of tetanus toxoid.
59.Nurses are aware that diagnosis of leprosy is highly She is aware that her baby will have protection against
dependent on recognition of symptoms. Which of the tetanus for
following is an early sign of leprosy? 1 year
Macular lesions 3 years
Inability to close eyelids 5 years
Thickened painful nerves Lifetime
Sinking of the nosebridge 67.Nurse Ron is aware that unused BCG should be discarded
after how many hours of reconstitution?
2 hours
4 hours Wash the cord with soap and water each day during a tub
8 hours bath.
At the end of the day 77.Nurse John is performing an assessment on a neonate.
68.The nurse explains to a breastfeeding mother that breast Which of the following findings is considered common in the
milk is sufficient for all of the baby’s nutrient needs only up healthy neonate?
to: Simian crease
5 months Conjunctival hemorrhage
6 months Cystic hygroma
1 year Bulging fontanelle
2 years 78.Dr. Esteves decides to artificially rupture the membranes
69.Nurse Ron is aware that the gestational age of a of a mother who is on labor. Following this procedure, the
conceptus that is considered viable (able to live outside the nurse Hazel checks the fetal heart tones for which the
womb) is: following reasons?
8 weeks To determine fetal well-being.
12 weeks To assess for prolapsed cord
24 weeks To assess fetal position
32 weeks To prepare for an imminent delivery.
70.When teaching parents of a neonate the proper position 79.Which of the following would be least likely to indicate
for the neonate’s sleep, the nurse Patricia stresses the anticipated bonding behaviors by new parents?
importance of placing the neonate on his back to reduce the The parents’ willingness to touch and hold the new born.
risk of which of the following? The parent’s expression of interest about the size of the new
Aspiration born.
Sudden infant death syndrome (SIDS) The parents’ indication that they want to see the newborn.
Suffocation The parents’ interactions with each other.
Gastroesophageal reflux (GER) 80.Following a precipitous delivery, examination of the
71.Which finding might be seen in baby James a neonate client’s vagina reveals
suspected of having an infection? a fourth-degree laceration. Which of the following would be
Flushed cheeks contraindicated when caring for this client?
Increased temperature Applying cold to limit edema during the first 12 to 24 hours.
Decreased temperature Instructing the client to use two or more peripads to cushion
Increased activity level the area.
72.Baby Jenny who is small-for-gestation is at increased risk Instructing the client on the use of sitz baths if ordered.
during the transitional period for which complication? Instructing the client about the importance of perineal
Anemia probably due to chronic fetal hyposia (kegel) exercises.
Hyperthermia due to decreased glycogen stores 81. A pregnant woman accompanied by her husband, seeks
Hyperglycemia due to decreased glycogen stores admission to the labor and delivery area. She states that
Polycythemia probably due to chronic fetal hypoxia she’s in labor and says she attended the facility clinic for
73.Marjorie has just given birth at 42 weeks’ gestation. When prenatal care. Which question should the nurse Oliver ask her
the nurse assessing the neonate, which physical finding is first?
expected? “Do you have any chronic illnesses?”
A sleepy, lethargic baby “Do you have any allergies?”
Lanugo covering the body “What is your expected due date?”
Desquamation of the epidermis “Who will be with you during labor?”
Vernix caseosa covering the body 82.A neonate begins to gag and turns a dusky color. What
74.After reviewing the Myrna’s maternal history of should the nurse do first?
magnesium sulfate during labor, which condition would Calm the neonate.
nurse Richard anticipate as a potential problem in the Notify the physician.
neonate? Provide oxygen via face mask as ordered
Hypoglycemia Aspirate the neonate’s nose and mouth with a bulb syringe.
Jitteriness 83. When a client states that her “water broke,” which of the
Respiratory depression following actions would be inappropriate for the nurse to do?
Tachycardia Observing the pooling of straw-colored fluid.
75.Which symptom would indicate the Baby Alexandra was Checking vaginal discharge with nitrazine paper.
adapting appropriately to extra-uterine life without difficulty? Conducting a bedside ultrasound for an amniotic fluid index.
Nasal flaring Observing for flakes of vernix in the vaginal discharge.
Light audible grunting 84. A baby girl is born 8 weeks premature. At birth, she has
Respiratory rate 40 to 60 breaths/minute no spontaneous respirations but is successfully resuscitated.
Respiratory rate 60 to 80 breaths/minute Within several hours she develops respiratory grunting,
76. When teaching umbilical cord care for Jennifer a new cyanosis, tachypnea, nasal flaring, and retractions. She’s
mother, the nurse Jenny would include which information? diagnosed with respiratory distress syndrome, intubated, and
Apply peroxide to the cord with each diaper change placed on a ventilator. Which nursing action should be
Cover the cord with petroleum jelly after bathing included in the baby’s plan of care to prevent retinopathy of
Keep the cord dry and open to air prematurity?
Cover his eyes while receiving oxygen. 94. Marlyn is screened for tuberculosis during her first
Keep her body temperature low. prenatal visit. An intradermal injection of purified protein
Monitor partial pressure of oxygen (Pao2) levels. derivative (PPD) of the tuberculin bacilli is given. She is
Humidify the oxygen. considered to have a positive test for which of the following
85. Which of the following is normal newborn calorie intake? results?
110 to 130 calories per kg. An indurated wheal under 10 mm in diameter appears in 6 to
30 to 40 calories per lb of body weight. 12 hours.
At least 2 ml per feeding An indurated wheal over 10 mm in diameter appears in 48 to
90 to 100 calories per kg 72 hours.
86. Nurse John is knowledgeable that usually individual twins A flat circumcised area under 10 mm in diameter appears in 6
will grow appropriately and at the same rate as singletons to 12 hours.
until how many weeks? A flat circumcised area over 10 mm in diameter appears in 48
16 to 18 weeks to 72 hours.
18 to 22 weeks 95. Dianne, 24 year-old is 27 weeks’ pregnant arrives at her
30 to 32 weeks physician’s office with complaints of fever, nausea, vomiting,
38 to 40 weeks malaise, unilateral flank pain, and costovertebral angle
87. Which of the following classifications applies to tenderness. Which of the following diagnoses is most likely?
monozygotic twins for whom the cleavage of the fertilized Asymptomatic bacteriuria
ovum occurs more than 13 days after fertilization? Bacterial vaginosis
conjoined twins Pyelonephritis
diamniotic dichorionic twins Urinary tract infection (UTI)
diamniotic monochorionic twin 96. Rh isoimmunization in a pregnant client develops during
monoamniotic monochorionic twins which of the following conditions?
88. Tyra experienced painless vaginal bleeding has just been Rh-positive maternal blood crosses into fetal blood,
diagnosed as having a placenta previa. Which of the following stimulating fetal antibodies.
procedures is usually performed to diagnose placenta previa? Rh-positive fetal blood crosses into maternal blood,
Amniocentesis stimulating maternal antibodies.
Digital or speculum examination Rh-negative fetal blood crosses into maternal blood,
External fetal monitoring stimulating maternal antibodies.
Ultrasound Rh-negative maternal blood crosses into fetal blood,
89. Nurse Arnold knows that the following changes in stimulating fetal antibodies.
respiratory functioning during pregnancy is considered 97. To promote comfort during labor, the nurse John advises
normal: a client to assume certain positions and avoid others. Which
Increased tidal volume position may cause maternal hypotension and fetal hypoxia?
Increased expiratory volume Lateral position
Decreased inspiratory capacity Squatting position
Decreased oxygen consumption Supine position
90. Emily has gestational diabetes and it is usually managed Standing position
by which of the following therapy? 98. Celeste who used heroin during her pregnancy delivers a
Diet neonate. When assessing the neonate, the nurse Lhynnette
Long-acting insulin expects to find:
Oral hypoglycemic Lethargy 2 days after birth.
Oral hypoglycemic drug and insulin Irritability and poor sucking.
91. Magnesium sulfate is given to Jemma with preeclampsia A flattened nose, small eyes, and thin lips.
to prevent which of the following condition? Congenital defects such as limb anomalies.
Hemorrhage 99. The uterus returns to the pelvic cavity in which of the
Hypertension following time frames?
Hypomagnesemia 7th to 9th day postpartum.
Seizure 2 weeks postpartum.
92. Cammile with sickle cell anemia has an increased risk for End of 6th week postpartum.
having a sickle cell crisis during pregnancy. Aggressive When the lochia changes to alba.
management of a sickle cell crisis includes which of the 100. Maureen, a primigravida client, age 20, has just
following measures? completed a difficult, forceps-assisted delivery of twins. Her
Antihypertensive agents labor was unusually long and required oxytocin (Pitocin)
Diuretic agents augmentation. The nurse who’s caring for her should stay
I.V. fluids alert for:
Acetaminophen (Tylenol) for pain Uterine inversion
93. Which of the following drugs is the antidote for Uterine atony
magnesium toxicity? Uterine involution
Calcium gluconate (Kalcinate) Uterine discomfort
Hydralazine (Apresoline)
Naloxone (Narcan) Answers and Rationales
Rho (D) immune globulin (RhoGAM)
1. Answer: (A) Inevitable. An inevitable abortion is Because they could damage the operative site, such as
termination of pregnancy that cannot be prevented. objects as pacifiers, suction catheters, and small
Moderate to severe bleeding with mild cramping and spoons shouldn’t be placed in a baby’s mouth after
cervical dilation would be noted in this type of cleft repair. A baby in a prone position may rub her
abortion. face on the sheets and traumatize the operative site.
2. Answer: (B) History of syphilis. Maternal infections The suture line should be cleaned gently to prevent
such as syphilis, toxoplasmosis, and rubella are causes infection, which could interfere with healing and
of spontaneous abortion. damage the cosmetic appearance of the repair.
3. Answer: (C) Monitoring apical pulse. Nursing care for 13. Answer: (B) Allow the infant to rest before feeding.
the client with a possible ectopic pregnancy is focused Because feeding requires so much energy, an infant
on preventing or identifying hypovolemic shock and with heart failure should rest before feeding.
controlling pain. An elevated pulse rate is an indicator 14. Answer: (C) Iron-rich formula only. The infants at age 5
of shock. months should receive iron-rich formula and that they
4. Answer: (B) Increased caloric intake. Glucose crosses shouldn’t receive solid food, even baby food until age
the placenta, but insulin does not. High fetal demands 6 months.
for glucose, combined with the insulin resistance 15. Answer: (D) 10 months. A 10 month old infant can sit
caused by hormonal changes in the last half of alone and understands object permanence, so he
pregnancy can result in elevation of maternal blood would look for the hidden toy. At age 4 to 6 months,
glucose levels. This increases the mother’s demand for infants can’t sit securely alone. At age 8 months,
insulin and is referred to as the diabetogenic effect of infants can sit securely alone but cannot understand
pregnancy. the permanence of objects.
5. Answer: (A) Excessive fetal activity. The most common 16. Answer: (D) Public health nursing focuses on
signs and symptoms of hydatidiform mole includes preventive, not curative, services. The catchments area
elevated levels of human chorionic gonadotropin, in PHN consists of a residential community, many of
vaginal bleeding, larger than normal uterus for whom are well individuals who have greater need for
gestational age, failure to detect fetal heart activity preventive rather than curative services.
even with sensitive instruments, excessive nausea and 17. Answer: (B) Efficiency. Efficiency is determining
vomiting, and early development of pregnancy- whether the goals were attained at the least possible
induced hypertension. Fetal activity would not be cost.
noted. 18. Answer: (D) Rural Health Unit. R.A. 7160 devolved
6. Answer: (B) Absent patellar reflexes. Absence of basic health services to local government units
patellar reflexes is an indicator of hypermagnesemia, (LGU’s ). The public health nurse is an employee of the
which requires administration of calcium gluconate. LGU.
7. Answer: (C) Presenting part in 2 cm below the plane of 19. Answer: (A) Mayor. The local executive serves as the
the ischial spines. Fetus at station plus two indicates chairman of the Municipal Health Board.
that the presenting part is 2 cm below the plane of the 20. Answer: (A) 1. Each rural health midwife is given a
ischial spines. population assignment of about 5,000.
8. Answer: (A) Contractions every 1 ½ minutes lasting 70- 21. Answer: (B) Health education and community
80 seconds. Contractions every 1 ½ minutes lasting 70- organizing are necessary in providing community
80 seconds, is indicative of hyperstimulation of the health services. The community health nurse develops
uterus, which could result in injury to the mother and the health capability of people through health
the fetus if Pitocin is not discontinued. education and community organizing activities.
9. Answer: (C) EKG tracings. A potential side effect of 22. Answer: (B) Measles. Presidential Proclamation No. 4 is
calcium gluconate administration is cardiac arrest. on the Ligtas Tigdas Program.
Continuous monitoring of cardiac activity (EKG) 23. Answer: (D) Core group formation. In core group
throught administration of calcium gluconate is an formation, the nurse is able to transfer the technology
essential part of care. of community organizing to the potential or informal
10. Answer: (D) First low transverse caesarean was for community leaders through a training program.
breech position. Fetus in this pregnancy is in a vertex 24. Answer: (D) To maximize the community’s resources in
presentation. This type of client has no obstetrical dealing with health problems. Community organizing is
indication for a caesarean section as she did with her a developmental service, with the goal of developing
first caesarean delivery. the people’s self-reliance in dealing with community
11. Answer: (A) Talk to the mother first and then to the health problems. A, B and C are objectives of
toddler. When dealing with a crying toddler, the best contributory objectives to this goal.
approach is to talk to the mother and ignore the 25. Answer: (D) Terminal. Tertiary prevention involves
toddler first. This approach helps the toddler get used rehabilitation, prevention of permanent disability and
to the nurse before she attempts any procedures. It disability limitation appropriate for convalescents, the
also gives the toddler an opportunity to see that the disabled, complicated cases and the terminally ill
mother trusts the nurse. (those in the terminal stage of a disease).
12. Answer: (D) Place the infant’s arms in soft elbow 26. Answer: (A) Intrauterine fetal death. Intrauterine fetal
restraints. Soft restraints from the upper arm to the death, abruptio placentae, septic shock, and amniotic
wrist prevent the infant from touching her lip but fluid embolism may trigger normal clotting
allow him to hold a favorite item such as a blanket. mechanisms; if clotting factors are depleted, DIC may
 occur. Placenta accreta, dysfunctional labor, and 40. Answer: (B) Walk one step ahead, with the child’s hand
premature rupture of the membranes aren’t on the nurse’s elbow. This procedure is generally
associated with DIC. recommended to follow in guiding a person who is
27. Answer: (C) 120 to 160 beats/minute. A rate of 120 to blind.
160 beats/minute in the fetal heart appropriate for 41. Answer: (A) Loud, machinery-like murmur. A loud,
filling the heart with blood and pumping it out to the machinery-like murmur is a characteristic finding
system. associated with patent ductus arteriosus.
28. Answer: (A) Change the diaper more often. Decreasing 42. Answer: (C) More oxygen, and the newborn’s
the amount of time the skin comes contact with wet metabolic rate increases. When cold, the infant
soiled diapers will help heal the irritation. requires more oxygen and there is an increase in
29. Answer: (D) Endocardial cushion defect. Endocardial metabolic rate. Non-shievering thermogenesis is a
cushion defects are seen most in children with Down complex process that increases the metabolic rate and
syndrome, asplenia, or polysplenia. rate of oxygen consumption, therefore, the newborn
30. Answer: (B) Decreased urine output. Decreased urine increase heat production.
output may occur in clients receiving I.V. magnesium 43. Answer: (D) Voided. Before administering potassium
and should be monitored closely to keep urine output I.V. to any client, the nurse must first check that the
at greater than 30 ml/hour, because magnesium is client’s kidneys are functioning and that the client is
excreted through the kidneys and can easily voiding. If the client is not voiding, the nurse should
accumulate to toxic levels. withhold the potassium and notify the physician.
31. Answer: (A) Menorrhagia. Menorrhagia is an excessive 44. Answer: (C) Laundry detergent. Eczema or dermatitis is
menstrual period. an allergic skin reaction caused by an offending
32. Answer: (C) Blood typing. Blood type would be a allergen. The topical allergen that is the most common
critical value to have because the risk of blood loss is causative factor is laundry detergent.
always a potential complication during the labor and 45. Answer: (A) 6 inches. This distance allows for easy flow
delivery process. Approximately 40% of a woman’s of the formula by gravity, but the flow will be slow
cardiac output is delivered to the uterus, therefore, enough not to overload the stomach too rapidly.
blood loss can occur quite rapidly in the event of 46. Answer: (A) The older one gets, the more susceptible
uncontrolled bleeding. he becomes to the complications of chicken pox.
33. Answer: (D) Physiologic anemia. Hemoglobin values Chicken pox is usually more severe in adults than in
and hematocrit decrease during pregnancy as the children. Complications, such as pneumonia, are higher
increase in plasma volume exceeds the increase in red in incidence in adults.
blood cell production. 47. Answer: (D) Consult a physician who may give them
34. Answer: (D) A 2 year old infant with stridorous breath rubella immunoglobulin. Rubella vaccine is made up of
sounds, sitting up in his mother’s arms and drooling. attenuated German measles viruses. This is
The infant with the airway emergency should be contraindicated in pregnancy. Immune globulin, a
treated first, because of the risk of epiglottitis. specific prophylactic against German measles, may be
35. Answer: (A) Placenta previa. Placenta previa with given to pregnant women.
painless vaginal bleeding. 48. Answer: (A) Contact tracing. Contact tracing is the
36. Answer: (D) Early in the morning. Based on the nurse’s most practical and reliable method of finding possible
knowledge of microbiology, the specimen should be sources of person-to-person transmitted infections,
collected early in the morning. The rationale for this such as sexually transmitted diseases.
timing is that, because the female worm lays eggs at 49. Answer: (D) Leptospirosis. Leptospirosis is transmitted
night around the perineal area, the first bowel through contact with the skin or mucous membrane
movement of the day will yield the best results. The with water or moist soil contaminated with urine of
specific type of stool specimen used in the diagnosis of infected animals, like rats.
pinworms is called the tape test. 50. Answer: (B) Cholera. Passage of profuse watery stools
37. Answer: (A) Irritability and seizures. Lead poisoning is the major symptom of cholera. Both amebic and
primarily affects the CNS, causing increased bacillary dysentery are characterized by the presence
intracranial pressure. This condition results in of blood and/or mucus in the stools. Giardiasis is
irritability and changes in level of consciousness, as characterized by fat malabsorption and, therefore,
well as seizure disorders, hyperactivity, and learning steatorrhea.
disabilities. 51. Answer: (A) Hemophilus influenzae. Hemophilus
38. Answer: (D) “I really need to use the diaphragm and meningitis is unusual over the age of 5 years. In
jelly most during the middle of my menstrual cycle”. developing countries, the peak incidence is in children
The woman must understand that, although the less than 6 months of age. Morbillivirus is the etiology
“fertile” period is approximately mid-cycle, hormonal of measles. Streptococcus pneumoniae and Neisseria
variations do occur and can result in early or late meningitidis may cause meningitis, but age distribution
ovulation. To be effective, the diaphragm should be is not specific in young children.
inserted before every intercourse. 52. Answer: (B) Buccal mucosa. Koplik’s spot may be seen
39. Answer: (C) Restlessness. In a child, restlessness is the on the mucosa of the mouth or the throat.
earliest sign of hypoxia. Late signs of hypoxia in a child 53. Answer: (A) 3 seconds. Adequate blood supply to the
are associated with a change in color, such as pallor or area allows the return of the color of the nailbed
cyanosis. within 3 seconds.
54. Answer: (B) Severe dehydration. The order of priority 66. Answer: (A) 1 year. The baby will have passive natural
in the management of severe dehydration is as immunity by placental transfer of antibodies. The
follows: intravenous fluid therapy, referral to a facility mother will have active artificial immunity lasting for
where IV fluids can be initiated within 30 minutes, about 10 years. 5 doses will give the mother lifetime
Oresol or nasogastric tube. When the foregoing protection.
measures are not possible or effective, then urgent 67. Answer: (B) 4 hours. While the unused portion of other
referral to the hospital is done. biologicals in EPI may be given until the end of the day,
55. Answer: (A) 45 infants. To estimate the number of only BCG is discarded 4 hours after reconstitution. This
infants, multiply total population by 3%. is why BCG immunization is scheduled only in the
56. Answer: (A) DPT. DPT is sensitive to freezing. The morning.
appropriate storage temperature of DPT is 2 to 8° C 68. Answer: (B) 6 months. After 6 months, the baby’s
only. OPV and measles vaccine are highly sensitive to nutrient needs, especially the baby’s iron requirement,
heat and require freezing. MMR is not an can no longer be provided by mother’s milk alone.
immunization in the Expanded Program on 69. Answer: (C) 24 weeks. At approximately 23 to 24
Immunization. weeks’ gestation, the lungs are developed enough to
57. Answer: (C) Proper use of sanitary toilets. The ova of sometimes maintain extrauterine life. The lungs are
the parasite get out of the human body together with the most immature system during the gestation
feces. Cutting the cycle at this stage is the most period. Medical care for premature labor begins much
effective way of preventing the spread of the disease earlier (aggressively at 21 weeks’ gestation)
to susceptible hosts. 70. Answer: (B) Sudden infant death syndrome (SIDS).
58. Answer: (D) 5 skin lesions, positive slit skin smear. A Supine positioning is recommended to reduce the risk
multibacillary leprosy case is one who has a positive of SIDS in infancy. The risk of aspiration is slightly
slit skin smear and at least 5 skin lesions. increased with the supine position. Suffocation would
59. Answer: (C) Thickened painful nerves. The lesion of be less likely with an infant supine than prone and the
leprosy is not macular. It is characterized by a change position for GER requires the head of the bed to be
in skin color (either reddish or whitish) and loss of elevated.
sensation, sweating and hair growth over the lesion. 71. Answer: (C) Decreased temperature. Temperature
Inability to close the eyelids (lagophthalmos) and instability, especially when it results in a low
sinking of the nosebridge are late symptoms. temperature in the neonate, may be a sign of
60. Answer: (B) Ask where the family resides. Because infection. The neonate’s color often changes with an
malaria is endemic, the first question to determine infection process but generally becomes ashen or
malaria risk is where the client’s family resides. If the mottled. The neonate with an infection will usually
area of residence is not a known endemic area, ask if show a decrease in activity level or lethargy.
the child had traveled within the past 6 months, where 72. Answer: (D) Polycythemia probably due to chronic
she was brought and whether she stayed overnight in fetal hypoxia. The small-for-gestation neonate is at risk
that area. for developing polycythemia during the transitional
61. Answer: (A) Inability to drink. A sick child aged 2 period in an attempt to decreasehypoxia. The
months to 5 years must be referred urgently to a neonates are also at increased risk for developing
hospital if he/she has one or more of the following hypoglycemia and hypothermia due to decreased
signs: not able to feed or drink, vomits everything, glycogen stores.
convulsions, abnormally sleepy or difficult to awaken. 73. Answer: (C) Desquamation of the epidermis. Postdate
62. Answer: (A) Refer the child urgently to a hospital for fetuses lose the vernix caseosa, and the epidermis may
confinement. “Baggy pants” is a sign of severe become desquamated. These neonates are usually
marasmus. The best management is urgent referral to very alert. Lanugo is missing in the postdate neonate.
a hospital. 74. Answer: (C) Respiratory depression. Magnesium
63. Answer: (D) Let the child rest for 10 minutes then sulfate crosses the placenta and adverse neonatal
continue giving Oresol more slowly. If the child vomits effects are respiratory depression, hypotonia, and
persistently, that is, he vomits everything that he takes bradycardia. The serum blood sugar isn’t affected by
in, he has to be referred urgently to a hospital. magnesium sulfate. The neonate would be floppy, not
Otherwise, vomiting is managed by letting the child jittery.
rest for 10 minutes and then continuing with Oresol 75. Answer: (C) Respiratory rate 40 to 60 breaths/minute.
administration. Teach the mother to give Oresol more A respiratory rate 40 to 60 breaths/minute is normal
slowly. for a neonate during the transitional period. Nasal
64. Answer: (B) Some dehydration. Using the assessment flaring, respiratory rate more than 60 breaths/minute,
guidelines of IMCI, a child (2 months to 5 years old) and audible grunting are signs of respiratory distress.
with diarrhea is classified as having SOME 76. Answer: (C) Keep the cord dry and open to air. Keeping
DEHYDRATION if he shows 2 or more of the following the cord dry and open to air helps reduce infection and
signs: restless or irritable, sunken eyes, the skin goes hastens drying. Infants aren’t given tub bath but are
back slow after a skin pinch. sponged off until the cord falls off. Petroleum jelly
65. Answer: (C) Normal. In IMCI, a respiratory rate of prevents the cord from drying and encourages
50/minute or more is fast breathing for an infant aged infection. Peroxide could be painful and isn’t
2 to 12 months. recommended.
77. Answer: (B) Conjunctival hemorrhage. Conjunctival increases the risk of acidosis, the infant should be kept
hemorrhages are commonly seen in neonates warm so that his respiratory distress isn’t aggravated.
secondary to the cranial pressure applied during the 85. Answer: (A) 110 to 130 calories per kg. Calories per kg
birth process. Bulging fontanelles are a sign of is the accepted way of determined appropriate
intracranial pressure. Simian creases are present in nutritional intake for a newborn. The recommended
40% of the neonates with trisomy 21. Cystic hygroma is calorie requirement is 110 to 130 calories per kg of
a neck mass that can affect the airway. newborn body weight. This level will maintain a
78. Answer: (B) To assess for prolapsed cord. After a client consistent blood glucose level and provide enough
has an amniotomy, the nurse should assure that the calories for continued growth and development.
cord isn’t prolapsed and that the baby tolerated the 86. Answer: (C) 30 to 32 weeks. Individual twins usually
procedure well. The most effective way to do this is to grow at the same rate as singletons until 30 to 32
check the fetal heart rate. Fetal well-being is assessed weeks’ gestation, then twins don’t’ gain weight as
via a nonstress test. Fetal position is determined by rapidly as singletons of the same gestational age. The
vaginal examination. Artificial rupture of membranes placenta can no longer keep pace with the nutritional
doesn’t indicate an imminent delivery. requirements of both fetuses after 32 weeks, so
79. Answer: (D) The parents’ interactions with each other. there’s some growth retardation in twins if they
Parental interaction will provide the nurse with a good remain in utero at 38 to 40 weeks.
assessment of the stability of the family’s home life 87. Answer: (A) conjoined twins. The type of placenta that
but it has no indication for parental bonding. develops in monozygotic twins depends on the time at
Willingness to touch and hold the newborn, expressing which cleavage of the ovum occurs. Cleavage in
interest about the newborn’s size, and indicating a conjoined twins occurs more than 13 days after
desire to see the newborn are behaviors indicating fertilization. Cleavage that occurs less than 3 day after
parental bonding. fertilization results in diamniotic dicchorionic twins.
80. Answer: (B) Instructing the client to use two or more Cleavage that occurs between days 3 and 8 results in
peripads to cushion the area. Using two or more diamniotic monochorionic twins. Cleavage that occurs
peripads would do little to reduce the pain or promote between days 8 to 13 result in monoamniotic
perineal healing. Cold applications, sitz baths, and monochorionic twins.
Kegel exercises are important measures when the 88. Answer: (D) Ultrasound. Once the mother and the
client has a fourth-degree laceration. fetus are stabilized, ultrasound evaluation of the
81. Answer: (C) “What is your expected due date?” When placenta should be done to determine the cause of the
obtaining the history of a client who may be in labor, bleeding. Amniocentesis is contraindicated in placenta
the nurse’s highest priority is to determine her current previa. A digital or speculum examination shouldn’t be
status, particularly her due date, gravidity, and parity. done as this may lead to severe bleeding or
Gravidity and parity affect the duration of labor and hemorrhage. External fetal monitoring won’t detect a
the potential for labor complications. Later, the nurse placenta previa, although it will detect fetal distress,
should ask about chronic illnesses, allergies, and which may result from blood loss or placenta
support persons. separation.
82. Answer: (D) Aspirate the neonate’s nose and mouth 89. Answer: (A) Increased tidal volume. A pregnant client
with a bulb syringe. The nurse’s first action should be breathes deeper, which increases the tidal volume of
to clear the neonate’s airway with a bulb syringe. After gas moved in and out of the respiratory tract with each
the airway is clear and the neonate’s color improves, breath. The expiratory volume and residual volume
the nurse should comfort and calm the neonate. If the decrease as the pregnancy progresses. The inspiratory
problem recurs or the neonate’s color doesn’t improve capacity increases during pregnancy. The increased
readily, the nurse should notify the physician. oxygen consumption in the pregnant client is 15% to
Administering oxygen when the airway isn’t clear 20% greater than in the nonpregnant state.
would be ineffective. 90. Answer: (A) Diet. Clients with gestational diabetes are
83. Answer: (C) Conducting a bedside ultrasound for an usually managed by diet alone to control their glucose
amniotic fluid index. It isn’t within a nurse’s scope of intolerance. Oral hypoglycemic drugs are
practice to perform and interpret a bedside ultrasound contraindicated in pregnancy. Long-acting insulin
under these conditions and without specialized usually isn’t needed for blood glucose control in the
training. Observing for pooling of straw-colored fluid, client with gestational diabetes.
checking vaginal discharge with nitrazine paper, and 91. Answer: (D) Seizure. The anticonvulsant mechanism of
observing for flakes of vernix are appropriate magnesium is believes to depress seizure foci in the
assessments for determining whether a client has brain and peripheral neuromuscular blockade.
ruptured membranes. Hypomagnesemia isn’t a complication of preeclampsia.
84. Answer: (C) Monitor partial pressure of oxygen (Pao2) Antihypertensive drug other than magnesium are
levels. Monitoring PaO2 levels and reducing the preferred for sustained hypertension. Magnesium
oxygen concentration to keep PaO2 within normal doesn’t help prevent hemorrhage in preeclamptic
limits reduces the risk of retinopathy of prematurity in clients.
a premature infant receiving oxygen. Covering the 92. Answer: (C) I.V. fluids. A sickle cell crisis during
infant’s eyes and humidifying the oxygen don’t reduce pregnancy is usually managed by exchange transfusion
the risk of retinopathy of prematurity. Because cooling oxygen, and L.V. Fluids. The client usually needs a
stronger analgesic than acetaminophen to control the
 pain of a crisis. Antihypertensive drugs usually aren’t 100. Answer: (B) Uterine atony. Multiple fetuses, extended
necessary. Diuretic wouldn’t be used unless fluid labor stimulation with oxytocin, and traumatic delivery
overload resulted. commonly are associated with uterine atony, which
93. Answer: (A) Calcium gluconate (Kalcinate). Calcium may lead to postpartum hemorrhage. Uterine
gluconate is the antidote for magnesium toxicity. Ten inversion may precede or follow delivery and
milliliters of 10% calcium gluconate is given L.V. push commonly results from apparent excessive traction on
over 3 to 5 minutes. Hydralazine is given for sustained the umbilical cord and attempts to deliver the placenta
elevated blood pressure in preeclamptic clients. Rho manually. Uterine involution and some uterine
(D) immune globulin is given to women with Rh- discomfort are normal after delivery.
negative blood to prevent antibody formation from
RH-positive conceptions. Naloxone is used to correct PNLE III for Care of Clients with Physiologic and Psychosocial
narcotic toxicity. Alterations (Part 1)
94. Answer: (B) An indurated wheal over 10 mm in 1. Nurse Michelle should know that the drainage is normal 4
diameter appears in 48 to 72 hours. A positive PPD days after a sigmoid colostomy when the stool is:
result would be an indurated wheal over 10 mm in Green liquid
diameter that appears in 48 to 72 hours. The area must Solid formed
be a raised wheal, not a flat circumcised area to be Loose, bloody
considered positive. Semiformed
95. Answer: (C) Pyelonephritis. The symptoms indicate 2. Where would nurse Kristine place the call light for a male
acute pyelonephritis, a serious condition in a pregnant client with a right-sided brain attack and left homonymous
client. UTI symptoms include dysuria, urgency, hemianopsia?
frequency, and suprapubic tenderness. Asymptomatic On the client’s right side
bacteriuria doesn’t cause symptoms. Bacterial On the client’s left side
vaginosis causes milky white vaginal discharge but no Directly in front of the client
systemic symptoms. Where the client like
96. Answer: (B) Rh-positive fetal blood crosses into 3. A male client is admitted to the emergency department
maternal blood, stimulating maternal antibodies. Rh following an accident. What are the first nursing actions of
isoimmunization occurs when Rh-positive fetal blood the nurse?
cells cross into the maternal circulation and stimulate Check respiration, circulation, neurological response.
maternal antibody production. In subsequent Align the spine, check pupils, and check for hemorrhage.
pregnancies with Rh-positive fetuses, maternal Check respirations, stabilize spine, and check circulation.
antibodies may cross back into the fetal circulation and Assess level of consciousness and circulation.
destroy the fetal blood cells. 4. In evaluating the effect of nitroglycerin, Nurse Arthur
97. Answer: (C) Supine position. The supine position should know that it reduces preload and relieves angina by:
causes compression of the client’s aorta and inferior Increasing contractility and slowing heart rate.
vena cava by the fetus. This, in turn, inhibits maternal Increasing AV conduction and heart rate.
circulation, leading to maternal hypotension and, Decreasing contractility and oxygen consumption.
ultimately, fetal hypoxia. The other positions promote Decreasing venous return through vasodilation.
comfort and aid labor progress. For instance, the 5. Nurse Patricia finds a female client who is post-myocardial
lateral, or side-lying, position improves maternal and infarction (MI) slumped on the side rails of the bed and
fetal circulation, enhances comfort, increases maternal unresponsive to shaking or shouting. Which is the nurse next
relaxation, reduces muscle tension, and eliminates action?
pressure points. The squatting position promotes Call for help and note the time.
comfort by taking advantage of gravity. The standing Clear the airway
position also takes advantage of gravity and aligns the Give two sharp thumps to the precordium, and check the
fetus with the pelvic angle. pulse.
98. Answer: (B) Irritability and poor sucking. Neonates of Administer two quick blows.
heroin-addicted mothers are physically dependent on 6. Nurse Monett is caring for a client recovering from gastro-
the drug and experience withdrawal when the drug is intestinal bleeding. The nurse should:
no longer supplied. Signs of heroin withdrawal include Plan care so the client can receive 8 hours of uninterrupted
irritability, poor sucking, and restlessness. Lethargy sleep each night.
isn’t associated with neonatal heroin addiction. A Monitor vital signs every 2 hours.
flattened nose, small eyes, and thin lips are seen in Make sure that the client takes food and medications at
infants with fetal alcohol syndrome. Heroin use during prescribed intervals.
pregnancy hasn’t been linked to specific congenital Provide milk every 2 to 3 hours.
anomalies. 7. A male client was on warfarin (Coumadin) before
99. Answer: (A) 7th to 9th day postpartum. The normal admission, and has been receiving heparin I.V. for 2 days. The
involutional process returns the uterus to the pelvic partial thromboplastin time (PTT) is 68 seconds. What should
cavity in 7 to 9 days. A significant involutional Nurse Carla do?
complication is the failure of the uterus to return to Stop the I.V. infusion of heparin and notify the physician.
the pelvic cavity within the prescribed time period. Continue treatment as ordered.
This is known as subinvolution. Expect the warfarin to increase the PTT.
Increase the dosage, because the level is lower than normal.
8. A client undergone ileostomy, when should the drainage Decrease in arterial oxygen saturation (SaO2) when
appliance be applied to the stoma? measured with a pulse oximeter.
24 hours later, when edema has subsided. Increase in systemic blood pressure.
In the operating room. Presence of premature ventricular contractions (PVCs) on a
After the ileostomy begin to function. cardiac monitor.
When the client is able to begin self-care procedures. Increase in intracranial pressure (ICP).
9. A client undergone spinal anesthetic, it will be important 17. Nurse Ron is caring for a male client taking an
that the nurse immediately position the client in: anticoagulant. The nurse should teach the client to:
On the side, to prevent obstruction of airway by tongue. Report incidents of diarrhea.
Flat on back. Avoid foods high in vitamin K
On the back, with knees flexed 15 degrees. Use a straight razor when shaving.
Flat on the stomach, with the head turned to the side. Take aspirin to pain relief.
10.While monitoring a male client several hours after a motor 18. Nurse Lhynnette is preparing a site for the insertion of an
vehicle accident, which assessment data suggest increasing I.V. catheter. The nurse should treat excess hair at the site by:
intracranial pressure? Leaving the hair intact
Blood pressure is decreased from 160/90 to 110/70. Shaving the area
Pulse is increased from 87 to 95, with an occasional skipped Clipping the hair in the area
beat. Removing the hair with a depilatory.
The client is oriented when aroused from sleep, and goes 19. Nurse Michelle is caring for an elderly female with
back to sleep immediately. osteoporosis. When teaching the client, the nurse should
The client refuses dinner because of anorexia. include information about which major complication:
11.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Bone fracture
Which of the following symptoms may appear first? Loss of estrogen
Altered mental status and dehydration Negative calcium balance
Fever and chills Dowager’s hump
Hemoptysis and Dyspnea 20. Nurse Len is teaching a group of women to perform BSE.
Pleuritic chest pain and cough The nurse should explain that the purpose of performing the
12. A male client has active tuberculosis (TB). Which of the examination is to discover:
following symptoms will be exhibit? Cancerous lumps
Chest and lower back pain Areas of thickness or fullness
Chills, fever, night sweats, and hemoptysis Changes from previous examinations.
Fever of more than 104°F (40°C) and nausea Fibrocystic masses
Headache and photophobia 21. When caring for a female client who is being treated for
13. Mark, a 7-year-old client is brought to the emergency hyperthyroidism, it is important to:
department. He’s tachypneic and afebrile and has a Provide extra blankets and clothing to keep the client warm.
respiratory rate of 36 breaths/minute and has a Monitor the client for signs of restlessness, sweating, and
nonproductive cough. He recently had a cold. Form this excessive weight loss during thyroid replacement therapy.
history; the client may have which of the following Balance the client’s periods of activity and rest.
conditions? Encourage the client to be active to prevent constipation.
Acute asthma 22. Nurse Kris is teaching a client with history of
Bronchial pneumonia atherosclerosis. To decrease the risk of atherosclerosis, the
Chronic obstructive pulmonary disease (COPD) nurse should encourage the client to:
Emphysema Avoid focusing on his weight.
14. Marichu was given morphine sulfate for pain. She is Increase his activity level.
sleeping and her respiratory rate is 4 breaths/minute. If Follow a regular diet.
action isn’t taken quickly, she might have which of the Continue leading a high-stress lifestyle.
following reactions? 23. Nurse Greta is working on a surgical floor. Nurse Greta
Asthma attack must logroll a client following a:
Respiratory arrest Laminectomy
Seizure Thoracotomy
Wake up on his own Hemorrhoidectomy
15. A 77-year-old male client is admitted for elective knee Cystectomy.
surgery. Physical examination reveals shallow respirations 24. A 55-year old client underwent cataract removal with
but no sign of respiratory distress. Which of the following is a intraocular lens implant. Nurse Oliver is giving the client
normal physiologic change related to aging? discharge instructions. These instructions should include
Increased elastic recoil of the lungs which of the following?
Increased number of functional capillaries in the alveoli Avoid lifting objects weighing more than 5 lb (2.25 kg).
Decreased residual volume Lie on your abdomen when in bed
Decreased vital capacity Keep rooms brightly lit.
16. Nurse John is caring for a male client receiving lidocaine Avoiding straining during bowel movement or bending at the
I.V. Which factor is the most relevant to administration of waist.
this medication? 25. George should be taught about testicular examinations
during:
when sexual activity starts Leave him to get assistance
After age 69 Stay with him but not intervene at this time.
After age 40 33. Nurse Ron is taking a health history of an 84 year old
Before age 20. client. Which information will be most useful to the nurse for
26. A male client undergone a colon resection. While turning planning care?
him, wound dehiscence with evisceration occurs. Nurse Trish General health for the last 10 years.
first response is to: Current health promotion activities.
Call the physician Family history of diseases.
Place a saline-soaked sterile dressing on the wound. Marital status.
Take a blood pressure and pulse. 34. When performing oral care on a comatose client, Nurse
Pull the dehiscence closed. Krina should:
27. Nurse Audrey is caring for a client who has suffered a Apply lemon glycerin to the client’s lips at least every 2 hours.
severe cerebrovascular accident. During routine assessment, Brush the teeth with client lying supine.
the nurse notices Cheyne- Strokes respirations. Cheyne- Place the client in a side lying position, with the head of the
strokes respirations are: bed lowered.
A progressively deeper breaths followed by shallower breaths Clean the client’s mouth with hydrogen peroxide.
with apneic periods. 35. A 77-year-old male client is admitted with a diagnosis of
Rapid, deep breathing with abrupt pauses between each dehydration and change in mental status. He’s being
breath. hydrated with L.V. fluids. When the nurse takes his vital signs,
Rapid, deep breathing and irregular breathing without she notes he has a fever of 103°F (39.4°C) a cough producing
pauses. yellow sputum and pleuritic chest pain. The nurse suspects
Shallow breathing with an increased respiratory rate. this client may have which of the following conditions?
28. Nurse Bea is assessing a male client with heart failure. Adult respiratory distress syndrome (ARDS)
The breath sounds commonly auscultated in clients with Myocardial infarction (MI)
heart failure are: Pneumonia
Tracheal Tuberculosis
Fine crackles 36. Nurse Oliver is working in a out patient clinic. He has been
Coarse crackles alerted that there is an outbreak of tuberculosis (TB). Which
Friction rubs of the following clients entering the clinic today most likely to
29. The nurse is caring for Kenneth experiencing an acute have TB?
asthma attack. The client stops wheezing and breath sounds A 16-year-old female high school student
aren’t audible. The reason for this change is that: A 33-year-old day-care worker
The attack is over. A 43-yesr-old homeless man with a history of alcoholism
The airways are so swollen that no air cannot get through. A 54-year-old businessman
The swelling has decreased. 37. Virgie with a positive Mantoux test result will be sent for
Crackles have replaced wheezes. a chest X-ray. The nurse is aware that which of the following
30. Mike with epilepsy is having a seizure. During the active reasons this is done?
seizure phase, the nurse should: To confirm the diagnosis
Place the client on his back remove dangerous objects, and To determine if a repeat skin test is needed
insert a bite block. To determine the extent of lesions
Place the client on his side, remove dangerous objects, and To determine if this is a primary or secondary infection
insert a bite block. 38. Kennedy with acute asthma showing inspiratory and
Place the client o his back, remove dangerous objects, and expiratory wheezes and a decreased forced expiratory
hold down his arms. volume should be treated with which of the following classes
Place the client on his side, remove dangerous objects, and of medication right away?
protect his head. Beta-adrenergic blockers
31. After insertion of a cheat tube for a pneumothorax, a Bronchodilators
client becomes hypotensive with neck vein distention, Inhaled steroids
tracheal shift, absent breath sounds, and diaphoresis. Nurse Oral steroids
Amanda suspects a tension pneumothorax has occurred. 39. Mr. Vasquez 56-year-old client with a 40-year history of
What cause of tension pneumothorax should the nurse check smoking one to two packs of cigarettes per day has a chronic
for? cough producing thick sputum, peripheral edema and
Infection of the lung. cyanotic nail beds. Based on this information, he most likely
Kinked or obstructed chest tube has which of the following conditions?
Excessive water in the water-seal chamber Adult respiratory distress syndrome (ARDS)
Excessive chest tube drainage Asthma
32. Nurse Maureen is talking to a male client, the client Chronic obstructive bronchitis
begins choking on his lunch. He’s coughing forcefully. The Emphysema
nurse should: Situation: Francis, age 46 is admitted to the hospital with
Stand him up and perform the abdominal thrust maneuver diagnosis of Chronic Lymphocytic Leukemia.
from behind. 40. The treatment for patients with leukemia is bone marrow
Lay him down, straddle him, and perform the abdominal transplantation. Which statement about bone marrow
thrust maneuver. transplantation is not correct?
The patient is under local anesthesia during the procedure 47. A 51-year-old female client tells the nurse in-charge that
The aspirated bone marrow is mixed with heparin. she has found a painless lump in her right breast during her
The aspiration site is the posterior or anterior iliac crest. monthly self-examination. Which assessment finding would
The recipient receives cyclophosphamide (Cytoxan) for 4 strongly suggest that this client’s lump is cancerous?
consecutive days before the procedure. Eversion of the right nipple and mobile mass
41. After several days of admission, Francis becomes Nonmobile mass with irregular edges
disoriented and complains of frequent headaches. The nurse Mobile mass that is soft and easily delineated
in-charge first action would be: Nonpalpable right axillary lymph nodes
Call the physician 48. A 35-year-old client with vaginal cancer asks the nurse,
Document the patient’s status in his charts. “What is the usual treatment for this type of cancer?” Which
Prepare oxygen treatment treatment should the nurse name?
Raise the side rails Surgery
42. During routine care, Francis asks the nurse, “How can I be Chemotherapy
anemic if this disease causes increased my white blood cell Radiation
production?” The nurse in-charge best response would be Immunotherapy
that the increased number of white blood cells (WBC) is: 49. Cristina undergoes a biopsy of a suspicious lesion. The
Crowd red blood cells biopsy report classifies the lesion according to the TNM
Are not responsible for the anemia. staging system as follows: TIS, N0, M0. What does this
Uses nutrients from other cells classification mean?
Have an abnormally short life span of cells. No evidence of primary tumor, no abnormal regional lymph
43. Diagnostic assessment of Francis would probably not nodes, and no evidence of distant metastasis
reveal: Carcinoma in situ, no abnormal regional lymph nodes, and no
Predominance of lymhoblasts evidence of distant metastasis
Leukocytosis Can’t assess tumor or regional lymph nodes and no evidence
Abnormal blast cells in the bone marrow of metastasis
Elevated thrombocyte counts Carcinoma in situ, no demonstrable metastasis of the
44. Robert, a 57-year-old client with acute arterial occlusion regional lymph nodes, and ascending degrees of distant
of the left leg undergoes an emergency embolectomy. Six metastasis
hours later, the nurse isn’t able to obtain pulses in his left 50. Lydia undergoes a laryngectomy to treat laryngeal cancer.
foot using Doppler ultrasound. The nurse immediately When teaching the client how to care for the neck stoma, the
notifies the physician, and asks her to prepare the client for nurse should include which instruction?
surgery. As the nurse enters the client’s room to prepare him, “Keep the stoma uncovered.”
he states that he won’t have any more surgery. Which of the “Keep the stoma dry.”
following is the best initial response by the nurse? “Have a family member perform stoma care initially until you
Explain the risks of not having the surgery get used to the procedure.”
Notifying the physician immediately “Keep the stoma moist.”
Notifying the nursing supervisor 51. A 37-year-old client with uterine cancer asks the nurse,
Recording the client’s refusal in the nurses’ notes “Which is the most common type of cancer in women?” The
45. During the endorsement, which of the following clients nurse replies that it’s breast cancer. Which type of cancer
should the on-duty nurse assess first? causes the most deaths in women?
The 58-year-old client who was admitted 2 days ago with Breast cancer
heart failure, blood pressure of 126/76 mm Hg, and a Lung cancer
respiratory rate of 22 breaths/minute. Brain cancer
The 89-year-old client with end-stage right-sided heart Colon and rectal cancer
failure, blood pressure of 78/50 mm Hg, and a “do not 52. Antonio with lung cancer develops Horner’s syndrome
resuscitate” order when the tumor invades the ribs and affects the sympathetic
The 62-year-old client who was admitted 1 day ago with nerve ganglia. When assessing for signs and symptoms of this
thrombophlebitis and is receiving L.V. heparin syndrome, the nurse should note:
The 75-year-old client who was admitted 1 hour ago with miosis, partial eyelid ptosis, and anhidrosis on the affected
new-onset atrial fibrillation and is receiving L.V. dilitiazem side of the face.
(Cardizem) chest pain, dyspnea, cough, weight loss, and fever.
46. Honey, a 23-year old client complains of substernal chest arm and shoulder pain and atrophy of arm and hand muscles,
pain and states that her heart feels like “it’s racing out of the both on the affected side.
chest”. She reports no history of cardiac disorders. The nurse hoarseness and dysphagia.
attaches her to a cardiac monitor and notes sinus tachycardia 53. Vic asks the nurse what PSA is. The nurse should reply
with a rate of 136beats/minutes. Breath sounds are clear and that it stands for:
the respiratory rate is 26 breaths/minutes. Which of the prostate-specific antigen, which is used to screen for prostate
following drugs should the nurse question the client about cancer.
using? protein serum antigen, which is used to determine protein
Barbiturates levels.
Opioids pneumococcal strep antigen, which is a bacteria that causes
Cocaine pneumonia.
Benzodiazepines
Papanicolaou-specific antigen, which is used to screen for 62. A heparin infusion at 1,500 unit/hour is ordered for a 64-
cervical cancer. year-old client with stroke in evolution. The infusion contains
54. What is the most important postoperative instruction 25,000 units of heparin in 500 ml of saline solution. How
that nurse Kate must give a client who has just returned from many milliliters per hour should be given?
the operating room after receiving a subarachnoid block? 15 ml/hour
“Avoid drinking liquids until the gag reflex returns.” 30 ml/hour
“Avoid eating milk products for 24 hours.” 45 ml/hour
“Notify a nurse if you experience blood in your urine.” 50 ml/hour
“Remain supine for the time specified by the physician.” 63. A 76-year-old male client had a thromboembolic right
55. A male client suspected of having colorectal cancer will stroke; his left arm is swollen. Which of the following
require which diagnostic study to confirm the diagnosis? conditions may cause swelling after a stroke?
Stool Hematest Elbow contracture secondary to spasticity
Carcinoembryonic antigen (CEA) Loss of muscle contraction decreasing venous return
Sigmoidoscopy Deep vein thrombosis (DVT) due to immobility of the
Abdominal computed tomography (CT) scan ipsilateral side
56. During a breast examination, which finding most strongly Hypoalbuminemia due to protein escaping from an inflamed
suggests that the Luz has breast cancer? glomerulus
Slight asymmetry of the breasts. 64. Heberden’s nodes are a common sign of osteoarthritis.
A fixed nodular mass with dimpling of the overlying skin Which of the following statement is correct about this
Bloody discharge from the nipple deformity?
Multiple firm, round, freely movable masses that change with It appears only in men
the menstrual cycle It appears on the distal interphalangeal joint
57. A female client with cancer is being evaluated for possible It appears on the proximal interphalangeal joint
metastasis. Which of the following is one of the most It appears on the dorsolateral aspect of the interphalangeal
common metastasis sites for cancer cells? joint.
Liver 65. Which of the following statements explains the main
Colon difference between rheumatoid arthritis and osteoarthritis?
Reproductive tract Osteoarthritis is gender-specific, rheumatoid arthritis isn’t
White blood cells (WBCs) Osteoarthritis is a localized disease rheumatoid arthritis is
58. Nurse Mandy is preparing a client for magnetic resonance systemic
imaging (MRI) to confirm or rule out a spinal cord lesion. Osteoarthritis is a systemic disease, rheumatoid arthritis is
During the MRI scan, which of the following would pose a localized
threat to the client? Osteoarthritis has dislocations and subluxations, rheumatoid
The client lies still. arthritis doesn’t
The client asks questions. 66. Mrs. Cruz uses a cane for assistance in walking. Which of
The client hears thumping sounds. the following statements is true about a cane or other
The client wears a watch and wedding band. assistive devices?
59. Nurse Cecile is teaching a female client about preventing A walker is a better choice than a cane.
osteoporosis. Which of the following teaching points is The cane should be used on the affected side
correct? The cane should be used on the unaffected side
Obtaining an X-ray of the bones every 3 years is A client with osteoarthritis should be encouraged to
recommended to detect bone loss. ambulate without the cane
To avoid fractures, the client should avoid strenuous 67. A male client with type 1 diabetes is scheduled to receive
exercise. 30 U of 70/30 insulin. There is no 70/30 insulin available. As a
The recommended daily allowance of calcium may be found substitution, the nurse may give the client:
in a wide variety of foods. 9 U regular insulin and 21 U neutral protamine Hagedorn
Obtaining the recommended daily allowance of calcium (NPH).
requires taking a calcium supplement. 21 U regular insulin and 9 U NPH.
60. Before Jacob undergoes arthroscopy, the nurse reviews 10 U regular insulin and 20 U NPH.
the assessment findings for contraindications for this 20 U regular insulin and 10 U NPH.
procedure. Which finding is a contraindication? 68. Nurse Len should expect to administer which medication
Joint pain to a client with gout?
Joint deformity aspirin
Joint flexion of less than 50% furosemide (Lasix)
Joint stiffness colchicines
61. Mr. Rodriguez is admitted with severe pain in the knees. calcium gluconate (Kalcinate)
Which form of arthritis is characterized by urate deposits and 69. Mr. Domingo with a history of hypertension is diagnosed
joint pain, usually in the feet and legs, and occurs primarily in with primary hyperaldosteronism. This diagnosis indicates
men over age 30? that the client’s hypertension is caused by excessive hormone
Septic arthritis secretion from which of the following glands?
Traumatic arthritis Adrenal cortex
Intermittent arthritis Pancreas
Gouty arthritis Adrenal medulla
Parathyroid Alkaline phosphatase level
70. For a diabetic male client with a foot ulcer, the doctor Carcinoembryonic antigen level
orders bed rest, a wetto- dry dressing change every shift, and 78. Francis with anemia has been admitted to the medical-
blood glucose monitoring before meals and bedtime. Why surgical unit. Which assessment findings are characteristic of
are wet-to-dry dressings used for this client? iron-deficiency anemia?
They contain exudate and provide a moist wound Nights sweats, weight loss, and diarrhea
environment. Dyspnea, tachycardia, and pallor
They protect the wound from mechanical trauma and Nausea, vomiting, and anorexia
promote healing. Itching, rash, and jaundice
They debride the wound and promote healing by secondary 79. In teaching a female client who is HIV-positive about
intention. pregnancy, the nurse would know more teaching is necessary
They prevent the entrance of microorganisms and minimize when the client says:
wound discomfort. The baby can get the virus from my placenta.”
71. Nurse Zeny is caring for a client in acute addisonian crisis. “I’m planning on starting on birth control pills.”
Which laboratory data would the nurse expect to find? “Not everyone who has the virus gives birth to a baby who
Hyperkalemia has the virus.”
Reduced blood urea nitrogen (BUN) “I’ll need to have a C-section if I become pregnant and have a
Hypernatremia baby.”
Hyperglycemia 80. When preparing Judy with acquired immunodeficiency
72. A client is admitted for treatment of the syndrome of syndrome (AIDS) for discharge to the home, the nurse should
inappropriate antidiuretic hormone (SIADH). Which nursing be sure to include which instruction?
intervention is appropriate? “Put on disposable gloves before bathing.”
Infusing I.V. fluids rapidly as ordered “Sterilize all plates and utensils in boiling water.”
Encouraging increased oral intake “Avoid sharing such articles as toothbrushes and razors.”
Restricting fluids “Avoid eating foods from serving dishes shared by other
Administering glucose-containing I.V. fluids as ordered family members.”
73. A female client tells nurse Nikki that she has been 81. Nurse Marie is caring for a 32-year-old client admitted
working hard for the last 3 months to control her type 2 with pernicious anemia. Which set of findings should the
diabetes mellitus with diet and exercise. To determine the nurse expect when assessing the
effectiveness of the client’s efforts, the nurse should check: client?
urine glucose level. Pallor, bradycardia, and reduced pulse pressure
fasting blood glucose level. Pallor, tachycardia, and a sore tongue
serum fructosamine level. Sore tongue, dyspnea, and weight gain
glycosylated hemoglobin level. Angina, double vision, and anorexia
74. Nurse Trinity administered neutral protamine Hagedorn 82. After receiving a dose of penicillin, a client develops
(NPH) insulin to a diabetic client at 7 a.m. At what time would dyspnea and hypotension. Nurse Celestina suspects the client
the nurse expect the client to be most at risk for a is experiencing anaphylactic shock. What should the nurse do
hypoglycemic reaction? first?
10:00 am Page an anesthesiologist immediately and prepare to
Noon intubate the client.
4:00 pm Administer epinephrine, as prescribed, and prepare to
10:00 pm intubate the client if necessary.
75. The adrenal cortex is responsible for producing which Administer the antidote for penicillin, as prescribed, and
substances? continue to monitor the client’s vital signs.
Glucocorticoids and androgens Insert an indwelling urinary catheter and begin to infuse I.V.
Catecholamines and epinephrine fluids as ordered.
Mineralocorticoids and catecholamines 83. Mr. Marquez with rheumatoid arthritis is about to begin
Norepinephrine and epinephrine aspirin therapy to reduce inflammation. When teaching the
76. On the third day after a partial thyroidectomy, Proserfina client about aspirin, the nurse discusses adverse reactions to
exhibits muscle twitching and hyperirritability of the nervous prolonged aspirin therapy. These include:
system. When questioned, the client reports numbness and weight gain.
tingling of the mouth and fingertips. Suspecting a fine motor tremors.
lifethreatening electrolyte disturbance, the nurse notifies the respiratory acidosis.
surgeon immediately. Which electrolyte disturbance most bilateral hearing loss.
commonly follows thyroid surgery? 84. A 23-year-old client is diagnosed with human
Hypocalcemia immunodeficiency virus (HIV). After recovering from the
Hyponatremia initial shock of the diagnosis, the client expresses a desire to
Hyperkalemia learn as much as possible about HIV and acquired
Hypermagnesemia immunodeficiency syndrome (AIDS). When teaching the
77. Which laboratory test value is elevated in clients who client about the immune system, the nurse states that
smoke and can’t be used as a general indicator of cancer? adaptive immunity is provided by which type of white blood
Acid phosphatase level cell?
Serum calcitonin level Neutrophil
Basophil 92. Nurse Sarah is caring for clients on the surgical floor and
Monocyte has just received report from the previous shift. Which of the
Lymphocyte following clients should the nurse see first?
85. In an individual with Sjögren’s syndrome, nursing care A 35-year-old admitted three hours ago with a gunshot
should focus on: wound; 1.5 cm area of dark drainage noted on the dressing.
moisture replacement. A 43-year-old who had a mastectomy two days ago; 23 ml of
electrolyte balance. serosanguinous fluid noted in the Jackson-Pratt drain.
nutritional supplementation. A 59-year-old with a collapsed lung due to an accident; no
arrhythmia management. drainage noted in the previous eight hours.
86. During chemotherapy for lymphocytic leukemia, Mathew A 62-year-old who had an abdominal-perineal resection three
develops abdominal pain, fever, and “horse barn” smelling days ago; client complaints of chills.
diarrhea. It would be most important for the nurse to advise 93. Nurse Eve is caring for a client who had a thyroidectomy
the physician to order: 12 hours ago for treatment of Grave’s disease. The nurse
enzyme-linked immunosuppressant assay (ELISA) test. would be most concerned if which of the following was
electrolyte panel and hemogram. observed?
stool for Clostridium difficile test. Blood pressure 138/82, respirations 16, oral temperature 99
flat plate X-ray of the abdomen. degrees Fahrenheit.
87. A male client seeks medical evaluation for fatigue, night The client supports his head and neck when turning his head
sweats, and a 20-lb weight loss in 6 weeks. To confirm that to the right.
the client has been infected with the human The client spontaneously flexes his wrist when the blood
immunodeficiency virus (HIV), the nurse expects the pressure is obtained.
physician to order: The client is drowsy and complains of sore throat.
E-rosette immunofluorescence. 94. Julius is admitted with complaints of severe pain in the
quantification of T-lymphocytes. lower right quadrant of the abdomen. To assist with pain
enzyme-linked immunosorbent assay (ELISA). relief, the nurse should take which of the following actions?
Western blot test with ELISA. Encourage the client to change positions frequently in bed.
88. A complete blood count is commonly performed before a Administer Demerol 50 mg IM q 4 hours and PRN.
Joe goes into surgery. What does this test seek to identify? Apply warmth to the abdomen with a heating pad.
Potential hepatic dysfunction indicated by decreased blood Use comfort measures and pillows to position the client.
urea nitrogen (BUN) and creatinine levels 95. Nurse Tina prepares a client for peritoneal dialysis. Which
Low levels of urine constituents normally excreted in the of the following actions should the nurse take first?
urine Assess for a bruit and a thrill.
Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels Warm the dialysate solution.
Electrolyte imbalance that could affect the blood’s ability to Position the client on the left side.
coagulate properly Insert a Foley catheter
89. While monitoring a client for the development of 96. Nurse Jannah teaches an elderly client with right-sided
disseminated intravascular coagulation (DIC), the nurse weakness how to use cane. Which of the following behaviors,
should take note of what assessment parameters? if demonstrated by the client to the nurse, indicates that the
Platelet count, prothrombin time, and partial thromboplastin teaching was effective?
time The client holds the cane with his right hand, moves the can
Platelet count, blood glucose levels, and white blood cell forward followed by the right leg, and then moves the left
(WBC) count leg.
Thrombin time, calcium levels, and potassium levels The client holds the cane with his right hand, moves the cane
Fibrinogen level, WBC, and platelet count forward followed by his left leg, and then moves the right leg.
90. When taking a dietary history from a newly admitted The client holds the cane with his left hand, moves the cane
female client, Nurse Len should remember that which of the forward followed by the right leg, and then moves the left
following foods is a common allergen? leg.
Bread The client holds the cane with his left hand, moves the cane
Carrots forward followed by his left leg, and then moves the right leg.
Orange 97. An elderly client is admitted to the nursing home setting.
Strawberries The client is occasionally confused and her gait is often
91. Nurse John is caring for clients in the outpatient clinic. unsteady. Which of the following actions, if taken by the
Which of the following phone calls should the nurse return nurse, is most appropriate?
first? Ask the woman’s family to provide personal items such as
A client with hepatitis A who states, “My arms and legs are photos or mementos.
itching.” Select a room with a bed by the door so the woman can look
A client with cast on the right leg who states, “I have a funny down the hall.
feeling in my right leg.” Suggest the woman eat her meals in the room with her
A client with osteomyelitis of the spine who states, “I am so roommate.
nauseous that I can’t eat.” Encourage the woman to ambulate in the halls twice a day.
A client with rheumatoid arthritis who states, “I am having 98. Nurse Evangeline teaches an elderly client how to use a
trouble sleeping.” standard aluminum walker. Which of the following behaviors,
if demonstrated by the client, indicates that the nurse’s digestive enzymes and highly irritating to the skin.
teaching was effective? Protection of the skin from the effects of these
The client slowly pushes the walker forward 12 inches, then enzymes is begun at once. Skin exposed to these
takes small steps forward while leaning on the walker. enzymes even for a short time becomes reddened,
The client lifts the walker, moves it forward 10 inches, and painful, and excoriated.
then takes several small steps forward. 9. Answer: (B) Flat on back. To avoid the complication of
The client supports his weight on the walker while advancing a painful spinal headache that can last for several days,
it forward, then takes small steps while balancing on the the client is kept in flat in a supine position for
walker. approximately 4 to 12 hours postoperatively.
The client slides the walker 18 inches forward, then takes Headaches are believed to be causes by the seepage of
small steps while holding onto the walker for balance. cerebral spinal fluid from the puncture site. By keeping
99. Nurse Deric is supervising a group of elderly clients in a the client flat, cerebral spinal fluid pressures are
residential home setting. The nurse knows that the elderly equalized, which avoids trauma to the neurons.
are at greater risk of developing sensory deprivation for what 10. Answer: (C) The client is oriented when aroused from
reason? sleep, and goes back to sleep immediately. This finding
Increased sensitivity to the side effects of medications. suggest that the level of consciousness is decreasing.
Decreased visual, auditory, and gustatory abilities. 11. Answer: (A) Altered mental status and dehydration.
Isolation from their families and familiar surroundings. Fever, chills, hemortysis, dyspnea, cough, and pleuritic
Decrease musculoskeletal function and mobility. chest pain are the common symptoms of pneumonia,
100. A male client with emphysema becomes restless and but elderly clients may first appear with only an
confused. What step should nurse Jasmine take next? altered lentil status and dehydration due to a blunted
Encourage the client to perform pursed lip breathing. immune response.
Check the client’s temperature. 12. Answer: (B) Chills, fever, night sweats, and hemoptysis.
Assess the client’s potassium level. Typical signs and symptoms are chills, fever, night
Increase the client’s oxygen flow rate. sweats, and hemoptysis. Chest pain may be present
from coughing, but isn’t usual. Clients with TB typically
Answers and Rationales have low-grade fevers, not higher than 102°F (38.9°C).
1. Answer: (C) Loose, bloody. Normal bowel function and Nausea, headache, and photophobia aren’t usual TB
soft-formed stool usually do not occur until around the symptoms.
seventh day following surgery. The stool consistency is 13. Answer:(A) Acute asthma. Based on the client’s history
related to how much water is being absorbed. and symptoms, acute asthma is the most likely
2. Answer: (A) On the client’s right side. The client has diagnosis. He’s unlikely to have bronchial pneumonia
left visual field blindness. The client will see only from without a productive cough and fever and he’s too
the right side. young to have developed (COPD) and emphysema.
3. Answer: (C) Check respirations, stabilize spine, and 14. Answer: (B) Respiratory arrest. Narcotics can cause
check circulation. Checking the airway would be respiratory arrest if given in large quantities. It’s
priority, and a neck injury should be suspected. unlikely the client will have asthma attack or a seizure
4. Answer: (D) Decreasing venous return through or wake up on his own.
vasodilation. The significant effect of nitroglycerin is 15. Answer: (D) Decreased vital capacity. Reduction in
vasodilation and decreased venous return, so the heart vital capacity is a normal physiologic changes include
does not have to work hard. decreased elastic recoil of the lungs, fewer functional
5. Answer: (A) Call for help and note the time. Having capillaries in the alveoli, and an increased in residual
established, by stimulating the client, that the client is volume.
unconscious rather than sleep, the nurse should 16. Answer: (C) Presence of premature ventricular
immediately call for help. This may be done by dialing contractions (PVCs) on a cardiac monitor. Lidocaine
the operator from the client’s phone and giving the drips are commonly used to treat clients whose
hospital code for cardiac arrest and the client’s room arrhythmias haven’t been controlled with oral
number to the operator, of if the phone is not medication and who are having PVCs that are visible
available, by pulling the emergency call button. Noting on the cardiac monitor. SaO2, blood pressure, and ICP
the time is important baseline information for cardiac are important factors but aren’t as significant as PVCs
arrest procedure. in the situation.
6. Answer: (C) Make sure that the client takes food and 17. Answer: (B) Avoid foods high in vitamin K. The client
medications at prescribed intervals. Food and drug should avoid consuming large amounts of vitamin K
therapy will prevent the accumulation of hydrochloric because vitamin K can interfere with anticoagulation.
acid, or will neutralize and buffer the acid that does The client may need to report diarrhea, but isn’t effect
accumulate. of taking an anticoagulant. An electric razor-not a
7. Answer: (B) Continue treatment as ordered. The straight razor-should be used to prevent cuts that
effects of heparin are monitored by the PTT is normally cause bleeding. Aspirin may increase the risk of
30 to 45 seconds; the therapeutic level is 1.5 to 2 times bleeding; acetaminophen should be used to pain relief.
the normal level. 18. Answer: (C) Clipping the hair in the area. Hair can be a
8. Answer: (B) In the operating room. The stoma drainage source of infection and should be removed by clipping.
bag is applied in the operating room. Drainage from Shaving the area can cause skin abrasions and
the ileostomy contains secretions that are rich in depilatories can irritate the skin.
19. Answer: (A) Bone fracture. Bone fracture is a major each breath, and equal depth between each breath.
complication of osteoporosis that results when loss of Kussmaul’s respirations are rapid, deep breathing
calcium and phosphate increased the fragility of bones. without pauses. Tachypnea is shallow breathing with
Estrogen deficiencies result from menopause-not increased respiratory rate.
osteoporosis. Calcium and vitamin D supplements may 28. Answer: (B) Fine crackles. Fine crackles are caused by
be used to support normal bone metabolism, But a fluid in the alveoli and commonly occur in clients with
negative calcium balance isn’t a complication of heart failure. Tracheal breath sounds are auscultated
osteoporosis. Dowager’s hump results from bone over the trachea. Coarse crackles are caused by
fractures. It develops when repeated vertebral secretion accumulation in the airways. Friction rubs
fractures increase spinal curvature. occur with pleural inflammation.
20. Answer: (C) Changes from previous examinations. 29. Answer: (B) The airways are so swollen that no air
Women are instructed to examine themselves to cannot get through. During an acute attack, wheezing
discover changes that have occurred in the breast. may stop and breath sounds become inaudible
Only a physician can diagnose lumps that are because the airways are so swollen that air can’t get
cancerous, areas of thickness or fullness that signal the through. If the attack is over and swelling has
presence of a malignancy, or masses that are decreased, there would be no more wheezing and less
fibrocystic as opposed to malignant. emergent concern. Crackles do not replace wheezes
21. Answer: (C) Balance the client’s periods of activity and during an acute asthma attack.
rest. A client with hyperthyroidism needs to be 30. Answer: (D) Place the client on his side, remove
encouraged to balance periods of activity and rest. dangerous objects, and protect his head. During the
Many clients with hyperthyroidism are hyperactive active seizure phase, initiate precautions by placing the
and complain of feeling very warm. client on his side, removing dangerous objects, and
22. Answer: (B) Increase his activity level. The client protecting his head from injury. A bite block should
should be encouraged to increase his activity level. never be inserted during the active seizure phase.
Maintaining an ideal weight; following a low- Insertion can break the teeth and lead to aspiration.
cholesterol, low sodium diet; and avoiding stress are 31. Answer: (B) Kinked or obstructed chest tube. Kinking
all important factors in decreasing the risk of and blockage of the chest tube is a common cause of a
atherosclerosis. tension pneumothorax. Infection and excessive
23. Answer: (A) Laminectomy. The client who has had drainage won’t cause a tension pneumothorax.
spinal surgery, such as laminectomy, must be log rolled Excessive water won’t affect the chest tube drainage.
to keep the spinal column straight when turning. 32. Answer: (D) Stay with him but not intervene at this
Thoracotomy and cystectomy may turn themselves or time. If the client is coughing, he should be able to
may be assisted into a comfortable position. Under dislodge the object or cause a complete obstruction. If
normal circumstances, hemorrhoidectomy is an complete obstruction occurs, the nurse should perform
outpatient procedure, and the client may resume the abdominal thrust maneuver with the client
normal activities immediately after surgery. standing. If the client is unconscious, she should lay
24. Answer: (D) Avoiding straining during bowel him down. A nurse should never leave a choking client
movement or bending at the waist. The client should alone.
avoid straining, lifting heavy objects, and coughing 33. Answer: (B) Current health promotion activities.
harshly because these activities increase intraocular Recognizing an individual’s positive health measures is
pressure. Typically, the client is instructed to avoid very useful. General health in the previous 10 years is
lifting objects weighing more than 15 lb (7kg) – not 5lb. important, however, the current activities of an 84
instruct the client when lying in bed to lie on either the year old client are most significant in planning care.
side or back. The client should avoid bright light by Family history of disease for a client in later years is of
wearing sunglasses. minor significance. Marital status information may be
25. Answer: (D) Before age 20. Testicular cancer commonly important for discharge planning but is not as
occurs in men between ages 20 and 30. A male client significant for addressing the immediate medical
should be taught how to perform testicular problem.
selfexamination before age 20, preferably when he 34. Answer: (C) Place the client in a side lying position,
enters his teens. with the head of the bed lowered. The client should
26. Answer: (B) Place a saline-soaked sterile dressing on be positioned in a side-lying position with the head of
the wound. The nurse should first place saline-soaked the bed lowered to prevent aspiration. A small amount
sterile dressings on the open wound to prevent tissue of toothpaste should be used and the mouth swabbed
drying and possible infection. Then the nurse should or suctioned to remove pooled secretions. Lemon
call the physician and take the client’s vital signs. The glycerin can be drying if used for extended periods.
dehiscence needs to be surgically closed, so the nurse Brushing the teeth with the client lying supine may
should never try to close it. lead to aspiration. Hydrogen peroxide is caustic to
27. Answer: (A) A progressively deeper breaths followed tissues and should not be used.
by shallower breaths with apneic periods. Cheyne- 35. Answer: (C) Pneumonia. Fever productive cough and
Strokes respirations are breaths that become pleuritic chest pain are common signs and symptoms
progressively deeper fallowed by shallower of pneumonia. The client with ARDS has dyspnea and
respirations with apneas periods. Biot’s respirations hypoxia with worsening hypoxia over time, if not
are rapid, deep breathing with abrupt pauses between treated aggressively. Pleuritic chest pain varies with
 respiration, unlike the constant chest pain during an should assess the client with thrombophlebitis who is
MI; so this client most likely isn’t having an MI. the receiving a heparin infusion, and then the 58- year-old
client with TB typically has a cough producing blood- client admitted 2 days ago with heart failure (his signs
tinged sputum. A sputum culture should be obtained and symptoms are resolving and don’t require
to confirm the nurse’s suspicions. immediate attention). The lowest priority is the 89-
36. Answer: (C) A 43-yesr-old homeless man with a history year-old with end stage right-sided heart failure, who
of alcoholism. Clients who are economically requires time-consuming supportive measures.
disadvantaged, malnourished, and have reduced 46. Answer: (C) Cocaine. Because of the client’s age and
immunity, such as a client with a history of alcoholism, negative medical history, the nurse should question
are at extremely high risk for developing TB. A high her about cocaine use. Cocaine increases myocardial
school student, daycare worker, and businessman oxygen consumption and can cause coronary artery
probably have a much low risk of contracting TB. spasm, leading to tachycardia, ventricular fibrillation,
37. Answer: (C ) To determine the extent of lesions. If the myocardial ischemia, and myocardial infarction.
lesions are large enough, the chest X-ray will show Barbiturate overdose may trigger respiratory
their presence in the lungs. Sputum culture confirms depression and slow pulse. Opioids can cause marked
the diagnosis. There can be false-positive and false- respiratory depression, while benzodiazepines can
negative skin test results. A chest X-ray can’t cause drowsiness and confusion.
determine if this is a primary or secondary infection. 47. Answer: (B) Nonmobile mass with irregular edges.
38. Answer: (B) Bronchodilators. Bronchodilators are the Breast cancer tumors are fixed, hard, and poorly
first line of treatment for asthma because broncho- delineated with irregular edges. A mobile mass that is
constriction is the cause of reduced airflow. Beta soft and easily delineated is most often a fluid-filled
adrenergic blockers aren’t used to treat asthma and benign cyst. Axillary lymph nodes may or may not be
can cause bronchoconstriction. Inhaled oral steroids palpable on initial detection of a cancerous mass.
may be given to reduce the inflammation but aren’t Nipple retraction — not eversion — may be a sign of
used for emergency relief. cancer.
39. Answer: (C) Chronic obstructive bronchitis. Because of 48. Answer: (C) Radiation. The usual treatment for vaginal
this extensive smoking history and symptoms the cancer is external or intravaginal radiation therapy.
client most likely has chronic obstructive bronchitis. Less often, surgery is performed. Chemotherapy
Client with ARDS have acute symptoms of hypoxia and typically is prescribed only if vaginal cancer is
typically need large amounts of oxygen. Clients with diagnosed in an early stage, which is rare.
asthma and emphysema tend not to have chronic Immunotherapy isn’t used to treat vaginal cancer.
cough or peripheral edema. 49. Answer: (B) Carcinoma in situ, no abnormal regional
40. Answer: (A) The patient is under local anesthesia lymph nodes, and no evidence of distant metastasis.
during the procedure. Before the procedure, the TIS, N0, M0 denotes carcinoma in situ, no abnormal
patient is administered with drugs that would help to regional lymph nodes, and no evidence of distant
prevent infection and rejection of the transplanted metastasis. No evidence of primary tumor, no
cells such as antibiotics, cytotoxic, and corticosteroids. abnormal regional lymph nodes, and no evidence of
During the transplant, the patient is placed under distant metastasis is classified as T0, N0, M0. If the
general anesthesia. tumor and regional lymph nodes can’t be assessed and
41. Answer: (D) Raise the side rails. A patient who is no evidence of metastasis exists, the lesion is classified
disoriented is at risk of falling out of bed. The initial as TX, NX, M0. A progressive increase in tumor size, no
action of the nurse should be raising the side rails to demonstrable metastasis of the regional lymph nodes,
ensure patients safety. and ascending degrees of distant metastasis is
42. Answer: (A) Crowd red blood cells. The excessive classified as T1, T2, T3, or T4; N0; and M1, M2, or M3.
production of white blood cells crowd out red blood 50. Answer: (D) “Keep the stoma moist.” The nurse should
cells production which causes anemia to occur. instruct the client to keep the stoma moist, such as by
43. Answer: (B) Leukocytosis. Chronic Lymphocytic applying a thin layer of petroleum jelly around the
leukemia (CLL) is characterized by increased edges, because a dry stoma may become irritated. The
production of leukocytes and lymphocytes resulting in nurse should recommend placing a stoma bib over the
leukocytosis, and proliferation of these cells within the stoma to filter and warm air before it enters the
bone marrow, spleen and liver. stoma. The client should begin performing stoma care
44. Answer: (A) Explain the risks of not having the surgery. without assistance as soon as possible to gain
The best initial response is to explain the risks of not independence in self-care activities.
having the surgery. If the client understands the risks 51. Answer: (B) Lung cancer. Lung cancer is the most
but still refuses the nurse should notify the physician deadly type of cancer in both women and men. Breast
and the nurse supervisor and then record the client’s cancer ranks second in women, followed (in
refusal in the nurses’ notes. descending order) by colon and rectal cancer,
45. Answer: (D) The 75-year-old client who was admitted 1 pancreatic cancer, ovarian cancer, uterine cancer,
hour ago with new-onset atrial fibrillation and is lymphoma, leukemia, liver cancer, brain cancer,
receiving L.V. dilitiazem (Cardizem). The client with stomach cancer, and multiple myeloma.
atrial fibrillation has the greatest potential to become 52. Answer: (A) miosis, partial eyelid ptosis, and anhidrosis
unstable and is on L.V. medication that requires close on the affected side of the face. Horner’s syndrome,
monitoring. After assessing this client, the nurse which occurs when a lung tumor invades the ribs and
 affects the sympathetic nerve ganglia, is characterized 30% of the bone loss has occurred. Bone densitometry
by miosis, partial eyelid ptosis, and anhidrosis on the can detect bone loss of 3% or less. This test is
affected side of the face. Chest pain, dyspnea, cough, sometimes recommended routinely for women over 35
weight loss, and fever are associated with pleural who are at risk. Strenuous exercise won’t cause
tumors. Arm and shoulder pain and atrophy of the arm fractures.
and hand muscles on the affected side suggest 60. Answer: (C) Joint flexion of less than 50%. Arthroscopy
Pancoast’s tumor, a lung tumor involving the first is contraindicated in clients with joint flexion of less
thoracic and eighth cervical nerves within the brachial than 50% because of technical problems in inserting
plexus. Hoarseness in a client with lung cancer the instrument into the joint to see it clearly. Other
suggests that the tumor has extended to the recurrent contraindications for this procedure include skin and
laryngeal nerve; dysphagia suggests that the lung wound infections. Joint pain may be an indication, not
tumor is compressing the esophagus. a contraindication, for arthroscopy. Joint deformity
53. Answer: (A) prostate-specific antigen, which is used to and joint stiffness aren’t contraindications for this
screen for prostate cancer. PSA stands for prostate- procedure.
specific antigen, which is used to screen for prostate 61. Answer: (D) Gouty arthritis. Gouty arthritis, a
cancer. The other answers are incorrect. metabolic disease, is characterized by urate deposits
54. Answer: (D) “Remain supine for the time specified by and pain in the joints, especially those in the feet and
the physician.” The nurse should instruct the client to legs. Urate deposits don’t occur in septic or traumatic
remain supine for the time specified by the physician. arthritis. Septic arthritis results from bacterial invasion
Local anesthetics used in a subarachnoid block don’t of a joint and leads to inflammation of the synovial
alter the gag reflex. No interactions between local lining. Traumatic arthritis results from blunt trauma to
anesthetics and food occur. Local anesthetics don’t a joint or ligament. Intermittent arthritis is a rare,
cause hematuria. benign condition marked by regular, recurrent joint
55. Answer: (C) Sigmoidoscopy. Used to visualize the lower effusions, especially in the knees.
GI tract, sigmoidoscopy and proctoscopy aid in the 62. Answer: (B) 30 ml/hour. An infusion prepared with
detection of two-thirds of all colorectal cancers. Stool 25,000 units of heparin in 500 ml of saline solution
Hematest detects blood, which is a sign of colorectal yields 50 units of heparin per milliliter of solution. The
cancer; however, the test doesn’t confirm the equation is set up as 50 units times X (the unknown
diagnosis. CEA may be elevated in colorectal cancer quantity) equals 1,500 units/hour, X equals 30
but isn’t considered a confirming test. An abdominal ml/hour.
CT scan is used to stage the presence of colorectal 63. Answer: (B) Loss of muscle contraction decreasing
cancer. venous return. In clients with hemiplegia or
56. Answer: (B) A fixed nodular mass with dimpling of the hemiparesis loss of muscle contraction decreases
overlying skin. A fixed nodular mass with dimpling of venous return and may cause swelling of the affected
the overlying skin is common during late stages of extremity. Contractures, or bony calcifications may
breast cancer. Many women have slightly occur with a stroke, but don’t appear with swelling.
asymmetrical breasts. Bloody nipple discharge is a sign DVT may develop in clients with a stroke but is more
of intraductal papilloma, a benign condition. Multiple likely to occur in the lower extremities. A stroke isn’t
firm, round, freely movable masses that change with linked to protein loss.
the menstrual cycle indicate fibrocystic breasts, a 64. Answer: (B) It appears on the distal interphalangeal
benign condition. joint. Heberden’s nodes appear on the distal
57. Answer: (A) Liver. The liver is one of the five most interphalageal joint on both men and women.
common cancer metastasis sites. The others are the Bouchard’s node appears on the dorsolateral aspect of
lymph nodes, lung, bone, and brain. The colon, the proximal interphalangeal joint.
reproductive tract, and WBCs are occasional 65. Answer: (B) Osteoarthritis is a localized disease
metastasis sites. rheumatoid arthritis is systemic. Osteoarthritis is a
58. Answer: (D) The client wears a watch and wedding localized disease, rheumatoid arthritis is systemic.
band. During an MRI, the client should wear no metal Osteoarthritis isn’t gender-specific, but rheumatoid
objects, such as jewelry, because the strong magnetic arthritis is. Clients have dislocations and subluxations
field can pull on them, causing injury to the client and in both disorders.
(if they fly off) to others. The client must lie still during 66. Answer: (C) The cane should be used on the unaffected
the MRI but can talk to those performing the test by side. A cane should be used on the unaffected side. A
way of the microphone inside the scanner tunnel. The client with osteoarthritis should be encouraged to
client should hear thumping sounds, which are caused ambulate with a cane, walker, or other assistive device
by the sound waves thumping on the magnetic field. as needed; their use takes weight and stress off joints.
59. Answer: (C) The recommended daily allowance of 67. Answer: (A) 9 U regular insulin and 21 U neutral
calcium may be found in a wide variety of foods. protamine Hagedorn (NPH). A 70/30 insulin
Premenopausal women require 1,000 mg of calcium preparation is 70% NPH and 30% regular insulin.
per day. Postmenopausal women require 1,500 mg per Therefore, a correct substitution requires mixing 21 U
day. It’s often, though not always, possible to get the of NPH and 9 U of regular insulin. The other choices are
recommended daily requirement in the foods we eat. incorrect dosages for the prescribed insulin.
Supplements are available but not always necessary. 68. Answer: (C) colchicines. A disease characterized by
Osteoporosis doesn’t show up on ordinary X-rays until joint inflammation (especially in the great toe), gout is
 caused by urate crystal deposits in the joints. The androgens. The medulla produces catecholamines —
physician prescribes colchicine to reduce these epinephrine and norepinephrine.
deposits and thus ease joint inflammation. Although 76. Answer: (A) Hypocalcemia. Hypocalcemia may follow
aspirin is used to reduce joint inflammation and pain in thyroid surgery if the parathyroid glands were
clients with osteoarthritis and rheumatoid arthritis, it removed accidentally. Signs and symptoms of
isn’t indicated for gout because it has no effect on hypocalcemia may be delayed for up to 7 days after
urate crystal formation. Furosemide, a diuretic, doesn’t surgery. Thyroid surgery doesn’t directly cause serum
relieve gout. Calcium gluconate is used to reverse a sodium, potassium, or magnesium abnormalities.
negative calcium balance and relieve muscle cramps, Hyponatremia may occur if the client inadvertently
not to treat gout. received too much fluid; however, this can happen to
69. Answer: (A) Adrenal cortex. Excessive secretion of any surgical client receiving I.V. fluid therapy, not just
aldosterone in the adrenal cortex is responsible for the one recovering from thyroid surgery. Hyperkalemia
client’s hypertension. This hormone acts on the renal and hypermagnesemia usually are associated with
tubule, where it promotes reabsorption of sodium and reduced renal excretion of potassium and magnesium,
excretion of potassium and hydrogen ions. The not thyroid surgery.
pancreas mainly secretes hormones involved in fuel 77. Answer: (D) Carcinoembryonic antigen level. In clients
metabolism. The adrenal medulla secretes the who smoke, the level of carcinoembryonic antigen is
catecholamines — epinephrine and norepinephrine. elevated. Therefore, it can’t be used as a general
The parathyroids secrete parathyroid hormone. indicator of cancer. However, it is helpful in monitoring
70. Answer: (C) They debride the wound and promote cancer treatment because the level usually falls to
healing by secondary intention. For this client, wet-to- normal within 1 month if treatment is successful. An
dry dressings are most appropriate because they clean elevated acid phosphatase level may indicate prostate
the foot ulcer by debriding exudate and necrotic tissue, cancer. An elevated alkaline phosphatase level may
thus promoting healing by secondary intention. Moist, reflect bone metastasis. An elevated serum calcitonin
transparent dressings contain exudate and provide a level usually signals thyroid cancer.
moist wound environment. Hydrocolloid dressings 78. Answer: (B) Dyspnea, tachycardia, and pallor. Signs of
prevent the entrance of microorganisms and minimize iron-deficiency anemia include dyspnea, tachycardia,
wound discomfort. Dry sterile dressings protect the and pallor as well as fatigue, listlessness, irritability,
wound from mechanical trauma and promote healing. and headache. Night sweats, weight loss, and diarrhea
71. Answer: (A) Hyperkalemia. In adrenal insufficiency, the may signal acquired immunodeficiency syndrome
client has hyperkalemia due to reduced aldosterone (AIDS). Nausea, vomiting, and anorexia may be signs of
secretion. BUN increases as the glomerular filtration hepatitis B. Itching, rash, and jaundice may result from
rate is reduced. Hyponatremia is caused by reduced an allergic or hemolytic reaction.
aldosterone secretion. Reduced cortisol secretion leads 79. Answer: (D) “I’ll need to have a C-section if I become
to impaired glyconeogenesis and a reduction of pregnant and have a baby.” The human
glycogen in the liver and muscle, causing immunodeficiency virus (HIV) is transmitted from
hypoglycemia. mother to child via the transplacental route, but a
72. Answer: (C) Restricting fluids. To reduce water Cesarean section delivery isn’t necessary when the
retention in a client with the SIADH, the nurse should mother is HIV-positive. The use of birth control will
restrict fluids. Administering fluids by any route would prevent the conception of a child who might have HIV.
further increase the client’s already heightened fluid It’s true that a mother who’s HIV positive can give
load. birth to a baby who’s HIV negative.
73. Answer: (D) glycosylated hemoglobin level. Because 80. Answer: (C) “Avoid sharing such articles as
some of the glucose in the bloodstream attaches to toothbrushes and razors.” The human
some of the hemoglobin and stays attached during the immunodeficiency virus (HIV), which causes AIDS, is
120-day life span of red blood cells, glycosylated most concentrated in the blood. For this reason, the
hemoglobin levels provide information about blood client shouldn’t share personal articles that may be
glucose levels during the previous 3 months. Fasting blood-contaminated, such as toothbrushes and razors,
blood glucose and urine glucose levels only give with other family members. HIV isn’t transmitted by
information about glucose levels at the point in time bathing or by eating from plates, utensils, or serving
when they were obtained. Serum fructosamine levels dishes used by a person with AIDS.
provide information about blood glucose control over 81. Answer: (B) Pallor, tachycardia, and a sore tongue.
the past 2 to 3 weeks. Pallor, tachycardia, and a sore tongue are all
74. Answer: (C) 4:00 pm. NPH is an intermediate-acting characteristic findings in pernicious anemia. Other
insulin that peaks 8 to 12 hours after administration. clinical manifestations include anorexia; weight loss; a
Because the nurse administered NPH insulin at 7 a.m., smooth, beefy red tongue; a wide pulse pressure;
the client is at greatest risk for hypoglycemia from 3 palpitations; angina; weakness; fatigue; and
p.m. to 7 p.m. paresthesia of the hands and feet. Bradycardia,
75. Answer: (A) Glucocorticoids and androgens. The reduced pulse pressure, weight gain, and double vision
adrenal glands have two divisions, the cortex and aren’t characteristic findings in pernicious anemia.
medulla. The cortex produces three types of 82. Answer: (B) Administer epinephrine, as prescribed, and
hormones: glucocorticoids, mineralocorticoids, and prepare to intubate the client if necessary. To reverse
anaphylactic shock, the nurse first should administer
 epinephrine, a potent bronchodilator as prescribed. a positive ELISA result must be confirmed by the
The physician is likely to order additional medications, Western blot test.
such as antihistamines and corticosteroids; if these 88. Answer: (C) Abnormally low hematocrit (HCT) and
medications don’t relieve the respiratory compromise hemoglobin (Hb) levels. Low preoperative HCT and Hb
associated with anaphylaxis, the nurse should prepare levels indicate the client may require a blood
to intubate the client. No antidote for penicillin exists; transfusion before surgery. If the HCT and Hb levels
however, the nurse should continue to monitor the decrease during surgery because of blood loss, the
client’s vital signs. A client who remains hypotensive potential need for a transfusion increases. Possible
may need fluid resuscitation and fluid intake and renal failure is indicated by elevated BUN or creatinine
output monitoring; however, administering levels. Urine constituents aren’t found in the blood.
epinephrine is the first priority. Coagulation is determined by the presence of
83. Answer: (D) bilateral hearing loss. Prolonged use of appropriate clotting factors, not electrolytes.
aspirin and other salicylates sometimes causes 89. Answer: (A) Platelet count, prothrombin time, and
bilateral hearing loss of 30 to 40 decibels. Usually, this partial thromboplastin time. The diagnosis of DIC is
adverse effect resolves within 2 weeks after the based on the results of laboratory studies of
therapy is discontinued. Aspirin doesn’t lead to weight prothrombin time, platelet count, thrombin time,
gain or fine motor tremors. Large or toxic salicylate partial thromboplastin time, and fibrinogen level as
doses may cause respiratory alkalosis, not respiratory well as client history and other assessment factors.
acidosis. Blood glucose levels, WBC count, calcium levels, and
84. Answer: (D) Lymphocyte. The lymphocyte provides potassium levels aren’t used to confirm a diagnosis of
adaptive immunity — recognition of a foreign antigen DIC.
and formation of memory cells against the antigen. 90. Answer: (D) Strawberries. Common food allergens
Adaptive immunity is mediated by B and T include berries, peanuts, Brazil nuts, cashews, shellfish,
lymphocytes and can be acquired actively or passively. and eggs. Bread, carrots, and oranges rarely cause
The neutrophil is crucial to phagocytosis. The basophil allergic reactions.
plays an important role in the release of inflammatory 91. Answer: (B) A client with cast on the right leg who
mediators. The monocyte functions in phagocytosis states, “I have a funny feeling in my right leg.” It may
and monokine production. indicate neurovascular compromise, requires
85. Answer: (A) moisture replacement. Sjogren’s immediate assessment.
syndrome is an autoimmune disorder leading to 92. Answer: (D) A 62-year-old who had an abdominal-
progressive loss of lubrication of the skin, GI tract, perineal resection three days ago; client complaints of
ears, nose, and vagina. Moisture replacement is the chills. The client is at risk for peritonitis; should be
mainstay of therapy. Though malnutrition and assessed for further symptoms and infection.
electrolyte imbalance may occur as a result of 93. Answer: (C) The client spontaneously flexes his wrist
Sjogren’s syndrome’s effect on the GI tract, it isn’t the when the blood pressure is obtained. Carpal spasms
predominant problem. Arrhythmias aren’t a problem indicate hypocalcemia.
associated with Sjogren’s syndrome. 94. Answer: (D) Use comfort measures and pillows to
86. Answer: (C) stool for Clostridium difficile test. position the client.Using comfort measures and pillows
Immunosuppressed clients — for example, clients to position the client is a non-pharmacological
receiving chemotherapy, — are at risk for infection methods of pain relief.
with C. difficile, which causes “horse barn” smelling 95. Answer: (B) Warm the dialysate solution. Cold
diarrhea. Successful treatment begins with an accurate dialysate increases discomfort. The solution should be
diagnosis, which includes a stool test. The ELISA test is warmed to body temperature in warmer or heating
diagnostic for human immunodeficiency virus (HIV) pad; don’t use microwave oven.
and isn’t indicated in this case. An electrolyte panel 96. Answer: (C) The client holds the cane with his left
and hemogram may be useful in the overall evaluation hand, moves the cane forward followed by the right
of a client but aren’t diagnostic for specific causes of leg, and then moves the left leg. The cane acts as a
diarrhea. A flat plate of the abdomen may provide support and aids in weight bearing for the weaker right
useful information about bowel function but isn’t leg.
indicated in the case of “horse barn” smelling diarrhea. 97. Answer: (A) Ask the woman’s family to provide
87. Answer: (D) Western blot test with ELISA. HIV infection personal items such as photos or mementos.Photos
is detected by analyzing blood for antibodies to HIV, and mementos provide visual stimulation to reduce
which form approximately 2 to 12 weeks after sensory deprivation.
exposure to HIV and denote infection. The Western 98. Answer: (B) The client lifts the walker, moves it
blot test — electrophoresis of antibody proteins — is forward 10 inches, and then takes several small steps
more than 98% accurate in detecting HIV antibodies forward. A walker needs to be picked up, placed down
when used in conjunction with the ELISA. It isn’t on all legs.
specific when used alone. Erosette 99. Answer: (C) Isolation from their families and familiar
immunofluorescence is used to detect viruses in surroundings. Gradual loss of sight, hearing, and taste
general; it doesn’t confirm HIV infection. interferes with normal functioning.
Quantification of T-lymphocytes is a useful monitoring 100. Answer: (A) Encourage the client to perform pursed lip
test but isn’t diagnostic for HIV. The ELISA test detects breathing. Purse lip breathing prevents the collapse of
HIV antibody particles but may yield inaccurate results;
 lung unit and helps client control rate and depth of Restrict foods high in protein
breathing Increase oral intake of cheese and milk.
Administer large amounts of normal saline via I.V.
PNLE IV for Care of Clients with Physiologic and Psychosocial 9. Mario has burn injury. After Forty48 hours, the physician
Alterations (Part 2) orders for Mario 2 liters of IV fluid to be administered q12 h.
1. Randy has undergone kidney transplant, what assessment The drop factor of the tubing is 10 gtt/ml. The nurse should
would prompt Nurse Katrina to suspect organ rejection? set the flow to provide:
Sudden weight loss 18 gtt/min
Polyuria 28 gtt/min
Hypertension 32 gtt/min
Shock 36 gtt/min
2. The immediate objective of nursing care for an overweight, 10.Terence suffered form burn injury. Using the rule of nines,
mildly hypertensive male client with ureteral colic and which has the largest percent of burns?
hematuria is to decrease: Face and neck
Pain Right upper arm and penis
Weight Right thigh and penis
Hematuria Upper trunk
Hypertension 11. Herbert, a 45 year old construction engineer is brought to
3. Matilda, with hyperthyroidism is to receive Lugol’s iodine the hospital unconscious after falling from a 2-story building.
solution before a subtotal thyroidectomy is performed. The When assessing the client, the nurse would be most
nurse is aware that this medication is given to: concerned if the assessment revealed:
Decrease the total basal metabolic rate. Reactive pupils
Maintain the function of the parathyroid glands. A depressed fontanel
Block the formation of thyroxine by the thyroid gland. Bleeding from ears
Decrease the size and vascularity of the thyroid gland. An elevated temperature
4. Ricardo, was diagnosed with type I diabetes. The nurse is 12. Nurse Sherry is teaching male client regarding his
aware that acute hypoglycemia also can develop in the client permanent artificial pacemaker. Which information given by
who is diagnosed with: the nurse shows her knowledge deficit about the artificial
Liver disease cardiac pacemaker?
Hypertension take the pulse rate once a day, in the morning upon
Type 2 diabetes awakening
Hyperthyroidism May be allowed to use electrical appliances
5. Tracy is receiving combination chemotherapy for Have regular follow up care
treatment of metastatic carcinoma. Nurse Ruby should May engage in contact sports
monitor the client for the systemic side effect of: 13.The nurse is ware that the most relevant knowledge about
Ascites oxygen administration to a male client with COPD is
Nystagmus Oxygen at 1-2L/min is given to maintain the hypoxic stimulus
Leukopenia for breathing.
Polycythemia Hypoxia stimulates the central chemoreceptors in the
6. Norma, with recent colostomy expresses concern about medulla that makes the client breath.
the inability to control the passage of gas. Nurse Oliver Oxygen is administered best using a non-rebreathing mask
should suggest that the client plan to: Blood gases are monitored using a pulse oximeter.
Eliminate foods high in cellulose. 14.Tonny has undergoes a left thoracotomy and a partial
Decrease fluid intake at meal times. pneumonectomy. Chest tubes are inserted, and one-bottle
Avoid foods that in the past caused flatus. water-seal drainage is instituted in the operating room. In the
Adhere to a bland diet prior to social events. postanesthesia care unit Tonny is placed in Fowler’s position
7. Nurse Ron begins to teach a male client how to perform on either his right side or on his back. The nurse is aware that
colostomy irrigations. The nurse would evaluate that the this position:
instructions were understood when the client states, “I Reduce incisional pain.
should: Facilitate ventilation of the left lung.
Lie on my left side while instilling the irrigating solution.” Equalize pressure in the pleural space.
Keep the irrigating container less than 18 inches above the Increase venous return
stoma.” 15.Kristine is scheduled for a bronchoscopy. When teaching
Instill a minimum of 1200 ml of irrigating solution to Kristine what to expect afterward, the nurse’s highest priority
stimulate evacuation of the bowel.” of information would be:
Insert the irrigating catheter deeper into the stoma if Food and fluids will be withheld for at least 2 hours.
cramping occurs during the procedure.” Warm saline gargles will be done q 2h.
8. Patrick is in the oliguric phase of acute tubular necrosis and Coughing and deep-breathing exercises will be done q2h.
is experiencing fluid and electrolyte imbalances. The client is Only ice chips and cold liquids will be allowed initially.
somewhat confused and complains of nausea and muscle 16.Nurse Tristan is caring for a male client in acute renal
weakness. As part of the prescribed therapy to correct this failure. The nurse should expect hypertonic glucose, insulin
electrolyte imbalance, the nurse would expect to: infusions, and sodium bicarbonate to be used to treat:
Administer Kayexalate hypernatremia.
hypokalemia. To prevent confusion
hyperkalemia. To prevent seizures
hypercalcemia. To prevent cerebrospinal fluid (CSF) leakage
17.Ms. X has just been diagnosed with condylomata To prevent cardiac arrhythmias
acuminata (genital warts). What information is appropriate 23.A male client had a nephrectomy 2 days ago and is now
to tell this client? complaining of abdominal pressure and nausea. The first
This condition puts her at a higher risk for cervical cancer; nursing action should be to:
therefore, she should have a Papanicolaou (Pap) smear Auscultate bowel sounds.
annually. Palpate the abdomen.
The most common treatment is metronidazole (Flagyl), which Change the client’s position.
should eradicate the problem within 7 to 10 days. Insert a rectal tube.
The potential for transmission to her sexual partner will be 24.Wilfredo with a recent history of rectal bleeding is being
eliminated if condoms are used every time they have sexual prepared for a colonoscopy. How should the nurse Patricia
intercourse. position the client for this test initially?
The human papillomavirus (HPV), which causes condylomata Lying on the right side with legs straight
acuminata, can’t be transmitted during oral sex. Lying on the left side with knees bent
18.Maritess was recently diagnosed with a genitourinary Prone with the torso elevated
problem and is being examined in the emergency Bent over with hands touching the floor
department. When palpating the her kidneys, the nurse 25.A male client with inflammatory bowel disease undergoes
should keep which anatomical fact in mind? an ileostomy. On the first day after surgery, Nurse Oliver
The left kidney usually is slightly higher than the right one. notes that the client’s stoma appears dusky. How should the
The kidneys are situated just above the adrenal glands. nurse interpret this finding?
The average kidney is approximately 5 cm (2″) long and 2 to 3 Blood supply to the stoma has been interrupted.
cm (¾” to 1-1/8″) wide. This is a normal finding 1 day after surgery.
The kidneys lie between the 10th and 12th thoracic The ostomy bag should be adjusted.
vertebrae. An intestinal obstruction has occurred.
19.Jestoni with chronic renal failure (CRF) is admitted to the 26.Anthony suffers burns on the legs, which nursing
urology unit. The nurse is aware that the diagnostic test are intervention helps prevent contractures?
consistent with CRF if the result is: Applying knee splints
Increased pH with decreased hydrogen ions. Elevating the foot of the bed
Increased serum levels of potassium, magnesium, and Hyperextending the client’s palms
calcium. Performing shoulder range-of-motion exercises
Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 27.Nurse Ron is assessing a client admitted with second- and
6.5 mg/ dl. third-degree burns on the face, arms, and chest. Which
Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) finding indicates a potential problem?
excretion 75%. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
20. Katrina has an abnormal result on a Papanicolaou test. Urine output of 20 ml/hour.
After admitting that she read her chart while the nurse was White pulmonary secretions.
out of the room, Katrina asks what dysplasia means. Which Rectal temperature of 100.6° F (38° C).
definition should the nurse provide? 28. Mr. Mendoza who has suffered a cerebrovascular
Presence of completely undifferentiated tumor cells that accident (CVA) is too weak to move on his own. To help the
don’t resemble cells of the tissues of their origin. client avoid pressure ulcers, Nurse Celia should:
Increase in the number of normal cells in a normal Turn him frequently.
arrangement in a tissue or an organ. Perform passive range-of-motion (ROM) exercises.
Replacement of one type of fully differentiated cell by Reduce the client’s fluid intake.
another in tissues where the second type normally isn’t Encourage the client to use a footboard.
found. 29.Nurse Maria plans to administer dexamethasone cream to
Alteration in the size, shape, and organization of a female client who has dermatitis over the anterior chest.
differentiated cells. How should the nurse apply this topical agent?
21. During a routine checkup, Nurse Mariane assesses a male With a circular motion, to enhance absorption.
client with acquired immunodeficiency syndrome (AIDS) for With an upward motion, to increase blood supply to the
signs and symptoms of cancer. What is the most common affected area
AIDS-related cancer? In long, even, outward, and downward strokes in the
Squamous cell carcinoma direction of hair growth
Multiple myeloma In long, even, outward, and upward strokes in the direction
Leukemia opposite hair growth
Kaposi’s sarcoma 30.Nurse Kate is aware that one of the following classes of
22.Ricardo is scheduled for a prostatectomy, and the medication protect the ischemic myocardium by blocking
anesthesiologist plans to use a spinal (subarachnoid) block catecholamines and sympathetic nerve stimulation is:
during surgery. In the operating room, the nurse positions Beta -adrenergic blockers
the client according to the anesthesiologist’s instructions. Calcium channel blocker
Why does the client require special positioning for this type Narcotics
of anesthesia? Nitrates
31.A male client has jugular distention. On what position Electrocardiogram, complete blood count, testing for occult
should the nurse place the head of the bed to obtain the blood, comprehensive serum metabolic panel.
most accurate reading of jugular vein distention? Electroencephalogram, alkaline phosphatase and aspartate
High Fowler’s aminotransferase levels, basic serum metabolic panel
Raised 10 degrees 38. Macario had coronary artery bypass graft (CABG) surgery
Raised 30 degrees 3 days ago. Which of the following conditions is suspected by
Supine position the nurse when a decrease in platelet count from 230,000 ul
32.The nurse is aware that one of the following classes of to 5,000 ul is noted?
medications maximizes cardiac performance in clients with Pancytopenia
heart failure by increasing ventricular contractility? Idiopathic thrombocytopemic purpura (ITP)
Beta-adrenergic blockers Disseminated intravascular coagulation (DIC)
Calcium channel blocker Heparin-associated thrombosis and thrombocytopenia
Diuretics (HATT)
Inotropic agents 39. Which of the following drugs would be ordered by the
33.A male client has a reduced serum high-density physician to improve the platelet count in a male client with
lipoprotein (HDL) level and an elevated low-density idiopathic thrombocytopenic purpura (ITP)?
lipoprotein (LDL) level. Which of the following dietary Acetylsalicylic acid (ASA)
modifications is not appropriate for this client? Corticosteroids
Fiber intake of 25 to 30 g daily Methotrezate
Less than 30% of calories form fat Vitamin K
Cholesterol intake of less than 300 mg daily 40. A female client is scheduled to receive a heart valve
Less than 10% of calories from saturated fat replacement with a porcine valve. Which of the following
34. A 37-year-old male client was admitted to the coronary types of transplant is this?
care unit (CCU) 2 days ago with an acute myocardial Allogeneic
infarction. Which of the following actions would breach the Autologous
client confidentiality? Syngeneic
The CCU nurse gives a verbal report to the nurse on the Xenogeneic
telemetry unit before transferring the client to that unit 41. Marco falls off his bicycle and injuries his ankle. Which of
The CCU nurse notifies the on-call physician about a change the following actions shows the initial response to the injury
in the client’s condition in the extrinsic pathway?
The emergency department nurse calls up the latest Release of Calcium
electrocardiogram results to check the client’s progress. Release of tissue thromboplastin
At the client’s request, the CCU nurse updates the client’s Conversion of factors XII to factor XIIa
wife on his condition Conversion of factor VIII to factor VIIIa
35. A male client arriving in the emergency department is 42. Instructions for a client with systemic lupus
receiving cardiopulmonary resuscitation from paramedics erythematosus (SLE) would include information about which
who are giving ventilations through an endotracheal (ET) of the following blood dyscrasias?
tube that they placed in the client’s home. During a pause in Dressler’s syndrome
compressions, the cardiac monitor shows narrow QRS Polycythemia
complexes and a heart rate of beats/minute with a palpable Essential thrombocytopenia
pulse. Which of the following actions Von Willebrand’s disease
should the nurse take first? 43. The nurse is aware that the following symptoms is most
Start an L.V. line and administer amiodarone (Cardarone), commonly an early indication of stage 1 Hodgkin’s disease?
300 mg L.V. over 10 minutes. Pericarditis
Check endotracheal tube placement. Night sweat
Obtain an arterial blood gas (ABG) sample. Splenomegaly
Administer atropine, 1 mg L.V. Persistent hypothermia
36. After cardiac surgery, a client’s blood pressure measures 44. Francis with leukemia has neutropenia. Which of the
126/80 mm Hg. Nurse Katrina determines that mean arterial following functions must frequently assessed?
pressure (MAP) is which of the following? Blood pressure
46 mm Hg Bowel sounds
80 mm Hg Heart sounds
95 mm Hg Breath sounds
90 mm Hg 45. The nurse knows that neurologic complications of
37. A female client arrives at the emergency department with multiple myeloma (MM) usually involve which of the
chest and stomach pain and a report of black tarry stool for following body system?
several months. Which of the following order should the Brain
nurse Oliver anticipate? Muscle spasm
Cardiac monitor, oxygen, creatine kinase and lactate Renal dysfunction
dehydrogenase levels Myocardial irritability
Prothrombin time, partial thromboplastin time, fibrinogen 46. Nurse Patricia is aware that the average length of time
and fibrin split product values. from human immunodeficiency virus (HIV) infection to the
development of acquired immunodeficiency syndrome Notify the physician
(AIDS)? Flush the IV line with saline solution
Less than 5 years Immediately discontinue the infusion
5 to 7 years Apply an ice pack to the site, followed by warm compress.
10 years 54. The term “blue bloater” refers to a male client which of
More than 10 years the following conditions?
47. An 18-year-old male client admitted with heat stroke Adult respiratory distress syndrome (ARDS)
begins to show signs of disseminated intravascular Asthma
coagulation (DIC). Which of the following laboratory findings Chronic obstructive bronchitis
is most consistent with DIC? Emphysema
Low platelet count 55. The term “pink puffer” refers to the female client with
Elevated fibrinogen levels which of the following conditions?
Low levels of fibrin degradation products Adult respiratory distress syndrome (ARDS)
Reduced prothrombin time Asthma
48. Mario comes to the clinic complaining of fever, drenching Chronic obstructive bronchitis
night sweats, and unexplained weight loss over the past 3 Emphysema
months. Physical examination reveals a single enlarged 56. Jose is in danger of respiratory arrest following the
supraclavicular lymph node. Which of the following is the administration of a narcotic analgesic. An arterial blood gas
most probable diagnosis? value is obtained. Nurse Oliver would expect the paco2 to be
Influenza which of the following values?
Sickle cell anemia 15 mm Hg
Leukemia 30 mm Hg
Hodgkin’s disease 40 mm Hg
49. A male client with a gunshot wound requires an 80 mm Hg
emergency blood transfusion. His blood type is AB negative. 57. Timothy’s arterial blood gas (ABG) results are as follows;
Which blood type would be the safest for him to receive? pH 7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L;
AB Rh-positive Sao2 81%. This ABG result represents which of the following
A Rh-positive conditions?
A Rh-negative Metabolic acidosis
O Rh-positive Metabolic alkalosis
Situation: Stacy is diagnosed with acute lymphoid leukemia Respiratory acidosis
(ALL) and beginning chemotherapy. Respirator y alkalosis
50. Stacy is discharged from the hospital following her 58. Norma has started a new drug for hypertension. Thirty
chemotherapy treatments. Which statement of Stacy’s minutes after she takes the drug, she develops chest
mother indicated that she understands when she will contact tightness and becomes short of breath and tachypneic. She
the physician? has a decreased level of consciousness. These signs indicate
“I should contact the physician if Stacy has difficulty in which of the following conditions?
sleeping”. Asthma attack
“I will call my doctor if Stacy has persistent vomiting and Pulmonary embolism
diarrhea”. Respiratory failure
“My physician should be called if Stacy is irritable and Rheumatoid arthritis
unhappy”. Situation: Mr. Gonzales was admitted to the hospital with
“Should Stacy have continued hair loss, I need to call the ascites and jaundice. To rule out cirrhosis of the liver:
doctor”. 59. Which laboratory test indicates liver cirrhosis?
51. Stacy’s mother states to the nurse that it is hard to see Decreased red blood cell count
Stacy with no hair. The best response for the nurse is: Decreased serum acid phosphate level
“Stacy looks very nice wearing a hat”. Elevated white blood cell count
“You should not worry about her hair, just be glad that she is Elevated serum aminotransferase
alive”. 60.The biopsy of Mr. Gonzales confirms the diagnosis of
“Yes it is upsetting. But try to cover up your feelings when cirrhosis. Mr. Gonzales is at increased risk for excessive
you are with her or else she may be upset”. bleeding primarily because of:
“This is only temporary; Stacy will re-grow new hair in 3-6 Impaired clotting mechanism
months, but may be different in texture”. Varix formation
52. Stacy has beginning stomatitis. To promote oral hygiene Inadequate nutrition
and comfort, the nurse in-charge should: Trauma of invasive procedure
Provide frequent mouthwash with normal saline. 61. Mr. Gonzales develops hepatic encephalopathy. Which
Apply viscous Lidocaine to oral ulcers as needed. clinical manifestation is most common with this condition?
Use lemon glycerine swabs every 2 hours. Increased urine output
Rinse mouth with Hydrogen Peroxide. Altered level of consciousness
53. During the administration of chemotherapy agents, Nurse Decreased tendon reflex
Oliver observed that the IV site is red and swollen, when the Hypotension
IV is touched Stacy shouts in pain. The first nursing action to
take is:
62. When Mr. Gonzales regained consciousness, the discharge, he complains of a headache. When offered
physician orders 50 ml of Lactose p.o. every 2 hours. Mr. acetaminophen, his mother tells the nurse the headache is
Gozales develops diarrhea. The nurse best action would be: severe and she would like her son to have something
“I’ll see if your physician is in the hospital”. stronger. Which of the following responses by the nurse is
“Maybe your reacting to the drug; I will withhold the next appropriate?
dose”. “Your son had a mild concussion, acetaminophen is strong
“I’ll lower the dosage as ordered so the drug causes only 2 to enough.”
4 stools a day”. “Aspirin is avoided because of the danger of Reye’s syndrome
“Frequently, bowel movements are needed to reduce sodium in children or young adults.”
level”. “Narcotics are avoided after a head injury because they may
63. Which of the following groups of symptoms indicates a hide a worsening condition.”
ruptured abdominal aortic aneurysm? Stronger medications may lead to vomiting, which increases
Lower back pain, increased blood pressure, decreased re the intracarnial pressure (ICP).”
blood cell (RBC) count, increased white blood (WBC) count. 71. When evaluating an arterial blood gas from a male client
Severe lower back pain, decreased blood pressure, decreased with a subdural hematoma, the nurse notes the Paco2 is 30
RBC count, increased WBC count. mm Hg. Which of the following responses best describes the
Severe lower back pain, decreased blood pressure, decreased result?
RBC count, decreased RBC count, decreased WBC count. Appropriate; lowering carbon dioxide (CO2) reduces
Intermitted lower back pain, decreased blood pressure, intracranial pressure (ICP)
decreased RBC count, increased WBC count. Emergent; the client is poorly oxygenated
64. After undergoing a cardiac catheterization, Tracy has a Normal
large puddle of blood under his buttocks. Which of the Significant; the client has alveolar hypoventilation
following steps should the nurse take first? 72. When prioritizing care, which of the following clients
Call for help. should the nurse Olivia assess first?
Obtain vital signs A 17-year-old clients 24-hours postappendectomy
Ask the client to “lift up” A 33-year-old client with a recent diagnosis of Guillain-Barre
Apply gloves and assess the groin site syndrome
65. Which of the following treatment is a suitable surgical A 50-year-old client 3 days postmyocardial infarction
intervention for a client with unstable angina? A 50-year-old client with diverticulitis
Cardiac catheterization 73. JP has been diagnosed with gout and wants to know why
Echocardiogram colchicine is used in the treatment of gout. Which of the
Nitroglycerin following actions of colchicines explains why it’s effective for
Percutaneous transluminal coronary angioplasty (PTCA) gout?
66. The nurse is aware that the following terms used to Replaces estrogen
describe reduced cardiac output and perfusion impairment Decreases infection
due to ineffective pumping of the heart is: Decreases inflammation
Anaphylactic shock Decreases bone demineralization
Cardiogenic shock 74. Norma asks for information about osteoarthritis. Which
Distributive shock of the following statements about osteoarthritis is correct?
Myocardial infarction (MI) Osteoarthritis is rarely debilitating
67. A client with hypertension ask the nurse which factors Osteoarthritis is a rare form of arthritis
can cause blood pressure to drop to normal levels? Osteoarthritis is the most common form of arthritis
Kidneys’ excretion to sodium only. Osteoarthritis afflicts people over 60
Kidneys’ retention of sodium and water 75. Ruby is receiving thyroid replacement therapy develops
Kidneys’ excretion of sodium and water the flu and forgets to take her thyroid replacement medicine.
Kidneys’ retention of sodium and excretion of water The nurse understands that skipping this medication will put
68. Nurse Rose is aware that the statement that best explains the client at risk for developing which of the following
why furosemide (Lasix) is administered to treat hypertension lifethreatening complications?
is: Exophthalmos
It dilates peripheral blood vessels. Thyroid storm
It decreases sympathetic cardioacceleration. Myxedema coma
It inhibits the angiotensin-coverting enzymes Tibial myxedema
It inhibits reabsorption of sodium and water in the loop of 76. Nurse Sugar is assessing a client with Cushing’s syndrome.
Henle. Which observation should the nurse report to the physician
69. Nurse Nikki knows that laboratory results supports the immediately?
diagnosis of systemic lupus erythematosus (SLE) is: Pitting edema of the legs
Elavated serum complement level An irregular apical pulse
Thrombocytosis, elevated sedimentation rate Dry mucous membranes
Pancytopenia, elevated antinuclear antibody (ANA) titer Frequent urination
Leukocysis, elevated blood urea nitrogen (BUN) and 77. Cyrill with severe head trauma sustained in a car accident
creatinine levels is admitted to the intensive care unit. Thirty-six hours later,
70. Arnold, a 19-year-old client with a mild concussion is the client’s urine output suddenly rises above 200 ml/hour,
discharged from the emergency department. Before leading the nurse to suspect diabetes insipidus. Which
laboratory findings support the nurse’s suspicion of diabetes capillary glucose level of 250 mg/dl for which he receives 8 U
insipidus? of regular insulin. Nurse Mariner should expect the dose’s:
Above-normal urine and serum osmolality levels onset to be at 2 p.m. and its peak to be at 3 p.m.
Below-normal urine and serum osmolality levels onset to be at 2:15 p.m. and its peak to be at 3 p.m.
Above-normal urine osmolality level, below-normal serum onset to be at 2:30 p.m. and its peak to be at 4 p.m.
osmolality level onset to be at 4 p.m. and its peak to be at 6 p.m.
Below-normal urine osmolality level, above-normal serum 84. The physician orders laboratory tests to confirm
osmolality level hyperthyroidism in a female client with classic signs and
78. Jomari is diagnosed with hyperosmolar hyperglycemic symptoms of this disorder. Which test result would confirm
nonketotic syndrome (HHNS) is stabilized and prepared for the diagnosis?
discharge. When preparing the client for discharge and home No increase in the thyroid-stimulating hormone (TSH) level
management, which of the following statements indicates after 30 minutes during the TSH stimulation test
that the client understands her condition and how to control A decreased TSH level
it? An increase in the TSH level after 30 minutes during the TSH
“I can avoid getting sick by not becoming dehydrated and by stimulation test
paying attention to my need to urinate, drink, or eat more Below-normal levels of serum triiodothyronine (T3) and
than usual.” serum thyroxine (T4) as detected by radioimmunoassay
“If I experience trembling, weakness, and headache, I should 85. Rico with diabetes mellitus must learn how to self-
drink a glass of soda that contains sugar.” administer insulin. The physician has prescribed 10 U of U-
“I will have to monitor my blood glucose level closely and 100 regular insulin and 35 U of U-100 isophane insulin
notify the physician if it’s constantly elevated.” suspension (NPH) to be taken before breakfast. When
“If I begin to feel especially hungry and thirsty, I’ll eat a snack teaching the client how to select and rotate insulin injection
high in carbohydrates.” sites, the nurse should provide which instruction?
79. A 66-year-old client has been complaining of sleeping “Inject insulin into healthy tissue with large blood vessels and
more, increased urination, anorexia, weakness, irritability, nerves.”
depression, and bone pain that interferes with her going “Rotate injection sites within the same anatomic region, not
outdoors. Based on these assessment findings, the nurse among different regions.”
would suspect which of the following disorders? “Administer insulin into areas of scar tissue or hypotrophy
Diabetes mellitus whenever possible.”
Diabetes insipidus “Administer insulin into sites above muscles that you plan to
Hypoparathyroidism exercise heavily later that day.”
Hyperparathyroidism 86. Nurse Sarah expects to note an elevated serum glucose
80. Nurse Lourdes is teaching a client recovering from level in a client with hyperosmolar hyperglycemic nonketotic
addisonian crisis about the need to take fludrocortisone syndrome (HHNS). Which other laboratory finding should the
acetate and hydrocortisone at home. Which statement by the nurse anticipate?
client indicates an understanding of the instructions? Elevated serum acetone level
“I’ll take my hydrocortisone in the late afternoon, before Serum ketone bodies
dinner.” Serum alkalosis
“I’ll take all of my hydrocortisone in the morning, right after I Below-normal serum potassium level
wake up.” 87. For a client with Graves’ disease, which nursing
“I’ll take two-thirds of the dose when I wake up and one-third intervention promotes comfort?
in the late afternoon.” Restricting intake of oral fluids
“I’ll take the entire dose at bedtime.” Placing extra blankets on the client’s bed
81. Which of the following laboratory test results would Limiting intake of high-carbohydrate foods
suggest to the nurse Len that a client has a corticotropin- Maintaining room temperature in the low-normal range
secreting pituitary adenoma? 88. Patrick is treated in the emergency department for a
High corticotropin and low cortisol levels Colles’ fracture sustained during a fall. What is a Colles’
Low corticotropin and high cortisol levels fracture?
High corticotropin and high cortisol levels Fracture of the distal radius
Low corticotropin and low cortisol levels Fracture of the olecranon
82. A male client is scheduled for a transsphenoidal Fracture of the humerus
hypophysectomy to remove a pituitary tumor. Fracture of the carpal scaphoid
Preoperatively, the nurse should assess for potential 89. Cleo is diagnosed with osteoporosis. Which electrolytes
complications by doing which of the following? are involved in the development of this disorder?
Testing for ketones in the urine Calcium and sodium
Testing urine specific gravity Calcium and phosphorous
Checking temperature every 4 hours Phosphorous and potassium
Performing capillary glucose testing every 4 hours Potassium and sodium
83. Capillary glucose monitoring is being performed every 4 90. Johnny a firefighter was involved in extinguishing a house
hours for a client diagnosed with diabetic ketoacidosis. fire and is being treated to smoke inhalation. He develops
Insulin is administered using a scale of regular insulin severe hypoxia 48 hours after the incident, requiring
according to glucose results. At 2 p.m., the client has a intubation and mechanical ventilation. He most likely has
developed which of the following conditions?
Adult respiratory distress syndrome (ARDS) 18
Atelectasis 21
Bronchitis 35
Pneumonia 40
91. A 67-year-old client develops acute shortness of breath 99. Mickey, a 6-year-old child with a congenital heart
and progressive hypoxia requiring right femur. The hypoxia disorder is admitted with congestive heart failure. Digoxin
was probably caused by which of the following conditions? (lanoxin) 0.12 mg is ordered for the child. The bottle of
Asthma attack Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What
Atelectasis amount should the nurse administer to the child?
Bronchitis 1.2 ml
Fat embolism 2.4 ml
92. A client with shortness of breath has decreased to absent 3.5 ml
breath sounds on the right side, from the apex to the base. 4.2 ml
Which of the following conditions would best explain this? 100. Nurse Alexandra teaches a client about elastic stockings.
Acute asthma Which of the following statements, if made by the client,
Chronic bronchitis indicates to the nurse that the teaching was successful?
Pneumonia “I will wear the stockings until the physician tells me to
Spontaneous pneumothorax remove them.”
93. A 62-year-old male client was in a motor vehicle accident “I should wear the stockings even when I am sleep.”
as an unrestrained driver. He’s now in the emergency “Every four hours I should remove the stockings for a half
department complaining of difficulty of breathing and chest hour.”
pain. On auscultation of his lung field, no breath sounds are “I should put on the stockings before getting out of bed in the
present in the upper lobe. This client may have which of the morning.”
following conditions?
Bronchitis Answers and Rationales
Pneumonia 1. Answer: (C) Hypertension. Hypertension, along with
Pneumothorax fever, and tenderness over the grafted kidney, reflects
Tuberculosis (TB) acute rejection.
94. If a client requires a pneumonectomy, what fills the area 2. Answer: (A) Pain. Sharp, severe pain (renal colic)
of the thoracic cavity? radiating toward the genitalia and thigh is caused by
The space remains filled with air only uretheral distention and smooth muscle spasm; relief
The surgeon fills the space with a gel form pain is the priority.
Serous fluids fills the space and consolidates the region 3. Answer: (D) Decrease the size and vascularity of the
The tissue from the other lung grows over to the other side thyroid gland. Lugol’s solution provides iodine, which
95. Hemoptysis may be present in the client with a aids in decreasing the vascularity of the thyroid gland,
pulmonary embolism because of which of the following which limits the risk of hemorrhage when surgery is
reasons? performed.
Alveolar damage in the infracted area 4. Answer: (A) Liver Disease. The client with liver disease
Involvement of major blood vessels in the occluded area has a decreased ability to metabolize carbohydrates
Loss of lung parenchyma because of a decreased ability to form glycogen
Loss of lung tissue (glycogenesis) and to form glucose from glycogen.
96. Aldo with a massive pulmonary embolism will have an 5. Answer: (C) Leukopenia. Leukopenia, a reduction in
arterial blood gas analysis performed to determine the extent WBCs, is a systemic effect of chemotherapy as a result
of hypoxia. The acid-base disorder that may be present is? of myelosuppression.
Metabolic acidosis 6. Answer: (C) Avoid foods that in the past caused flatus.
Metabolic alkalosis Foods that bothered a person preoperatively will
Respiratory acidosis continue to do so after a colostomy.
Respiratory alkalosis 7. Answer: (B) Keep the irrigating container less than 18
97. After a motor vehicle accident, Armand an 22-year-old inches above the stoma.” This height permits the
client is admitted with a pneumothorax. The surgeon inserts solution to flow slowly with little force so that
a chest tube and attaches it to a chest drainage system. excessive peristalsis is not immediately precipitated.
Bubbling soon appears in the water seal chamber. Which of 8. Answer: (A) Administer Kayexalate. Kayexalate,a
the following is the most likely cause of the bubbling? potassium exchange resin, permits sodium to be
Air leak exchanged for potassium in the intestine, reducing the
Adequate suction serum potassium level.
Inadequate suction 9. Answer:(B) 28 gtt/min. This is the correct flow rate;
Kinked chest tube multiply the amount to be infused (2000 ml) by the
98. Nurse Michelle calculates the IV flow rate for a drop factor (10) and divide the result by the amount of
postoperative client. The client receives 3,000 ml of Ringer’s time in minutes (12 hours x 60 minutes)
lactate solution IV to run over 24 hours. The IV infusion set 10. Answer: (D) Upper trunk. The percentage designated
has a drop factor of 10 drops per milliliter. The nurse should for each burned part of the body using the rule of
regulate the client’s IV to deliver how many drops per nines: Head and neck 9%; Right upper extremity 9%;
minute? Left upper extremity 9%; Anterior trunk 18%; Posterior
 trunk 18%; Right lower extremity 18%; Left lower 19. Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and
extremity 18%; Perineum 1%. serum creatinine 6.5 mg/dl. The normal BUN level
11. Answer: (C) Bleeding from ears. The nurse needs to ranges 8 to 23 mg/dl; the normal serum creatinine
perform a thorough assessment that could indicate level ranges from 0.7 to 1.5 mg/dl. The test results in
alterations in cerebral function, increased intracranial option C are abnormally elevated, reflecting CRF and
pressures, fractures and bleeding. Bleeding from the the kidneys’ decreased ability to remove nonprotein
ears occurs only with basal skull fractures that can nitrogen waste from the blood. CRF causes decreased
easily contribute to increased intracranial pressure and pH and increased hydrogen ions — not vice versa. CRF
brain herniation. also increases serum levels of potassium, magnesium,
12. Answer: (D) may engage in contact sports. The client and phosphorous, and decreases serum levels of
should be advised by the nurse to avoid contact sports. calcium. A uric acid analysis of 3.5 mg/dl falls within
This will prevent trauma to the area of the pacemaker the normal range of 2.7 to 7.7 mg/dl; PSP excretion of
generator. 75% also falls with the normal range of 60% to 75%.
13. Answer: (A) Oxygen at 1-2L/min is given to maintain 20. Answer: (D) Alteration in the size, shape, and
the hypoxic stimulus for breathing. COPD causes a organization of differentiated cells. Dysplasia refers to
chronic CO2 retention that renders the medulla an alteration in the size, shape, and organization of
insensitive to the CO2 stimulation for breathing. The differentiated cells. The presence of completely
hypoxic state of the client then becomes the stimulus undifferentiated tumor cells that don’t resemble cells
for breathing. Giving the client oxygen in low of the tissues of their origin is called anaplasia. An
concentrations will maintain the client’s hypoxic drive. increase in the number of normal cells in a normal
14. Answer: (B) Facilitate ventilation of the left lung. Since arrangement in a tissue or an organ is called
only a partial pneumonectomy is done, there is a need hyperplasia. Replacement of one type of fully
to promote expansion of this remaining Left lung by differentiated cell by another in tissues where the
positioning the client on the opposite unoperated side. second type normally isn’t found is called metaplasia.
15. Answer: (A) Food and fluids will be withheld for at 21. Answer: (D) Kaposi’s sarcoma. Kaposi’s sarcoma is the
least 2 hours. Prior to bronchoscopy, the doctors most common cancer associated with AIDS. Squamous
sprays the back of the throat with anesthetic to cell carcinoma, multiple myeloma, and leukemia may
minimize the gag reflex and thus facilitate the insertion occur in anyone and aren’t associated specifically with
of the bronchoscope. Giving the client food and drink AIDS.
after the procedure without checking on the return of 22. Answer: (C) To prevent cerebrospinal fluid (CSF)
the gag reflex can cause the client to aspirate. The gag leakage. The client receiving a subarachnoid block
reflex usually returns after two hours. requires special positioning to prevent CSF leakage and
16. Answer: (C) hyperkalemia. Hyperkalemia is a common headache and to ensure proper anesthetic distribution.
complication of acute renal failure. It’s life-threatening Proper positioning doesn’t help prevent confusion,
if immediate action isn’t taken to reverse it. The seizures, or cardiac arrhythmias.
administration of glucose and regular insulin, with 23. Answer: (A) Auscultate bowel sounds. If abdominal
sodium bicarbonate if necessary, can temporarily distention is accompanied by nausea, the nurse must
prevent cardiac arrest by moving potassium into the first auscultate bowel sounds. If bowel sounds are
cells and temporarily reducing serum potassium levels. absent, the nurse should suspect gastric or small
Hypernatremia, hypokalemia, and hypercalcemia don’t intestine dilation and these findings must be reported
usually occur with acute renal failure and aren’t to the physician. Palpation should be avoided
treated with glucose, insulin, or sodium bicarbonate. postoperatively with abdominal distention. If
17. Answer: (A) This condition puts her at a higher risk for peristalsis is absent, changing positions and inserting a
cervical cancer; therefore, she should have a rectal tube won’t relieve the client’s discomfort.
Papanicolaou (Pap) smear annually. Women with 24. Answer: (B) Lying on the left side with knees bent. For
condylomata acuminata are at risk for cancer of the a colonoscopy, the nurse initially should position the
cervix and vulva. Yearly Pap smears are very important client on the left side with knees bent. Placing the
for early detection. Because condylomata acuminata is client on the right side with legs straight, prone with
a virus, there is no permanent cure. Because the torso elevated, or bent over with hands touching
condylomata acuminata can occur on the vulva, a the floor wouldn’t allow proper visualization of the
condom won’t protect sexual partners. HPV can be large intestine.
transmitted to other parts of the body, such as the 25. Answer: (A) Blood supply to the stoma has been
mouth, oropharynx, and larynx. interrupted. An ileostomy stoma forms as the ileum is
18. Answer: (A) The left kidney usually is slightly higher brought through the abdominal wall to the surface
than the right one. The left kidney usually is slightly skin, creating an artificial opening for waste
higher than the right one. An adrenal gland lies atop elimination. The stoma should appear cherry red,
each kidney. The average kidney measures indicating adequate arterial perfusion. A dusky stoma
approximately 11 cm (4-3/8″) long, 5 to 5.8 cm (2″ to suggests decreased perfusion, which may result from
2¼”) wide, and 2.5 cm (1″) thick. The kidneys are interruption of the stoma’s blood supply and may lead
located retroperitoneally, in the posterior aspect of the to tissue damage or necrosis. A dusky stoma isn’t a
abdomen, on either side of the vertebral column. They normal finding. Adjusting the ostomy bag wouldn’t
lie between the 12th thoracic and 3rd lumbar affect stoma color, which depends on blood supply to
vertebrae.
 the area. An intestinal obstruction also wouldn’t 32. Answer: (D) Inotropic agents. Inotropic agents are
change stoma color. administered to increase the force of the heart’s
26. Answer: (A) Applying knee splints. Applying knee contractions, thereby increasing ventricular
splints prevents leg contractures by holding the joints contractility and ultimately increasing cardiac output.
in a position of function. Elevating the foot of the bed Beta-adrenergic blockers and calcium channel blockers
can’t prevent contractures because this action doesn’t decrease the heart rate and ultimately decreased the
hold the joints in a position of function. workload of the heart. Diuretics are administered to
Hyperextending a body part for an extended time is decrease the overall vascular volume, also decreasing
inappropriate because it can cause contractures. the workload of the heart.
Performing shoulder range-of-motion exercises can 33. Answer: (B) Less than 30% of calories form fat. A client
prevent contractures in the shoulders, but not in the with low serum HDL and high serum LDL levels should
legs. get less than 30% of daily calories from fat. The other
27. Answer: (B) Urine output of 20 ml/hour. A urine modifications are appropriate for this client.
output of less than 40 ml/hour in a client with burns 34. Answer: (C) The emergency department nurse calls up
indicates a fluid volume deficit. This client’s PaO2 the latest electrocardiogram results to check the
value falls within the normal range (80 to 100 mm Hg). client’s progress. The emergency department nurse is
White pulmonary secretions also are normal. The no longer directly involved with the client’s care and
client’s rectal temperature isn’t significantly elevated thus has no legal right to information about his present
and probably results from the fluid volume deficit. condition. Anyone directly involved in his care (such as
28. Answer: (A) Turn him frequently. The most important the telemetry nurse and the on-call physician) has the
intervention to prevent pressure ulcers is frequent right to information about his condition. Because the
position changes, which relieve pressure on the skin client requested that the nurse update his wife on his
and underlying tissues. If pressure isn’t relieved, condition, doing so doesn’t breach confidentiality.
capillaries become occluded, reducing circulation and 35. Answer: (B) Check endotracheal tube placement. ET
oxygenation of the tissues and resulting in cell death tube placement should be confirmed as soon as the
and ulcer formation. During passive ROM exercises, client arrives in the emergency department. Once the
the nurse moves each joint through its range of airways is secured, oxygenation and ventilation should
movement, which improves joint mobility and be confirmed using an end-tidal carbon dioxide
circulation to the affected area but doesn’t prevent monitor and pulse oximetry. Next, the nurse should
pressure ulcers. Adequate hydration is necessary to make sure L.V. access is established. If the client
maintain healthy skin and ensure tissue repair. A experiences symptomatic bradycardia, atropine is
footboard prevents plantar flexion and footdrop by administered as ordered 0.5 to 1 mg every 3 to 5
maintaining the foot in a dorsiflexed position. minutes to a total of 3 mg. Then the nurse should try
29. Answer: (C) In long, even, outward, and downward to find the cause of the client’s arrest by obtaining an
strokes in the direction of hair growth. When applying ABG sample. Amiodarone is indicated for ventricular
a topical agent, the nurse should begin at the midline tachycardia, ventricular fibrillation and atrial flutter –
and use long, even, outward, and downward strokes in not symptomatic bradycardia.
the direction of hair growth. This application pattern 36. Answer: (C) 95 mm Hg. Use the following formula to
reduces the risk of follicle irritation and skin calculate MAP
inflammation. MAP = systolic + 2 (diastolic) /3
30. Answer: (A) Beta -adrenergic blockers. Beta-adrenergic MAP=[126 mm Hg + 2 (80 mm Hg) ]/3
blockers work by blocking beta receptors in the MAP=286 mm HG/ 3
myocardium, reducing the response to catecholamines MAP=95 mm Hg
and sympathetic nerve stimulation. They protect the 37. Answer: (C) Electrocardiogram, complete blood count,
myocardium, helping to reduce the risk of another testing for occult blood, comprehensive serum
infraction by decreasing myocardial oxygen demand. metabolic panel. An electrocardiogram evaluates the
Calcium channel blockers reduce the workload of the complaints of chest pain, laboratory tests determines
heart by decreasing the heart rate. Narcotics reduce anemia, and the stool test for occult blood determines
myocardial oxygen demand, promote vasodilation, and blood in the stool. Cardiac monitoring, oxygen, and
decrease anxiety. Nitrates reduce myocardial oxygen creatine kinase and lactate dehydrogenase levels are
consumption bt decreasing left ventricular end appropriate for a cardiac primary problem. A basic
diastolic pressure (preload) and systemic vascular metabolic panel and alkaline phosphatase and
resistance (afterload). aspartate aminotransferase levels assess liver function.
31. Answer: (C) Raised 30 degrees. Jugular venous Prothrombin time, partial thromboplastin time,
pressure is measured with a centimeter ruler to obtain fibrinogen and fibrin split products are measured to
the vertical distance between the sternal angle and the verify bleeding dyscrasias, An electroencephalogram
point of highest pulsation with the head of the bed evaluates brain electrical activity.
inclined between 15 to 30 degrees. Increased pressure 38. Answer: (D) Heparin-associated thrombosis and
can’t be seen when the client is supine or when the thrombocytopenia (HATT). HATT may occur after CABG
head of the bed is raised 10 degrees because the point surgery due to heparin use during surgery. Although
that marks the pressure level is above the jaw DIC and ITP cause platelet aggregation and bleeding,
(therefore, not visible). In high Fowler’s position, the neither is common in a client after revascularization
veins would be barely discernible above the clavicle. surgery. Pancytopenia is a reduction in all blood cells.
39. Answer: (B) Corticosteroids. Corticosteroid therapy can mucous membrane, fatigue, and decreased tolerance
decrease antibody production and phagocytosis of the for exercise; they don’t show fever, night sweats,
antibody-coated platelets, retaining more functioning weight loss or lymph node enlargement. Leukemia
platelets. Methotrexate can cause thrombocytopenia. doesn’t cause lymph node enlargement.
Vitamin K is used to treat an excessive anticoagulate 49. Answer: (C) A Rh-negative. Human blood can
state from warfarin overload, and ASA decreases sometimes contain an inherited D antigen. Persons
platelet aggregation. with the D antigen have Rh-positive blood type; those
40. Answer: (D) Xenogeneic. An xenogeneic transplant is lacking the antigen have Rh-negative blood. It’s
between is between human and another species. A important that a person with Rhnegative blood
syngeneic transplant is between identical twins, receives Rh-negative blood. If Rh-positive blood is
allogeneic transplant is between two humans, and administered to an Rh-negative person, the recipient
autologous is a transplant from the same individual. develops anti-Rh agglutinins, and sub sequent
41. Answer: (B). Tissue thromboplastin is released when transfusions with Rh-positive blood may cause serious
damaged tissue comes in contact with clotting factors. reactions with clumping and hemolysis of red blood
Calcium is released to assist the conversion of factors X cells.
to Xa. Conversion of factors XII to XIIa and VIII to VIII a 50. Answer: (B) “I will call my doctor if Stacy has persistent
are part of the intrinsic pathway. vomiting and diarrhea”. Persistent (more than 24
42. Answer: (C) Essential thrombocytopenia. Essential hours) vomiting, anorexia, and diarrhea are signs of
thrombocytopenia is linked to immunologic disorders, toxicity and the patient should stop the medication
such as SLE and human immunodeficiency vitus. The and notify the health care provider. The other
disorder known as von Willebrand’s disease is a type manifestations are expected side effects of
of hemophilia and isn’t linked to SLE. Moderate to chemotherapy.
severe anemia is associated with SLE, not 51. Answer: (D) “This is only temporary; Stacy will re-grow
polycythermia. Dressler’s syndrome is pericarditis that new hair in 3-6 months, but may be different in
occurs after a myocardial infarction and isn’t linked to texture”. This is the appropriate response. The nurse
SLE. should help the mother how to cope with her own
43. Answer: (B) Night sweat. In stage 1, symptoms include feelings regarding the child’s disease so as not to affect
a single enlarged lymph node (usually), unexplained the child negatively. When the hair grows back, it is
fever, night sweats, malaise, and generalized pruritis. still of the same color and texture.
Although splenomegaly may be present in some 52. Answer: (B) Apply viscous Lidocaine to oral ulcers as
clients, night sweats are generally more prevalent. needed. Stomatitis can cause pain and this can be
Pericarditis isn’t associated with Hodgkin’s disease, nor relieved by applying topical anesthetics such as
is hypothermia. Moreover, splenomegaly and lidocaine before mouth care. When the patient is
pericarditis aren’t symptoms. Persistent hypothermia already comfortable, the nurse can proceed with
is associated with Hodgkin’s but isn’t an early sign of providing the patient with oral rinses of saline solution
the disease. mixed with equal part of water or hydrogen peroxide
44. Answer: (D) Breath sounds. Pneumonia, both viral and mixed water in 1:3 concentrations to promote oral
fungal, is a common cause of death in clients with hygiene. Every 2-4 hours.
neutropenia, so frequent assessment of respiratory 53. Answer: (C) Immediately discontinue the infusion.
rate and breath sounds is required. Although assessing Edema or swelling at the IV site is a sign that the
blood pressure, bowel sounds, and heart sounds is needle has been dislodged and the IV solution is
important, it won’t help detect pneumonia. leaking into the tissues causing the edema. The patient
45. Answer: (B) Muscle spasm. Back pain or paresthesia in feels pain as the nerves are irritated by pressure and
the lower extremities may indicate impending spinal the IV solution. The first action of the nurse would be
cord compression from a spinal tumor. This should be to discontinue the infusion right away to prevent
recognized and treated promptly as progression of the further edema and other complication.
tumor may result in paraplegia. The other options, 54. Answer: (C) Chronic obstructive bronchitis. Clients with
which reflect parts of the nervous system, aren’t chronic obstructive bronchitis appear bloated; they
usually affected by MM. have large barrel chest and peripheral edema, cyanotic
46. Answer: (C)10 years. Epidermiologic studies show the nail beds, and at times, circumoral cyanosis. Clients
average time from initial contact with HIV to the with ARDS are acutely short of breath and frequently
development of AIDS is 10 years. need intubation for mechanical ventilation and large
47. Answer: (A) Low platelet count. In DIC, platelets and amount of oxygen. Clients with asthma don’t exhibit
clotting factors are consumed, resulting in characteristics of chronic disease, and clients with
microthrombi and excessive bleeding. As clots form, emphysema appear pink and cachectic.
fibrinogen levels decrease and the prothrombin time 55. Answer: (D) Emphysema. Because of the large amount
increases. Fibrin degeneration products increase as of energy it takes to breathe, clients with emphysema
fibrinolysis takes places. are usually cachectic. They’re pink and usually breathe
48. Answer: (D) Hodgkin’s disease. Hodgkin’s disease through pursed lips, hence the term “puffer.” Clients
typically causes fever night sweats, weight loss, and with ARDS are usually acutely short of breath. Clients
lymph mode enlargement. Influenza doesn’t last for with asthma don’t have any particular characteristics,
months. Clients with sickle cell anemia manifest signs and clients with chronic obstructive bronchitis are
and symptoms of chronic anemia with pallor of the bloated and cyanotic in appearance.
56. Answer: D 80 mm Hg. A client about to go into groin site is the second priority. This establishes where
respiratory arrest will have inefficient ventilation and the blood is coming from and determineshow much
will be retaining carbon dioxide. The value expected blood has been lost. The goal in this situation is to stop
would be around 80 mm Hg. All other values are lower the bleeding. The nurse would call for help if it were
than expected. warranted after the assessment of the situation. After
57. Answer: (C) Respiratory acidosis. Because Paco2 is high determining the extent of the bleeding, vital signs
at 80 mm Hg and the metabolic measure, HCO3- is assessment is important. The nurse should never move
normal, the client has respiratory acidosis. The pH is the client, in case a clot has formed. Moving can
less than 7.35, academic, which eliminates metabolic disturb the clot and cause rebleeding.
and respiratory alkalosis as possibilities. If the HCO3- 65. Answer: (D) Percutaneous transluminal coronary
was below 22 mEq/L the client would have metabolic angioplasty (PTCA). PTCA can alleviate the blockage
acidosis. and restore blood flow and oxygenation. An
58. Answer: (C) Respiratory failure. The client was reacting echocardiogram is a noninvasive diagnosis test.
to the drug with respiratory signs of impending Nitroglycerin is an oral sublingual medication. Cardiac
anaphylaxis, which could lead to eventually respiratory catheterization is a diagnostic tool – not a treatment.
failure. Although the signs are also related to an 66. Answer: (B) Cardiogenic shock. Cardiogenic shock is
asthma attack or a pulmonary embolism, consider the shock related to ineffective pumping of the heart.
new drug first. Rheumatoid arthritis doesn’t manifest Anaphylactic shock results from an allergic reaction.
these signs. Distributive shock results from changes in the
59. Answer: (D) Elevated serum aminotransferase. Hepatic intravascular volume distribution and is usually
cell death causes release of liver enzymes alanine associated with increased cardiac output. MI isn’t a
aminotransferase (ALT), aspartate aminotransferase shock state, though a severe MI can lead to shock.
(AST) and lactate dehydrogenase (LDH) into the 67. Answer: (C) Kidneys’ excretion of sodium and water.
circulation. Liver cirrhosis is a chronic and irreversible The kidneys respond to rise in blood pressure by
disease of the liver characterized by generalized excreting sodium and excess water. This response
inflammation and fibrosis of the liver tissues. ultimately affects sysmolic blood pressure by
60. Answer: (A) Impaired clotting mechanism. Cirrhosis of regulating blood volume. Sodium or water retention
the liver results in decreased Vitamin K absorption and would only further increase blood pressure. Sodium
formation of clotting factors resulting in impaired and water travel together across the membrane in the
clotting mechanism. kidneys; one can’t travel without the other.
61. Answer: (B) Altered level of consciousness. Changes in 68. Answer: (D) It inhibits reabsorption of sodium and
behavior and level of consciousness are the first sins of water in the loop of Henle. Furosemide is a loop
hepatic encephalopathy. Hepatic encephalopathy is diuretic that inhibits sodium and water reabsorption in
caused by liver failure and develops when the liver is the loop Henle, thereby causing a decrease in blood
unable to convert protein metabolic product ammonia pressure. Vasodilators cause dilation of peripheral
to urea. This results in accumulation of ammonia and blood vessels, directly relaxing vascular smooth muscle
other toxic in the blood that damages the cells. and decreasing blood pressure. Adrenergic blockers
62. Answer: (C) “I’ll lower the dosage as ordered so the decrease sympathetic cardioacceleration and decrease
drug causes only 2 to 4 stools a day”. Lactulose is given blood pressure. Angiotensin-converting enzyme
to a patients with hepatic encephalopathy to reduce inhibitors decrease blood pressure due to their action
absorption of ammonia in the intestines by binding on angiotensin.
with ammonia and promoting more frequent bowel 69. Answer: (C) Pancytopenia, elevated antinuclear
movements. If the patient experience diarrhea, it antibody (ANA) titer. Laboratory findings for clients
indicates over dosage and the nurse must reduce the with SLE usually show pancytopenia, elevated ANA
amount of medication given to the patient. The stool titer, and decreased serum complement levels. Clients
will be mashy or soft. Lactulose is also very sweet and may have elevated BUN and creatinine levels from
may cause cramping and bloating. nephritis, but the increase does not indicate SLE.
63. Answer: (B) Severe lower back pain, decreased blood 70. Answer: (C) Narcotics are avoided after a head injury
pressure, decreased RBC count, increased WBC because they may hide a worsening condition.
count.Severe lower back pain indicates an aneurysm Narcotics may mask changes in the level of
rupture, secondary to pressure being applied within consciousness that indicate increased ICP and
the abdominal cavity. When ruptured occurs, the pain shouldn’t acetaminophen is strong enough ignores the
is constant because it can’t be alleviated until the mother’s question and therefore isn’t appropriate.
aneurysm is repaired. Blood pressure decreases due to Aspirin is contraindicated in conditions that may have
the loss of blood. After the aneurysm ruptures, the bleeding, such as trauma, and for children or young
vasculature is interrupted and blood volume is lost, so adults with viral illnesses due to the danger of Reye’s
blood pressure wouldn’t increase. For the same syndrome. Stronger medications may not necessarily
reason, the RBC count is decreased – not increased. lead to vomiting but will sedate the client, thereby
The WBC count increases as cell migrate to the site of masking changes in his level of consciousness.
injury. 71. Answer: (A) Appropriate; lowering carbon dioxide
64. Answer: (D) Apply gloves and assess the groin site. (CO2) reduces intracranial pressure (ICP). A normal
Observing standard precautions is the first priority Paco2 value is 35 to 45 mm Hg CO2 has vasodilating
when dealing with any blood fluid. Assessment of the properties; therefore, lowering Paco2 through
 hyperventilation will lower ICP caused by dilated monitor blood glucose levels. A highcarbohydrate diet
cerebral vessels. Oxygenation is evaluated through would exacerbate the client’s condition, particularly if
Pao2 and oxygen saturation. Alveolar hypoventilation fluid intake is low.
would be reflected in an increased Paco2. 79. Answer: (D) Hyperparathyroidism.
72. Answer: (B) A 33-year-old client with a recent Hyperparathyroidism is most common in older women
diagnosis of Guillain-Barre syndrome . Guillain-Barre and is characterized by bone pain and weakness from
syndrome is characterized by ascending paralysis and excess parathyroid hormone (PTH). Clients also exhibit
potential respiratory failure. The order of client hypercaliuria-causing polyuria. While clients with
assessment should follow client priorities, with diabetes mellitus and diabetes insipidus also have
disorder of airways, breathing, and then circulation. polyuria, they don’t have bone pain and increased
There’s no information to suggest the postmyocardial sleeping. Hypoparathyroidism is characterized by
infarction client has an arrhythmia or other urinary frequency rather than polyuria.
complication. There’s no evidence to suggest 80. Answer: (C) “I’ll take two-thirds of the dose when I
hemorrhage or perforation for the remaining clients as wake up and one-third in the late afternoon.”
a priority of care. Hydrocortisone, a glucocorticoid, should be
73. Answer: (C) Decreases inflammation. Then action of administered according to a schedule that closely
colchicines is to decrease inflammation by reducing the reflects the body’s own secretion of this hormone;
migration of leukocytes to synovial fluid. Colchicine therefore, two-thirds of the dose of hydrocortisone
doesn’t replace estrogen, decrease infection, or should be taken in the morning and one-third in the
decrease bone demineralization. late afternoon. This dosage schedule reduces adverse
74. Answer: (C) Osteoarthritis is the most common form of effects.
arthritis. Osteoarthritis is the most common form of 81. Answer: (C) High corticotropin and high cortisol levels.
arthritis and can be extremely debilitating. It can afflict A corticotropin-secreting pituitary tumor would cause
people of any age, although most are elderly. high corticotropin and high cortisol levels. A high
75. Answer: (C) Myxedema coma. Myxedema coma, corticotropin level with a low cortisol level and a low
severe hypothyroidism, is a life-threatening condition corticotropin level with a low cortisol level would be
that may develop if thyroid replacement medication associated with hypocortisolism. Low corticotropin and
isn’t taken. Exophthalmos, protrusion of the eyeballs, high cortisol levels would be seen if there was a
is seen with hyperthyroidism. Thyroid storm is life- primary defect in the adrenal glands.
threatening but is caused by severe hyperthyroidism. 82. Answer: (D) Performing capillary glucose testing every
Tibial myxedema, peripheral mucinous edema 4 hours. The nurse should perform capillary glucose
involving the lower leg, is associated with testing every 4 hours because excess cortisol may
hypothyroidism but isn’t life-threatening. cause insulin resistance, placing the client at risk for
76. Answer: (B) An irregular apical pulse. Because hyperglycemia. Urine ketone testing isn’t indicated
Cushing’s syndrome causes aldosterone because the client does secrete insulin and, therefore,
overproduction, which increases urinary potassium isn’t at risk for ketosis. Urine specific gravity isn’t
loss, the disorder may lead to hypokalemia. Therefore, indicated because although fluid balance can be
the nurse should immediately report signs and compromised, it usually isn’t dangerously imbalanced.
symptoms of hypokalemia, such as an irregular apical Temperature regulation may be affected by excess
pulse, to the physician. Edema is an expected finding cortisol and isn’t an accurate indicator of infection.
because aldosterone overproduction causes sodium 83. Answer: (C) onset to be at 2:30 p.m. and its peak to be
and fluid retention. Dry mucous membranes and at 4 p.m.. Regular insulin, which is a short-acting
frequent urination signal dehydration, which isn’t insulin, has an onset of 15 to 30 minutes and a peak of
associated with Cushing’s syndrome. 2 to 4 hours. Because the nurse gave the insulin at 2
77. Answer: (D) Below-normal urine osmolality level, p.m., the expected onset would be from 2:15 p.m. to
above-normal serum osmolality level. In diabetes 2:30 p.m. and the peak from 4 p.m. to 6 p.m.
insipidus, excessive polyuria causes dilute urine, 84. Answer: (A) No increase in the thyroid-stimulating
resulting in a below-normal urine osmolality level. At hormone (TSH) level after 30 minutes during the TSH
the same time, polyuria depletes the body of water, stimulation test. In the TSH test, failure of the TSH
causing dehydration that leads to an above-normal level to rise after 30 minutes confirms
serum osmolality level. For the same reasons, diabetes hyperthyroidism. A decreased TSH level indicates a
insipidus doesn’t cause above-normal urine osmolality pituitary deficiency of this hormone. Below-normal
or below-normal serum osmolality levels. levels of T3 and T4, as detected by radioimmunoassay,
78. Answer: (A) “I can avoid getting sick by not becoming signal hypothyroidism. A below-normal T4 level also
dehydrated and by paying attention to my need to occurs in malnutrition and liver disease and may result
urinate, drink, or eat more than usual.” Inadequate from administration of phenytoin and certain other
fluid intake during hyperglycemic episodes often leads drugs.
to HHNS. By recognizing the signs of hyperglycemia 85. Answer: (B) “Rotate injection sites within the same
(polyuria, polydipsia, and polyphagia) and increasing anatomic region, not among different regions.” The
fluid intake, the client may prevent HHNS. Drinking a nurse should instruct the client to rotate injection sites
glass of nondiet soda would be appropriate for within the same anatomic region. Rotating sites among
hypoglycemia. A client whose diabetes is controlled different regions may cause excessive day-to-day
with oral antidiabetic agents usually doesn’t need to variations in the blood glucose level; also, insulin
 absorption differs from one region to the next. Insulin 93. Answer: (C) Pneumothorax. From the trauma the client
should be injected only into healthy tissue lacking experienced, it’s unlikely he has bronchitis,
large blood vessels, nerves, or scar tissue or other pneumonia, or TB; rhonchi with bronchitis, bronchial
deviations. Injecting insulin into areas of hypertrophy breath sounds with TB would be heard.
may delay absorption. The client shouldn’t inject 94. Answer: (C) Serous fluids fills the space and
insulin into areas of lipodystrophy (such as consolidates the region. Serous fluid fills the space and
hypertrophy or atrophy); to prevent lipodystrophy, the eventually consolidates, preventing extensive
client should rotate injection sites systematically. mediastinal shift of the heart and remaining lung. Air
Exercise speeds drug absorption, so the client can’t be left in the space. There’s no gel that can be
shouldn’t inject insulin into sites above muscles that placed in the pleural space. The tissue from the other
will be exercised heavily. lung can’t cross the mediastinum, although a
86. Answer: (D) Below-normal serum potassium level. A temporary mediastinal shift exits until the space is
client with HHNS has an overall body deficit of filled.
potassium resulting from diuresis, which occurs 95. Answer: (A) Alveolar damage in the infracted area. The
secondary to the hyperosmolar, hyperglycemic state infracted area produces alveolar damage that can lead
caused by the relative insulin deficiency. An elevated to the production of bloody sputum, sometimes in
serum acetone level and serum ketone bodies are massive amounts. Clot formation usually occurs in the
characteristic of diabetic ketoacidosis. Metabolic legs. There’s a loss of lung parenchyma and
acidosis, not serum alkalosis, may occur in HHNS. subsequent scar tissue formation.
87. Answer: (D) Maintaining room temperature in the low- 96. Answer: (D) Respiratory alkalosis. A client with massive
normal range. Graves’ disease causes signs and pulmonary embolism will have a large region and blow
symptoms of hypermetabolism, such as heat off large amount of carbon dioxide, which crosses the
intolerance, diaphoresis, excessive thirst and appetite, unaffected alveolar-capillary membrane more readily
and weight loss. To reduce heat intolerance and than does oxygen and results in respiratory alkalosis.
diaphoresis, the nurse should keep the client’s room 97. Answer: (A) Air leak. Bubbling in the water seal
temperature in the low-normal range. To replace fluids chamber of a chest drainage system stems from an air
lost via diaphoresis, the nurse should encourage, not leak. In pneumothorax an air leak can occur as air is
restrict, intake of oral fluids. Placing extra blankets on pulled from the pleural space. Bubbling doesn’t
the bed of a client with heat intolerance would cause normally occur with either adequate or inadequate
discomfort. To provide needed energy and calories, the suction or any preexisting bubbling in the water seal
nurse should encourage the client to eat high- chamber.
carbohydrate foods. 98. Answer: (B) 21. 3000 x 10 divided by 24 x 60.
88. Answer: (A) Fracture of the distal radius. Colles’ 99. Answer: (B) 2.4 ml. .05 mg/ 1 ml = .12mg/ x ml, .05x
fracture is a fracture of the distal radius, such as from a = .12, x = 2.4 ml.
fall on an outstretched hand. It’s most common in 100. Answer: (D) “I should put on the stockings before
women. Colles’ fracture doesn’t refer to a fracture of getting out of bed in the morning. Promote venous
the olecranon, humerus, or carpal scaphoid. return by applying external pressure on veins.
89. Answer: (B) Calcium and phosphorous. In osteoporosis,
bones lose calcium and phosphate salts, becoming PNLE V for Care of Clients with Physiologic and Psychosocial
porous, brittle, and abnormally vulnerable to fracture. Alterations (Part 3)
Sodium and potassium aren’t involved in the 1. Mr. Marquez reports of losing his job, not being able to
development of osteoporosis. sleep at night, and feeling upset with his wife. Nurse John
90. Answer: (A) Adult respiratory distress syndrome responds to the client, “You may want to talk about your
(ARDS). Severe hypoxia after smoke inhalation is employment situation in group today.” The Nurse is using
typically related to ARDS. The other conditions listed which therapeutic technique?
aren’t typically associated with smoke inhalation and
severe hypoxia. Observations
91. Answer: (D) Fat embolism. Long bone fractures are Restating
correlated with fat emboli, whichcause shortness of Exploring
breath and hypoxia. It’s unlikely the client has Focusing
developed asthma or bronchitis without a previous 2. Tony refuses his evening dose of Haloperidol (Haldol), then
history. He could develop atelectasis but it typically becomes extremely agitated in the dayroom while other
doesn’t produce progressive hypoxia. clients are watching television. He begins cursing and
92. Answer: (D) Spontaneous pneumothorax. A throwing furniture. Nurse Oliver first action is to:
spontaneous pneumothorax occurs when the client’s
lung collapses, causing an acute decreased in the Check the client’s medical record for an order for an as-
amount of functional lung used in oxygenation. The needed I.M. dose of medication for agitation.
sudden collapse was the cause of his chest pain and Place the client in full leather restraints.
shortness of breath. An asthma attack would show Call the attending physician and report the behavior.
wheezing breath sounds, and bronchitis would have Remove all other clients from the dayroom.
rhonchi. Pneumonia would have bronchial breath 3. Tina who is manic, but not yet on medication, comes to the
sounds over the area of consolidation. drug treatment center. The nurse would not let this client
join the group session because:
 10.What parental behavior toward a child during an
The client is disruptive. admission procedure should cause Nurse Ron to suspect child
The client is harmful to self. abuse?
The client is harmful to others.
The client needs to be on medication first. Flat affect
4. Dervid, an adolescent boy was admitted for substance Expressing guilt
abuse and hallucinations. The client’s mother asks Nurse Acting overly solicitous toward the child.
Armando to talk with his husband when he arrives at the Ignoring the child.
hospital. The mother says that she is afraid of what the father 11.Nurse Lynnette notices that a female client with
might say to the boy. The most appropriate nursing obsessive-compulsive disorder washes her hands for long
intervention would be to: periods each day. How should the nurse respond to this
compulsive behavior?
Inform the mother that she and the father can work through
this problem themselves. By designating times during which the client can focus on the
Refer the mother to the hospital social worker. behavior.
Agree to talk with the mother and the father together. By urging the client to reduce the frequency of the behavior
Suggest that the father and son work things out. as rapidly as possible.
5. What is Nurse John likely to note in a male client being By calling attention to or attempting to prevent the behavior.
admitted for alcohol withdrawal? By discouraging the client from verbalizing anxieties.
12.After seeking help at an outpatient mental health clinic,
Perceptual disorders. Ruby who was raped while walking her dog is diagnosed with
Impending coma. posttraumatic stress disorder (PTSD). Three months later,
Recent alcohol intake. Ruby returns to the clinic, complaining of fear, loss of control,
Depression with mutism. and helpless feelings. Which nursing intervention is most
6. Aira has taken amitriptyline HCL (Elavil) for 3 days, but now appropriate for Ruby?
complains that it “doesn’t help” and refuses to take it. What
should the nurse say or do? Recommending a high-protein, low-fat diet.
Giving sleep medication, as prescribed, to restore a normal
Withhold the drug. sleepwake cycle.
Record the client’s response. Allowing the client time to heal.
Encourage the client to tell the doctor. Exploring the meaning of the traumatic event with the client.
Suggest that it takes awhile before seeing the results. 13.Meryl, age 19, is highly dependent on her parents and
7. Dervid, an adolescent has a history of truancy from school, fears leaving home to go away to college. Shortly before the
running away from home and “barrowing” other people’s semester starts, she complains that her legs are paralyzed
things without their permission. The adolescent denies and is rushed to the emergency department. When physical
stealing, rationalizing instead that as long as no one was examination rules out a physical cause for her paralysis, the
using the items, it was all right to borrow them. It is physician admits her to the psychiatric unit where she is
important for the nurse to understand the diagnosed with conversion disorder. Meryl asks the nurse,
psychodynamically, this behavior may be largely attributed to “Why has this happened to me?” What is the nurse’s best
a developmental defect related to the: response?

Id “You’ve developed this paralysis so you can stay with your

Ego parents. You must deal with this conflict if you want to walk
Superego again.”
Oedipal complex “It must be awful not to be able to move your legs. You may
8. In preparing a female client for electroconvulsive therapy feel better if you realize the problem is psychological, not
(ECT), Nurse Michelle knows that succinylcoline (Anectine) physical.”
will be administered for which therapeutic effect? “Your problem is real but there is no physical basis for it.
We’ll work on what is going on in your life to find out why it’s
Short-acting anesthesia happened.”
Decreased oral and respiratory secretions. “It isn’t uncommon for someone with your personality to
Skeletal muscle paralysis. develop a conversion disorder during times of stress.”
Analgesia. 14.Nurse Krina knows that the following drugs have been
9. Nurse Gina is aware that the dietary implications for a known to be effective in treating obsessive-compulsive
client in manic phase of bipolar disorder is: disorder (OCD):

Serve the client a bowl of soup, buttered French bread, and benztropine (Cogentin) and diphenhydramine (Benadryl).
apple slices. chlordiazepoxide (Librium) and diazepam (Valium)
Increase calories, decrease fat, and decrease protein. fluvoxamine (Luvox) and clomipramine (Anafranil)
Give the client pieces of cut-up steak, carrots, and an apple. divalproex (Depakote) and lithium (Lithobid)
Increase calories, carbohydrates, and protein. 15.Alfred was newly diagnosed with anxiety disorder. The
physician prescribed buspirone (BuSpar). The nurse is aware
that the teaching instructions for newly prescribed buspirone d. A low tolerance for frustration
should include which of the following? 22.Nurse Amy is providing care for a male client undergoing
opiate withdrawal. Opiate withdrawal causes severe physical
A warning about the drugs delayed therapeutic effect, which discomfort and can be life-threatening. To minimize these
is from 14 to 30 days. effects, opiate users are commonly detoxified with:
A warning about the incidence of neuroleptic malignant
syndrome (NMS). Barbiturates
A reminder of the need to schedule blood work in 1 week to Amphetamines
check blood levels of the drug. Methadone
A warning that immediate sedation can occur with a resultant Benzodiazepines
drop in pulse. 23.Nurse Cristina is caring for a client who experiences false
16.Richard with agoraphobia has been symptom-free for 4 sensory perceptions with no basis in reality. These
months. Classic signs and symptoms of phobias include: perceptions are known as:

Insomnia and an inability to concentrate. Delusions

Severe anxiety and fear. Hallucinations
Depression and weight loss. Loose associations
Withdrawal and failure to distinguish reality from fantasy. Neologisms
17.Which medications have been found to help reduce or 24. Nurse Marco is developing a plan of care for a client with
eliminate panic attacks? anorexia nervosa. Which action should the nurse include in
the plan?
Antidepressants
Anticholinergics Restricts visits with the family and friends until the client
Antipsychotics begins to eat.
Mood stabilizers Provide privacy during meals.
18.A client seeks care because she feels depressed and has Set up a strict eating plan for the client.
gained weight. To treat her atypical depression, the physician Encourage the client to exercise, which will reduce her
prescribes tranylcypromine sulfate (Parnate), 10 mg by anxiety.
mouth twice per day. When this drug is used to treat atypical 25.Tim is admitted with a diagnosis of delusions of grandeur.
depression, what is its onset of action? The nurse is aware that this diagnosis reflects a belief that
one is:
1 to 2 days
3 to 5 days Highly important or famous.
6 to 8 days Being persecuted
10 to 14 days Connected to events unrelated to oneself
19. A 65 years old client is in the first stage of Alzheimer’s Responsible for the evil in the world.
disease. Nurse Patricia should plan to focus this client’s care 26.Nurse Jen is caring for a male client with manic
on: depression. The plan of care for a client in a manic state
would include:
Offering nourishing finger foods to help maintain the client’s
nutritional status. Offering a high-calorie meals and strongly encouraging the
Providing emotional support and individual counseling. client to finish all food.
Monitoring the client to prevent minor illnesses from turning Insisting that the client remain active through the day so that
into major problems. he’ll sleep at night.
Suggesting new activities for the client and family to do Allowing the client to exhibit hyperactive, demanding,
together. manipulative behavior without setting limits.
20.The nurse is assessing a client who has just been admitted Listening attentively with a neutral attitude and avoiding
to the emergency department. Which signs would suggest an power struggles.
overdose of an antianxiety agent? 27.Ramon is admitted for detoxification after a cocaine
overdose. The client tells the nurse that he frequently uses
Combativeness, sweating, and confusion cocaine but that he can control his use if he chooses. Which
Agitation, hyperactivity, and grandiose ideation coping mechanism is he using?
Emotional lability, euphoria, and impaired memory
Suspiciousness, dilated pupils, and increased blood pressure Withdrawal
21.The nurse is caring for a client diagnosed with antisocial Logical thinking
personality disorder. The client has a history of fighting, Repression
cruelty to animals, and stealing. Which of the following traits Denial
would the nurse be most likely to uncover during 28.Richard is admitted with a diagnosis of schizotypal
assessment? personality disorder. Which signs would this client exhibit
during social situations?
History of gainful employment
Frequent expression of guilt regarding antisocial behavior Aggressive behavior
Demonstrated ability to maintain close, stable relationships Paranoid thoughts
Emotional affect 36.Jen a nursing student is anxious about the upcoming
Independence needs board examination but is able to study intently and does not
29. Nurse Mickey is caring for a client diagnosed with bulimia. become distracted by a roommate’s talking and loud music.
The most appropriate initial goal for a client diagnosed with The student’s ability to ignore distractions and to focus on
bulimia is to: studying demonstrates:

Avoid shopping for large amounts of food. Mild-level anxiety

Control eating impulses. Panic-level anxiety
Identify anxiety-causing situations Severe-level anxiety
Eat only three meals per day. Moderate-level anxiety
30.Rudolf is admitted for an overdose of amphetamines. 37.When assessing a premorbid personality characteristics of
When assessing the client, the nurse should expect to see: a client with a major depression, it would be unusual for the
nurse to find that this client demonstrated:
Tension and irritability
Slow pulse Rigidity
Hypotension Stubbornness
Constipation Diverse interest
31.Nicolas is experiencing hallucinations tells the nurse, “The Over meticulousness
voices are telling me I’m no good.” The client asks if the nurse 38.Nurse Krina recognizes that the suicidal risk for depressed
hears the voices. The most appropriate response by the client is greatest:
nurse would be:
As their depression begins to improve
“It is the voice of your conscience, which only you can When their depression is most severe
control.” Before nay type of treatment is started
“No, I do not hear your voices, but I believe you can hear As they lose interest in the environment
them”. 39.Nurse Kate would expect that a client with vascular
“The voices are coming from within you and only you can dementis would experience:
hear them.”
“Oh, the voices are a symptom of your illness; don’t pay any Loss of remote memory related to anoxia
attention to them.” Loss of abstract thinking related to emotional state
32.The nurse is aware that the side effect of Inability to concentrate related to decreased stimuli
electroconvulsive therapy that a client may experience: Disturbance in recalling recent events related to cerebral
hypoxia.
Loss of appetite 40.Josefina is to be discharged on a regimen of lithium
Postural hypotension carbonate. In the teaching plan for discharge the nurse
Confusion for a time after treatment should include:
Complete loss of memory for a time
33.A dying male client gradually moves toward resolution of Advising the client to watch the diet carefully
feelings regarding impending death. Basing care on the Suggesting that the client take the pills with milk
theory of Kubler-Ross, Nurse Trish plans to use nonverbal Reminding the client that a CBC must be done once a month.
interventions when assessment reveals that the client is in Encouraging the client to have blood levels checked as
the: ordered.
41.The psychiatrist orders lithium carbonate 600 mg p.o t.i.d
Anger stage for a female client. Nurse Katrina would be aware that the
Denial stage teaching about the side effects of this drug were understood
Bargaining stage when the client state, “I will call my doctor immediately if I
Acceptance stage notice any:
34.The outcome that is unrelated to a crisis state is:
Sensitivity to bright light or sun
Learning more constructive coping skills Fine hand tremors or slurred speech
Decompensation to a lower level of functioning. Sexual dysfunction or breast enlargement
Adaptation and a return to a prior level of functioning. d. Inability to urinate or difficulty when urinating
A higher level of anxiety continuing for more than 3 months. 42.Nurse Mylene recognizes that the most important factor
35.Miranda a psychiatric client is to be discharged with necessary for the establishment of trust in a critical care area
orders for haloperidol (haldol) therapy. When developing a is:
teaching plan for discharge, the nurse should include
cautioning the client against: Privacy
Respect
Driving at night Empathy
Staying in the sun Presence
Ingesting wines and cheeses 43.When establishing an initial nurse-client relationship,
Taking medications containing aspirin Nurse Hazel should explore with the client the:
Client’s perception of the presenting problem. Dystonia.
Occurrence of fantasies the client may experience. Neuroleptic malignant syndrome.
Details of any ritualistic acts carried out by the client Akathisia.
Client’s feelings when external; controls are instituted. 51.Which nursing intervention would be most appropriate if
44.Tranylcypromine sulfate (Parnate) is prescribed for a a male client develop orthostatic hypotension while taking
depressed client who has not responded to the tricyclic amitriptyline (Elavil)?
antidepressants. After teaching the client about the
medication, Nurse Marian evaluates that learning has Consulting with the physician about substituting a different
occurred when the client states, “I will avoid: type of antidepressant.
Advising the client to sit up for 1 minute before getting out of
Citrus fruit, tuna, and yellow vegetables.” bed.
Chocolate milk, aged cheese, and yogurt’” Instructing the client to double the dosage until the problem
Green leafy vegetables, chicken, and milk.” resolves.
Whole grains, red meats, and carbonated soda.” Informing the client that this adverse reaction should
45.Nurse John is a aware that most crisis situations should disappear within 1 week.
resolve in about: 52.Mr. Cruz visits the physician’s office to seek treatment for
depression, feelings of hopelessness, poor appetite,
1 to 2 weeks insomnia, fatigue, low selfesteem, poor concentration, and
4 to 6 weeks difficulty making decisions. The client states that these
4 to 6 months symptoms began at least 2 years ago. Based on this report,
6 to 12 months the nurse Tyfany suspects:
46. Nurse Judy knows that statistics show that in adolescent
suicide behavior: Cyclothymic disorder.
Atypical affective disorder.
Females use more dramatic methods than males Major depression.
Males account for more attempts than do females Dysthymic disorder.
Females talk more about suicide before attempting it 53. After taking an overdose of phenobarbital (Barbita),
Males are more likely to use lethal methods than are females Mario is admitted to the emergency department. Dr. Trinidad
47. Dervid with paranoid schizophrenia repeatedly uses prescribes activated charcoal (Charcocaps) to be
profanity during an activity therapy session. Which response administered by mouth immediately. Before administering
by the nurse would be most appropriate? the dose, the nurse verifies the dosage ordered. What is the
usual minimum dose of activated charcoal?
“Your behavior won’t be tolerated. Go to your room
immediately.” 5 g mixed in 250 ml of water
“You’re just doing this to get back at me for making you come 15 g mixed in 500 ml of water
to therapy.” 30 g mixed in 250 ml of water
“Your cursing is interrupting the activity. Take time out in 60 g mixed in 500 ml of water
your room for 10 minutes.” 54.What herbal medication for depression, widely used in
“I’m disappointed in you. You can’t control yourself even for Europe, is now being prescribed in the United States?
a few minutes.”
48.Nurse Maureen knows that the nonantipsychotic Ginkgo biloba
medication used to treat some clients with schizoaffective Echinacea
disorder is: St. John’s wort
Ephedra
phenelzine (Nardil) 55.Cely with manic episodes is taking lithium. Which
chlordiazepoxide (Librium) electrolyte level should the nurse check before administering
lithium carbonate (Lithane) this medication?
imipramine (Tofranil)
49.Which information is most important for the nurse Trinity Calcium
to include in a teaching plan for a male schizophrenic client Sodium
taking clozapine (Clozaril)? Chloride
Potassium
Monthly blood tests will be necessary. 56.Nurse Josefina is caring for a client who has been
Report a sore throat or fever to the physician immediately. diagnosed with delirium. Which statement about delirium is
Blood pressure must be monitored for hypertension. true?
Stop the medication when symptoms subside.
50.Ricky with chronic schizophrenia takes neuroleptic It’s characterized by an acute onset and lasts about 1 month.
medication is admitted to the psychiatric unit. Nursing It’s characterized by a slowly evolving onset and lasts about 1
assessment reveals rigidity, fever, hypertension, and week.
diaphoresis. These findings suggest which lifethreatening It’s characterized by a slowly evolving onset and lasts about 1
reaction: month.
It’s characterized by an acute onset and lasts hours to a
Tardive dyskinesia. number of days.
57.Edward, a 66 year old client with slight memory Abnormal breathing through the nostrils accompanied by a
impairment and poor concentration is diagnosed with “thrill.”
primary degenerative dementia of the Alzheimer’s type. Early Severe headache, flushing, tremors, and ataxia.
signs of this dementia include subtle personality changes and Severe hypertension, migraine headache,
withdrawal from social interactions. To assess for progression 63.Dennis has a lithium level of 2.4 mEq/L. The nurse
to the middle stage of Alzheimer’s disease, the nurse should immediately would assess the client for which of the
observe the client for: following signs or symptoms?

Occasional irritable outbursts. Weakness

Impaired communication. Diarrhea
Lack of spontaneity. Blurred vision
Inability to perform self-care activities. Fecal incontinence
58.Isabel with a diagnosis of depression is started on 64.Nurse Jannah is monitoring a male client who has been
imipramine (Tofranil), 75 mg by mouth at bedtime. The nurse placed inrestraints because of violent behavior. Nurse
should tell the client that: determines that it will be safe to remove the restraints when:

This medication may be habit forming and will be The client verbalizes the reasons for the violent behavior.
discontinued as soon as the client feels better. The client apologizes and tells the nurse that it will never
This medication has no serious adverse effects. happen again.
The client should avoid eating such foods as aged cheeses, No acts of aggression have been observed within 1 hour after
yogurt, and chicken livers while taking the medication. the release of two of the extremity restraints.
This medication may initially cause tiredness, which should The administered medication has taken effect.
become less bothersome over time. 65.Nurse Irish is aware that Ritalin is the drug of choice for a
59.Kathleen is admitted to the psychiatric clinic for treatment child with ADHD. The side effects of the following may be
of anorexia nervosa. To promote the client’s physical health, noted by the nurse:
the nurse should plan to:
Increased attention span and concentration
Severely restrict the client’s physical activities. Increase in appetite
Weigh the client daily, after the evening meal. Sleepiness and lethargy
Monitor vital signs, serum electrolyte levels, and acid-base Bradycardia and diarrhea
balance. 66.Kitty, a 9 year old child has very limited vocabulary and
Instruct the client to keep an accurate record of food and interaction skills. She has an I.Q. of 45. She is diagnosed to
fluid intake. have Mental retardation of this classification:
60.Celia with a history of polysubstance abuse is admitted to
the facility. She complains of nausea and vomiting 24 hours Profound
after admission. The nurse assesses the client and notes Mild
piloerection, pupillary dilation, and lacrimation. The nurse Moderate
suspects that the client is going through which of the Severe
following withdrawals? 67.The therapeutic approach in the care of Armand an
autistic child include the following EXCEPT:
Alcohol withdrawal
Cannibis withdrawal Engage in diversionary activities when acting -out
Cocaine withdrawal Provide an atmosphere of acceptance
Opioid withdrawal Provide safety measures
61.Mr. Garcia, an attorney who throws books and furniture Rearrange the environment to activate the child
around the office after losing a case is referred to the 68.Jeremy is brought to the emergency room by friends who
psychiatric nurse in the law firm’s employee assistance state that he took something an hour ago. He is actively
program. Nurse Beatriz knows that the client’s behavior most hallucinating, agitated, with irritated nasal septum.
likely represents the use of which defense mechanism?
Heroin
Regression Cocaine
Projection LSD
Reaction-formation Marijuana
Intellectualization 69.Nurse Pauline is aware that Dementia unlike delirium is
62.Nurse Anne is caring for a client who has been treated characterized by:
long term with antipsychotic medication. During the
assessment, Nurse Anne checks the client for tardive Slurred speech
dyskinesia. If tardive dyskinesia is present, Nurse Anne would Insidious onset
most likely observe: Clouding of consciousness
Sensory perceptual change
Abnormal movements and involuntary movements of the 70.A 35 year old female has intense fear of riding an elevator.
mouth, tongue, and face. She claims “ As if I will die inside.” The client is suffering from:
Agoraphobia 78.An 83year-old male client is in extended care facility is
Social phobia anxious most of the time and frequently complains of a
Claustrophobia number of vague symptoms that interfere with his ability to
Xenophobia eat. These symptoms indicate which of the following
71.Nurse Myrna develops a counter-transference reaction. disorders?
This is evidenced by:
Conversion disorder
Revealing personal information to the client Hypochondriasis
Focusing on the feelings of the client. Severe anxiety
Confronting the client about discrepancies in verbal or non- Sublimation
verbal behavior 79. Charina, a college student who frequently visited the
The client feels angry towards the nurse who resembles his health center during the past year with multiple vague
mother. complaints of GI symptoms before course examinations.
72.Tristan is on Lithium has suffered from diarrhea and Although physical causes have been eliminated, the student
vomiting. What should the nurse in-charge do first: continues to express her belief that she has a serious illness.
These symptoms are typically of which of the following
Recognize this as a drug interaction disorders?
Give the client Cogentin
Reassure the client that these are common side effects of Conversion disorder
lithium therapy Depersonalization
Hold the next dose and obtain an order for a stat serum Hypochondriasis
lithium level Somatization disorder
73.Nurse Sarah ensures a therapeutic environment for all the 80. Nurse Daisy is aware that the following pharmacologic
client. Which of the following best describes a therapeutic agents are sedative hypnotic medication is used to induce
milieu? sleep for a client experiencing a sleep disorder is:

A therapy that rewards adaptive behavior Triazolam (Halcion)

A cognitive approach to change behavior Paroxetine (Paxil)\
A living, learning or working environment. Fluoxetine (Prozac)
A permissive and congenial environment Risperidone (Risperdal)
74.Anthony is very hostile toward one of the staff for no 81. Aldo, with a somatoform pain disorder may obtain
apparent reason. He is manifesting: secondary gain. Which of the following statement refers to a
secondary gain?
Splitting
Transference It brings some stability to the family
Countertransference It decreases the preoccupation with the physical illness
Resistance It enables the client to avoid some unpleasant activity
75.Marielle, 17 years old was sexually attacked while on her It promotes emotional support or attention for the client
way home from school. She is brought to the hospital by her 82. Dervid is diagnosed with panic disorder with agoraphobia
mother. Rape is an example of which type of crisis: is talking with the nurse in-charge about the progress made
in treatment. Which of the following statements indicates a
Situational positive client response?
Adventitious
Developmental “I went to the mall with my friends last Saturday”
Internal “I’m hyperventilating only when I have a panic attack”
76. Nurse Greta is aware that the following is classified as an “Today I decided that I can stop taking my medication”
Axis I disorder by the Diagnosis and Statistical Manual of “Last night I decided to eat more than a bowl of cereal”
Mental Disorders, Text Revision (DSM-IV-TR) is: 83. The effectiveness of monoamine oxidase (MAO) inhibitor
drug therapy in client with posttraumatic stress disorder can
Obesity be demonstrated by which of the following client self –
Borderline personality disorder reports?
Major depression
Hypertension “I’m sleeping better and don’t have nightmares”
77.Katrina, a newly admitted is extremely hostile toward a “I’m not losing my temper as much”
staff member she has just met, without apparent reason. “I’ve lost my craving for alcohol”
According to Freudian theory, the nurse should suspect that “I’ve lost my phobia for water”
the client is experiencing which of the following phenomena? 84. Mark, with a diagnosis of generalized anxiety disorder
wants to stop taking his lorazepam (Ativan). Which of the
Intellectualization following important facts should nurse Betty discuss with the
Transference client about discontinuing the medication?
Triangulation
Splitting Stopping the drug may cause depression
Stopping the drug increases cognitive abilities
Stopping the drug decreases sleeping difficulties
Stopping the drug can cause withdrawal symptoms Flight of ideas
85. Jennifer, an adolescent who is depressed and reported by Concrete thinking
his parents as having difficulty in school is brought to the Ideas of reference
community mental health center to be evaluated. Which of Loose association
the following other health problems would the nurse 92. Francis tells the nurse that her coworkers are sabotaging
suspect? the computer. When the nurse asks questions, the client
becomes argumentative. This behavior shows personality
Anxiety disorder traits associated with which of the following personality
Behavioral difficulties disorder?
Cognitive impairment
Labile moods Antisocial
86. Ricardo, an outpatient in psychiatric facility is diagnosed Histrionic
with dysthymic disorder. Which of the following statement Paranoid
about dysthymic disorder is true? Schizotypal
93. Which of the following interventions is important for a
It involves a mood range from moderate depression to Cely experiencing with paranoid personality disorder taking
hypomania olanzapine (Zyprexa)?
It involves a single manic depression
It’s a form of depression that occurs in the fall and winter Explain effects of serotonin syndrome
It’s a mood disorder similar to major depression but of mild Teach the client to watch for extrapyramidal adverse reaction
to moderate severity Explain that the drug is less affective if the client smokes
87. The nurse is aware that the following ways in vascular Discuss the need to report paradoxical effects such as
dementia different from Alzheimer’s disease is: euphoria
94. Nurse Alexandra notices other clients on the unit avoiding
Vascular dementia has more abrupt onset a client diagnosed with antisocial personality disorder. When
The duration of vascular dementia is usually brief discussing appropriate behavior in group therapy, which of
Personality change is common in vascular dementia the following comments is expected about this client by his
The inability to perform motor activities occurs in vascular peers?
dementia
88. Loretta, a newly admitted client was diagnosed with Lack of honesty
delirium and has history of hypertension and anxiety. She Belief in superstition
had been taking digoxin, furosemide (Lasix), and diazepam Show of temper tantrums
(Valium) for anxiety. This client’s impairment may be related Constant need for attention
to which of the following conditions? 95. Tommy, with dependent personality disorder is working
to increase his selfesteem. Which of the following statements
Infection by the Tommy shows teaching was successful?
Metabolic acidosis
Drug intoxication “I’m not going to look just at the negative things about
Hepatic encephalopathy myself”
89. Nurse Ron enters a client’s room, the client says, “They’re “I’m most concerned about my level of competence and
crawling on my sheets! Get them off my bed!” Which of the progress”
following assessment is the most accurate? “I’m not as envious of the things other people have as I used
to be”
The client is experiencing aphasia “I find I can’t stop myself from taking over things other
The client is experiencing dysarthria should be doing”
The client is experiencing a flight of ideas 96. Norma, a 42-year-old client with a diagnosis of chronic
The client is experiencing visual hallucination undifferentiated schizophrenia lives in a rooming house that
90. Which of the following descriptions of a client’s has a weekly nursing clinic. She scratches while she tells the
experience and behavior can be assessed as an illusion? nurse she feels creatures eating away at her skin. Which of
the following interventions should be done first?
The client tries to hit the nurse when vital signs must be
taken Talk about his hallucinations and fears
The client says, “I keep hearing a voice telling me to run Refer him for anticholinergic adverse reactions
away” Assess for possible physical problems such as rash
The client becomes anxious whenever the nurse leaves the Call his physician to get his medication increased to control
bedside his psychosis
The client looks at the shadow on a wall and tells the nurse 97. Ivy, who is on the psychiatric unit is copying and imitating
she sees frightening faces on the wall. the movements of her primary nurse. During recovery, she
91. During conversation of Nurse John with a client, he says, “I thought the nurse was my mirror. I felt connected
observes that the client shift from one topic to the next on a only when I saw my nurse.” This behavior is known by which
regular basis. Which of the following terms describes this of the following terms?
disorder?
Modeling 9. Answer: (D) Increase calories, carbohydrates, and
Echopraxia protein.This client increased protein for tissue building
Ego-syntonicity and increased calories to replace what is burned up
Ritualism (usually via carbohydrates).
98. Jun approaches the nurse and tells that he hears a voice 10. Answer: (C) Acting overly solicitous toward the child.
telling him that he’s evil and deserves to die. Which of the This behavior is an example of reaction formation, a
following terms describes the client’s perception? coping mechanism.
11. Answer: (A) By designating times during which the
Delusion client can focus on the behavior. The nurse should
Disorganized speech designate times during which the client can focus on
Hallucination the compulsive behavior or obsessive thoughts. The
Idea of reference nurse should urge the client to reduce the frequency of
99. Mike is admitted to a psychiatric unit with a diagnosis of the compulsive behavior gradually, not rapidly. She
undifferentiated schizophrenia. Which of the following shouldn’t call attention to or try to prevent the
defense mechanisms is probably used by mike? behavior. Trying to prevent the behavior may cause
pain and terror in the client. The nurse should
Projection encourage the client to verbalize anxieties to help
Rationalization distract attention from the compulsive behavior.
Regression 12. Answer: (D) Exploring the meaning of the traumatic
Repression event with the client. The client with PTSD needs
100. Rocky has started taking haloperidol (Haldol). Which of encouragement to examine and understand the
the following instructions is most appropriate for Ricky meaning of the traumatic event and consequent
before taking haloperidol? losses. Otherwise, symptoms may worsen and the
client may become depressed or engage in self-
Should report feelings of restlessness or agitation at once destructive behavior such as substance abuse. The
Use a sunscreen outdoors on a year-round basis client must explore the meaning of the event and
Be aware you’ll feel increased energy taking this drug won’t heal without this, no matter how much time
This drug will indirectly control essential hypertension passes. Behavioral techniques, such as relaxation
therapy, may help decrease the client’s anxiety and
Answers and Rationales induce sleep. The physician may prescribe antianxiety
1. Answer: (D) Focusing. The nurse is using focusing by agents or antidepressants cautiously to avoid
suggesting that the client discuss a specific issue. The dependence; sleep medication is rarely appropriate. A
nurse didn’t restate the question, make observation, special diet isn’t indicated unless the client also has an
or ask further question (exploring). eating disorder or a nutritional problem.
2. Answer: (D) Remove all other clients from the 13. Answer: (C) “Your problem is real but there is no
dayroom. The nurse’s first priority is to consider the physical basis for it. We’ll work on what is going on in
safety of the clients in the therapeutic setting. The your life to find out why it’s happened.” The nurse
other actions are appropriate responses after ensuring must be honest with the client by telling her that the
the safety of other clients. paralysis has no physiologic cause while also conveying
3. Answer: (A) The client is disruptive. Group activity empathy and acknowledging that her symptoms are
provides too much stimulation, which the client will real. The client will benefit from psychiatric treatment,
not be able to handle (harmful to self) and as a result which will help her understand the underlying cause of
will be disruptive to others. her symptoms. After the psychological conflict is
4. Answer: (C) Agree to talk with the mother and the resolved, her symptoms will disappear. Saying that it
father together. By agreeing to talk with both parents, must be awful not to be able to move her legs
the nurse can provide emotional support and further wouldn’t answer the client’s question; knowing that
assess and validate the family’s needs. the cause is psychological wouldn’t necessarily make
5. Answer: (A) Perceptual disorders. Frightening visual her feel better. Telling her that she has developed
hallucinations are especially common in clients paralysis to avoid leaving her parents or that her
experiencing alcohol withdrawal. personality caused her disorder wouldn’t help her
6. Answer: (D) Suggest that it takes awhile before seeing understand and resolve the underlying conflict.
the results. The client needs a specific response; that it 14. Answer: (C) fluvoxamine (Luvox) and clomipramine
takes 2 to 3 weeks (a delayed effect) until the (Anafranil). The antidepressants fluvoxamine and
therapeutic blood level is reached. clomipramine have been effective in the treatment of
7. Answer: (C) Superego. This behavior shows a weak OCD. Librium and Valium may be helpful in treating
sense of moral consciousness. According to Freudian anxiety related to OCD but aren’t drugs of choice to
theory, personality disorders stem from a weak treat the illness. The other medications mentioned
superego. aren’t effective in the treatment of OCD.
8. Answer: (C) Skeletal muscle paralysis. Anectine is a 15. Answer: (A) A warning about the drugs delayed
depolarizing muscle relaxant causing paralysis. It is therapeutic effect, which is from 14 to 30 days. The
used to reduce the intensity of muscle contractions client should be informed that the drug’s therapeutic
during the convulsive stage, thereby reducing the risk effect might not be reached for 14 to 30 days. The
of bone fractures or dislocation. client must be instructed to continue taking the drug
 as directed. Blood level checks aren’t necessary. NMS antisocial personality disorder commonly have
hasn’t been reported with this drug, but tachycardia is difficulty developing stable, close relationships.
frequently reported. 22. Answer: (C) Methadone. Methadone is used to
16. Answer: (B) Severe anxiety and fear. Phobias cause detoxify opiate users because it binds with opioid
severe anxiety (such as a panic attack) that is out of receptors at many sites in the central nervous system
proportion to the threat of the feared object or but doesn’t have the same deterious effects as other
situation. Physical signs and symptoms of phobias opiates, such as cocaine, heroin, and morphine.
include profuse sweating, poor motor control, Barbiturates, amphetamines, and benzodiazepines are
tachycardia, and elevated blood pressure. Insomnia, an highly addictive and would require detoxification
inability to concentrate, and weight loss are common treatment.
in depression. Withdrawal and failure to distinguish 23. Answer: (B) Hallucinations. Hallucinations are visual,
reality from fantasy occur in schizophrenia. auditory, gustatory, tactile, or olfactory perceptions
17. Answer: (A) Antidepressants. Tricyclic and monoamine that have no basis in reality. Delusions are false beliefs,
oxidase (MAO) inhibitor antidepressants have been rather than perceptions, that the client accepts as real.
found to be effective in treating clients with panic Loose associations are rapid shifts among unrelated
attacks. Why these drugs help control panic attacks ideas. Neologisms are bizarre words that have
isn’t clearly understood. Anticholinergic agents, which meaning only to the client.
are smooth-muscle relaxants, relieve physical 24. Answer: (C) Set up a strict eating plan for the client.
symptoms of anxiety but don’t relieve the anxiety Establishing a consistent eating plan and monitoring
itself. Antipsychotic drugs are inappropriate because the client’s weight are very important in this disorder.
clients who experience panic attacks aren’t psychotic. The family and friends should be included in the
Mood stabilizers aren’t indicated because panic attacks client’s care. The client should be monitored during
are rarely associated with mood changes. meals-not given privacy. Exercise must be limited and
18. Answer: (B) 3 to 5 days. Monoamine oxidase supervised.
inhibitors, such as tranylcypromine, have an onset of 25. Answer: (A) Highly important or famous. A delusion of
action of approximately 3 to 5 days. A full clinical grandeur is a false belief that one is highly important
response may be delayed for 3 to 4 weeks. The or famous. A delusion of persecution is a false belief
therapeutic effects may continue for 1 to 2 weeks after that one is being persecuted. A delusion of reference is
discontinuation. a false belief that one is connected to events unrelated
19. Answer: (B) Providing emotional support and to oneself or a belief that one is responsible for the evil
individual counseling. Clients in the first stage of in the world.
Alzheimer’s disease are aware that something is 26. Answer: (D) Listening attentively with a neutral
happening to them and may become overwhelmed attitude and avoiding power struggles. The nurse
and frightened. Therefore, nursing care typically should listen to the client’s requests, express
focuses on providing emotional support and individual willingness to seriously consider the request, and
counseling. The other options are appropriate during respond later. The nurse should encourage the client
the second stage of Alzheimer’s disease, when the to take short daytime naps because he expends so
client needs continuous monitoring to prevent minor much energy. The nurse shouldn’t try to restrain the
illnesses from progressing into major problems and client when he feels the need to move around as long
when maintaining adequate nutrition may become a as his activity isn’t harmful. High calorie finger foods
challenge. During this stage, offering nourishing finger should be offered to supplement the client’s diet, if he
foods helps clients to feed themselves and maintain can’t remain seated long enough to eat a complete
adequate nutrition. meal. The nurse shouldn’t be forced to stay seated at
20. Answer: (C) Emotional lability, euphoria, and impaired the table to finish a meal. The nurse should set limits in
memory. Signs of antianxiety agent overdose include a calm, clear, and self-confident tone of voice.
emotional lability, euphoria, and impaired memory. 27. Answer: (D) Denial. Denial is unconscious defense
Phencyclidine overdose can cause combativeness, mechanism in which emotional conflict and anxiety is
sweating, and confusion. Amphetamine overdose can avoided by refusing to acknowledge feelings, desires,
result in agitation, hyperactivity, and grandiose impulses, or external facts that are consciously
ideation. Hallucinogen overdose can produce intolerable. Withdrawal is a common response to
suspiciousness, dilated pupils, and increased blood stress, characterized by apathy. Logical thinking is the
pressure. ability to think rationally and make responsible
21. Answer: (D) A low tolerance for frustration. Clients decisions, which would lead the client admitting the
with an antisocial personality disorder exhibit a low problem and seeking help. Repression is suppressing
tolerance for frustration, emotional immaturity, and a past events from the consciousness because of guilty
lack of impulse control. They commonly have a history association.
of unemployment, miss work repeatedly, and quit 28. Answer: (B) Paranoid thoughts. Clients with
work without other plans for employment. They don’t schizotypal personality disorder experience excessive
feel guilt about their behavior and commonly perceive social anxiety that can lead to paranoid thoughts.
themselves as victims. They also display a lack of Aggressive behavior is uncommon, although these
responsibility for the outcome of their actions. clients may experience agitation with anxiety. Their
Because of a lack of trust in others, clients with behavior is emotionally cold with a flattened affect,
regardless of the situation. These clients demonstrate
 a reduced capacity for close or dependent concept of the problem that serves as the starting
relationships. point of the relationship.
29. Answer: (C) Identify anxiety-causing situations. Bulimic 44. Answer: (B) Chocolate milk, aged cheese, and yogurt’.
behavior is generally a maladaptive coping response to These high-tyramine foods, when ingested in the
stress and underlying issues. The client must identify presence of an MAO inhibitor, cause a severe
anxiety-causing situations that stimulate the bulimic hypertensive response.
behavior and then learn new ways of coping with the 45. Answer: (B) 4 to 6 weeks. Crisis is self-limiting and lasts
anxiety. from 4 to 6 weeks.
30. Answer: (A) Tension and irritability. An amphetamine 46. Answer: (D) Males are more likely to use lethal
is a nervous system stimulant that is subject to abuse methods than are females. This finding is supported
because of its ability to produce wakefulness and by research; females account for 90% of suicide
euphoria. An overdose increases tension and attempts but males are three times more successful
irritability. Options B and C are incorrect because because of methods used.
amphetamines stimulate norepinephrine, which 47. Answer: (C) “Your cursing is interrupting the activity.
increase the heart rate and blood flow. Diarrhea is a Take time out in your room for 10 minutes.” The nurse
common adverse effect so option D in is incorrect. should set limits on client behavior to ensure a
31. Answer: (B) “No, I do not hear your voices, but I comfortable environment for all clients. The nurse
believe you can hear them”. The nurse, demonstrating should accept hostile or quarrelsome client outbursts
knowledge and understanding, accepts the client’s within limits without becoming personally offended, as
perceptions even though they are hallucinatory. in option A. Option B is incorrect because it implies
32. Answer: (C) Confusion for a time after treatment. The that the client’s actions reflect feelings toward the
electrical energy passing through the cerebral cortex staff instead of the client’s own misery. Judgmental
during ECT results in a temporary state of confusion remarks, such as option D, may decrease the client’s
after treatment. self-esteem.
33. Answer: (D) Acceptance stage. Communication and 48. Answer: (C) lithium carbonate (Lithane). Lithium
intervention during this stage are mainly nonverbal, as carbonate, an antimania drug, is used to treat clients
when the client gestures to hold the nurse’s hand. with cyclical schizoaffective disorder, a psychotic
34. Answer: (D) A higher level of anxiety continuing for disorder once classified under schizophrenia that
more than 3 months. This is not an expected outcome causes affective symptoms, including maniclike
of a crisis because by definition a crisis would be activity. Lithium helps control the affective component
resolved in 6 weeks. of this disorder. Phenelzine is a monoamine oxidase
35. Answer: (B) Staying in the sun. Haldol causes inhibitor prescribed for clients who don’t respond to
photosensitivity. Severe sunburn can occur on other antidepressant drugs such as imipramine.
exposure to the sun. Chlordiazepoxide, an antianxiety agent, generally is
36. Answer: (D) Moderate-level anxiety. A moderately contraindicated in psychotic clients. Imipramine,
anxious person can ignore peripheral events and primarily considered an antidepressant agent, is also
focuses on central concerns. used to treat clients with agoraphobia and that
37. Answer: (C) Diverse interest. Before onset of undergoing cocaine detoxification.
depression, these clients usually have very narrow, 49. Answer: (B) Report a sore throat or fever to the
limited interest. physician immediately. A sore throat and fever are
38. Answer: (A) As their depression begins to improve. At indications of an infection caused by agranulocytosis, a
this point the client may have enough energy to plan potentially life-threatening complication of clozapine.
and execute an attempt. Because of the risk of agranulocytosis, white blood cell
39. Answer: (D) Disturbance in recalling recent events (WBC) counts are necessary weekly, not monthly. If
related to cerebral hypoxia. Cell damage seems to the WBC count drops below 3,000/μl, the medication
interfere with registering input stimuli, which affects must be stopped. Hypotension may occur in clients
the ability to register and recall recent events; vascular taking this medication. Warn the client to stand up
dementia is related to multiple vascular lesions of the slowly to avoid dizziness from orthostatic hypotension.
cerebral cortex and subcortical structure. The medication should be continued, even when
40. Answer: (D) Encouraging the client to have blood levels symptoms have been controlled. If the medication
checked as ordered. Blood levels must be checked must be stopped, it should be slowly tapered over 1 to
monthly or bimonthly when the client is on 2 weeks and only under the supervision of a physician.
maintenance therapy because there is only a small 50. Answer: (C) Neuroleptic malignant syndrome. The
range between therapeutic and toxic levels. client’s signs and symptoms suggest neuroleptic
41. Answer: (B) Fine hand tremors or slurred speech. malignant syndrome, a life-threatening reaction to
These are common side effects of lithium carbonate. neuroleptic medication that requires immediate
42. Answer: (D) Presence. The constant presence of a treatment. Tardive dyskinesia causes involuntary
nurse provides emotional support because the client movements of the tongue, mouth, facial muscles, and
knows that someone is attentive and available in case arm and leg muscles. Dystonia is characterized by
of an emergency. cramps and rigidity of the tongue, face, neck, and back
43. Answer: (A) Client’s perception of the presenting muscles. Akathisia causes restlessness, anxiety, and
problem. The nurse can be most therapeutic by jitteriness.
starting where the client is, because it is the client’s
51. Answer: (B) Advising the client to sit up for 1 minute impairment with obvious personality changes and
before getting out of bed. To minimize the effects of impaired communication, such as inappropriate
amitriptyline-induced orthostatic hypotension, the conversation, actions, and responses. During the late
nurse should advise the client to sit up for 1 minute stage, the client can’t perform self-care activities and
before getting out of bed. Orthostatic hypotension may become mute.
commonly occurs with tricyclic antidepressant therapy. 58. Answer: (D) This medication may initially cause
In these cases, the dosage may be reduced or the tiredness, which should become less bothersome over
physician may prescribe nortriptyline, another tricyclic time. Sedation is a common early adverse effect of
antidepressant. Orthostatic hypotension disappears imipramine, a tricyclic antidepressant, and usually
only when the drug is discontinued. decreases as tolerance develops. Antidepressants
52. Answer: (D) Dysthymic disorder. Dysthymic disorder is aren’t habit forming and don’t cause physical or
marked by feelings of depression lasting at least 2 psychological dependence. However, after a long
years, accompanied by at least two of the following course of high-dose therapy, the dosage should be
symptoms: sleep disturbance, appetite disturbance, decreased gradually to avoid mild withdrawal
low energy or fatigue, low selfesteem, poor symptoms. Serious adverse effects, although rare,
concentration, difficulty making decisions, and include myocardial infarction, heart failure, and
hopelessness. These symptoms may be relatively tachycardia. Dietary restrictions, such as avoiding aged
continuous or separated by intervening periods of cheeses, yogurt, and chicken livers, are necessary for a
normal mood that last a few days to a few weeks. client taking a monoamine oxidase inhibitor, not a
Cyclothymic disorder is a chronic mood disturbance of tricyclic antidepressant.
at least 2 years’ duration marked by numerous periods 59. Answer: (C) Monitor vital signs, serum electrolyte
of depression and hypomania. Atypical affective levels, and acid-base balance. An anorexic client who
disorder is characterized by manic signs and requires hospitalization is in poor physical condition
symptoms. Major depression is a recurring, persistent from starvation and may die as a result of arrhythmias,
sadness or loss of interest or pleasure in almost all hypothermia, malnutrition, infection, or cardiac
activities, with signs and symptoms recurring for at abnormalities secondary to electrolyte imbalances.
least 2 weeks. Therefore, monitoring the client’s vital signs, serum
53. Answer: (C) 30 g mixed in 250 ml of water. The usual electrolyte level, and acid base balance is crucial.
adult dosage of activated charcoal is 5 to 10 times the Option A may worsen anxiety. Option B is incorrect
estimated weight of the drug or chemical ingested, or a because a weight obtained after breakfast is more
minimum dose of 30 g, mixed in 250 ml of water. accurate than one obtained after the evening meal.
Doses less than this will be ineffective; doses greater Option D would reward the client with attention for
than this can increase the risk of adverse reactions, not eating and reinforce the control issues that are
although toxicity doesn’t occur with activated central to the underlying psychological problem; also,
charcoal, even at the maximum dose. the client may record food and fluid intake
54. Answer: (C) St. John’s wort. St. John’s wort has been inaccurately.
found to have serotonin-elevating properties, similar 60. Answer: (D) Opioid withdrawal. The symptoms listed
to prescription antidepressants. Ginkgo biloba is are specific to opioid withdrawal. Alcohol withdrawal
prescribed to enhance mental acuity. Echinacea has would show elevated vital signs. There is no real
immune-stimulating properties. Ephedra is a naturally withdrawal from cannibis. Symptoms of cocaine
occurring stimulant that is similar to ephedrine. withdrawal include depression, anxiety, and agitation.
55. Answer: (B) Sodium. Lithium is chemically similar to 61. Answer: (A) Regression. An adult who throws temper
sodium. If sodium levels are reduced, such as from tantrums, such as this one, is displaying regressive
sweating or diuresis, lithium will be reabsorbed by the behavior, or behavior that is appropriate at a younger
kidneys, increasing the risk of toxicity. Clients taking age. In projection, the client blames someone or
lithium shouldn’t restrict their intake of sodium and something other than the source. In reaction
should drink adequate amounts of fluid each day. The formation, the client acts in opposition to his feelings.
other electrolytes are important for normal body In intellectualization, the client overuses rational
functions but sodium is most important to the explanations orabstract thinking to decrease the
absorption of lithium. significance of a feeling or event.
56. Answer: (D) It’s characterized by an acute onset and 62. Answer: (A) Abnormal movements and involuntary
lasts hours to a number of days. Delirium has an acute movements of the mouth, tongue, and face. Tardive
onset and typically can last from several hours to dyskinesia is a severe reaction associated with long
several days. term use of antipsychotic medication. The clinical
57. Answer: (B) Impaired communication. Initially, manifestations include abnormal movements
memory impairment may be the only cognitive deficit (dyskinesia) and involuntary movements of the mouth,
in a client with Alzheimer’s disease. During the early tongue (fly catcher tongue), and face.
stage of this disease, subtle personality changes may 63. Answer: (C) Blurred vision. At lithium levels of 2 to 2.5
also be present. However, other than occasional mEq/L the client will experienced blurred vision,
irritable outbursts and lack of spontaneity, the client is muscle twitching, severe hypotension, and persistent
usually cooperative and exhibits socially appropriate nausea and vomiting. With levels between 1.5 and 2
behavior. Signs of advancement to the middle stage of mEq/L the client experiencing vomiting, diarrhea,
Alzheimer’s disease include exacerbated cognitive muscle weakness, ataxia, dizziness, slurred speech, and
 confusion. At lithium levels of 2.5 to 3 mEq/L or higher, extra pyramidal symptom side effects of
urinary and fecal incontinence occurs, as well as antipsychotics. C. The common side effects of Lithium
seizures, cardiac dysrythmias, peripheral vascular are fine hand tremors, nausea, polyuria and polydipsia.
collapse, and death. 73. Answer: (C) A living, learning or working environment.
64. Answer: (C) No acts of aggression have been observed A therapeutic milieu refers to a broad conceptual
within 1 hour after the release of two of the extremity approach in which all aspects of the environment are
restraints. The best indicator that the behavior is channeled to provide a therapeutic environment for
controlled, if the client exhibits no signs of aggression the client. The six environmental elements include
after partial release of restraints. Options A, B, and D structure, safety, norms; limit setting, balance and unit
do not ensure that the client has controlled the modification. A. Behavioral approach in psychiatric
behavior. care is based on the premise that behavior can be
65. Answer: (A) increased attention span and learned or unlearned through the use of reward and
concentration. The medication has a paradoxic effect punishment. B. Cognitive approach to change behavior
that decrease hyperactivity and impulsivity among is done by correcting distorted perceptions and
children with ADHD. B, C, D. Side effects of Ritalin irrational beliefs to correct maladaptive behaviors. D.
include anorexia, insomnia, diarrhea and irritability. This is not congruent with therapeutic milieu.
66. Answer: (C) Moderate. The child with moderate 74. Answer: (B) Transference. Transference is a positive or
mental retardation has an I.Q. of 35- 50 Profound negative feeling associated with a significant person in
Mental retardation has an I.Q. of below 20; Mild the client’s past that are unconsciously assigned to
mental retardation 50-70 and Severe mental another A. Splitting is a defense mechanism commonly
retardation has an I.Q. of 20-35. seen in a client with personality disorder in which the
67. Answer: (D) Rearrange the environment to activate the world is perceived as all good or all bad C. Countert-
child. The child with autistic disorder does not want transference is a phenomenon where the nurse shifts
change. Maintaining a consistent environment is feelings assigned to someone in her past to the patient
therapeutic. A. Angry outburst can be re-channeling D. Resistance is the client’s refusal to submit himself to
through safe activities. B. Acceptance enhances a the care of the nurse
trusting relationship. C. Ensure safety from self- 75. Answer: (B) Adventitious. Adventitious crisis is a crisis
destructive behaviors like head banging and hair involving a traumatic event. It is not part of everyday
pulling. life. A. Situational crisis is from an external source that
68. Answer: (B) cocaine. The manifestations indicate upset ones psychological equilibrium C and D. Are the
intoxication with cocaine, a CNS stimulant. A. same. They are transitional or developmental periods
Intoxication with heroine is manifested by euphoria in life
then impairment in judgment, attention and the 76. Answer: (C) Major depression. The DSM-IV-TR classifies
presence of papillary constriction. C. Intoxication with major depression as an Axis I disorder. Borderline
hallucinogen like LSD is manifested by grandiosity, personality disorder as an Axis II; obesity and
hallucinations, synesthesia and increase in vital signs hypertension, Axis III.
D. Intoxication with Marijuana, a cannabinoid is 77. Answer: (B) Transference. Transference is the
manifested by sensation of slowed time, conjunctival unconscious assignment of negative or positive
redness, social withdrawal, impaired judgment and feelings evoked by a significant person in the client’s
hallucinations. past to another person. Intellectualization is a defense
69. Answer: (B) insidious onset. Dementia has a gradual mechanism in which the client avoids dealing with
onset and progressive deterioration. It causes emotions by focusing on facts. Triangulation refers to
pronounced memory and cognitive disturbances. A,C conflicts involving three family members. Splitting is a
and D are all characteristics of delirium. defense mechanism commonly seen in clients with
70. Answer: (C) Claustrophobia. Claustrophobia is fear of personality disorder in which the world is perceived as
closed space. A. Agoraphobia is fear of open space or all good or all bad.
being a situation where escape is difficult. B. Social 78. Answer: (B) Hypochondriasis. Complains of vague
phobia is fear of performing in the presence of others physical symptoms that have no apparent medical
in a way that will be humiliating or embarrassing. D. causes are characteristic of clients with
Xenophobia is fear of strangers. hypochondriasis. In many cases, the GI system is
71. Answer: (A) Revealing personal information to the affected. Conversion disorders are characterized by
client. Counter-transference is an emotional reaction one or more neurologic symptoms. The client’s
of the nurse on the client based on her unconscious symptoms don’t suggest severe anxiety. A client
needs and conflicts. B and C. These are therapeutic experiencing sublimation channels maladaptive
approaches. D. This is transference reaction where a feelings or impulses into socially acceptable behavior
client has an emotional reaction towards the nurse 79. Answer: (C) Hypochondriasis. Hypochodriasis in this
based on her past. case is shown by the client’s belief that she has a
72. Answer: (D) Hold the next dose and obtain an order for serious illness, although pathologic causes have been
a stat serum lithium level. Diarrhea and vomiting are eliminated. The disturbance usually lasts at lease 6
manifestations of Lithium toxicity. The next dose of with identifiable life stressor such as, in this case,
lithium should be withheld and test is done to validate course examinations. Conversion disorders are
the observation. A. The manifestations are not due to characterized by one or more neurologic symptoms.
drug interaction. B. Cogentin is used to manage the Depersonalization refers to persistent recurrent
 episodes of feeling detached from one’s self or body. 87. Answer: (A) Vascular dementia has more abrupt onset.
Somatoform disorders generally have a chronic course Vascular dementia differs from Alzheimer’s disease in
with few remissions. that it has a more abrupt onset and runs a highly
80. Answer: (A) Triazolam (Halcion). Triazolam is one of a variable course. Personally change is common in
group of sedative hypnotic medication that can be Alzheimer’s disease. The duration of delirium is usually
used for a limited time because of the risk of brief. The inability to carry out motor activities is
dependence. Paroxetine is a scrotonin-specific reutake common in Alzheimer’s disease.
inhibitor used for treatment of depression panic 88. Answer: (C) Drug intoxication. This client was taking
disorder, and obsessive-compulsive disorder. several medications that have a propensity for
Fluoxetine is a scrotonin-specific reuptake inhibitor producing delirium; digoxin (a digitalis glycoxide),
used for depressive disorders and obsessive- furosemide (a thiazide diuretic), and diazepam (a
compulsive disorders. Risperidome is indicated for benzodiazepine). Sufficient supporting data don’t exist
psychotic disorders. to suspect the other options as causes.
81. Answer: (D) It promotes emotional support or 89. Answer: (D) The client is experiencing visual
attention for the client. Secondary gain refers to the hallucination. The presence of a sensory stimulus
benefits of the illness that allow the client to receive correlates with the definition of a hallucination, which
emotional support or attention. Primary gain enables is a false sensory perception. Aphasia refers to a
the client to avoid some unpleasant activity. A communication problem. Dysarthria is difficulty in
dysfunctional family may disregard the real issue, speech production. Flight of ideas is rapid shifting from
although some conflict is relieved. Somatoform pain one topic to another.
disorder is a preoccupation with pain in the absence of 90. Answer: (D) The client looks at the shadow on a wall
physical disease. and tells the nurse she sees frightening faces on the
82. Answer: (A) “I went to the mall with my friends last wall. Minor memory problems are distinguished from
Saturday”. Clients with panic disorder tent to be dementia by their minor severity and their lack of
socially withdrawn. Going to the mall is a sign of significant interference with the client’s social or
working on avoidance behaviors. Hyperventilating is a occupational lifestyle. Other options would be
key symptom of panic disorder. Teaching breathing included in the history data but don’t directly correlate
control is a major intervention for clients with panic with the client’s lifestyle.
disorder. The client taking medications for panic 91. Answer: (D) Loose association. Loose associations are
disorder; such as tricylic antidepressants and conversations that constantly shift in topic. Concrete
benzodiazepines, must be weaned off these drugs. thinking implies highly definitive thought processes.
Most clients with panic disorder with agoraphobia Flight of ideas is characterized by conversation that’s
don’t have nutritional problems. disorganized from the onset. Loose associations don’t
83. Answer: (A) “I’m sleeping better and don’t have necessarily start in a cogently, then becomes loose.
nightmares” MAO inhibitors are used to treat sleep 92. Answer: (C) Paranoid. Because of their suspiciousness,
problems, nightmares, and intrusive daytime thoughts paranoid personalities ascribe malevolent activities to
in individual with posttraumatic stress disorder. MAO others and tent to be defensive, becoming
inhibitors aren’t used to help control flashbacks or quarrelsome and argumentative. Clients with
phobias or to decrease the craving for alcohol. antisocial personality disorder can also be antagonistic
84. Answer: (D) Stopping the drug can cause withdrawal and argumentative but are less suspicious than
symptoms. Stopping antianxiety drugs such as paranoid personalities. Clients with histrionic
benzodiazepines can cause the client to have personality disorder are dramatic, not suspicious and
withdrawal symptoms. Stopping a benzodiazepine argumentative. Clients with schizoid personality
doesn’t tend to cause depression, increase cognitive disorder are usually detached from other and tend to
abilities, or decrease sleeping difficulties. have eccentric behavior.
85. Answer: (B) Behavioral difficulties. Adolescents tend to 93. Answer: (C) Explain that the drug is less affective if the
demonstrate severe irritability and behavioral client smokes. Olanzapine (Zyprexa) is less effective for
problems rather than simply a depressed mood. clients who smoke cigarettes. Serotonin syndrome
Anxiety disorder is more commonly associated with occurs with clients who take a combination of
small children rather than with adolescents. Cognitive antidepressant medications. Olanzapine doesn’t cause
impairment is typically associated with delirium or euphoria, and extrapyramidal adverse reactions aren’t
dementia. Labile mood is more characteristic of a a problem. However, the client should be aware of
client with cognitive impairment or bipolar disorder. adverse effects such as tardive dyskinesia.
86. Answer: (D) It’s a mood disorder similar to major 94. Answer: (A) Lack of honesty. Clients with antisocial
depression but of mild to moderate severity. personality disorder tent to engage in acts of
Dysthymic disorder is a mood disorder similar to major dishonesty, shown by lying. Clients with schizotypal
depression but it remains mild to moderate in severity. personality disorder tend to be superstitious. Clients
Cyclothymic disorder is a mood disorder characterized with histrionic personality disorders tend to overreact
by a mood range from moderate depression to to frustrations and disappointments, have temper
hypomania. Bipolar I disorder is characterized by a tantrums, and seek attention.
single manic episode with no past major depressive 95. Answer: (A) “I’m not going to look just at the negative
episodes. Seasonalaffective disorder is a form of things about myself”. As the clients makes progress on
depression occurring in the fall and winter. improving self-esteem, selfblame and negative self
 evaluation will decrease. Clients with dependent
personality disorder tend to feel fragile and
inadequate and would be extremely unlikely to discuss
their level of competence and progress. These clients
focus on self and aren’t envious or jealous. Individuals
with dependent personality disorders don’t take over
situations because they see themselves as inept and
inadequate.
96. Answer: (C) Assess for possible physical problems such
as rash. Clients with schizophrenia generally have poor
visceral recognition because they live so fully in their
fantasy world. They need to have as in-depth
assessment of physical complaints that may spill over
into their delusional symptoms. Talking with the client
won’t provide as assessment of his itching, and itching
isn’t as adverse reaction of antipsychotic drugs, calling
the physician to get the client’s medication increased
doesn’t address his physical complaints.
97. Answer: (B) Echopraxia. Echopraxia is the copying of
another’s behaviors and is the result of the loss of ego
boundaries. Modeling is the conscious copying of
someone’s behaviors. Ego-syntonicity refers to
behaviors that correspond with the individual’s sense
of self. Ritualism behaviors are repetitive and
compulsive.
98. Answer: (C) Hallucination. Hallucinations are sensory
experiences that are misrepresentations of reality or
have no basis in reality. Delusions are beliefs not based
in reality. Disorganized speech is characterized by
jumping from one topic to the next or using unrelated
words. An idea of reference is a belief that an
unrelated situation holds special meaning for the
client.
99. Answer: (C) Regression. Regression, a return to earlier
behavior to reduce anxiety, is the basic defense
mechanism in schizophrenia. Projection is a defense
mechanism in which one blames others and attempts
to justify actions; it’s used primarily by people with
paranoid schizophrenia and delusional disorder.
Rationalization is a defense mechanism used to justify
one’s action. Repression is the basic defense
mechanism in the neuroses; it’s an involuntary
exclusion of painful thoughts, feelings, or experiences
from awareness.
100. Answer: (A) Should report feelings of restlessness or
agitation at once. Agitation and restlessness are
adverse effect of haloperidol and can be treated with
antocholinergic drugs. Haloperidol isn’t likely to cause
photosensitivity or control essential hypertension.
Although the client may experience increased
concentration and activity, these effects are due to a
decreased in symptoms, not the drug itself.