Final Exam in NCM 104 Situation: A client was rushed to the OR for acute closure glaucoma.

During assessment, you found out that your client experienced acute pain on the left eye. 1. In caring for this client post-op, you monitor for increased intraocular pressure. Which of the following parameters indicate an increased intraocular pressure? a. an intraocular pressure of 20 mmHg c. an intraocular pressure of 15 mmHg b. an intraocular pressure of 22 mmHg d. an intraocular pressure of 26 mmHg 2. Acute closure glaucoma is characterized by which of the following? a. narrowing of the angle between the iris and the cornea b. increased production of aqueous humor c. hyperactivity of the ciliary body d. impairment in the outflow of intraocular fluid 3. In assessing the clients visual acuity, you will observe which manifestation in those with glaucoma? a. halo vision c. loss of peripheral vision b. clouding and blurring of vision d. presence of floaters in the visual field 4. To confirm the diagnosis of glaucoma, you will expect the physician to order which diagnostic procedure to measure the clients intraocular pressure? a. visual acuity test c. visual field test b. tonometry d. magnetic resonance imaging 5. In doing health teaching to a client with glaucoma, the following information should be included EXCEPT? a. avoid going to the movie house b. limit driving at night c. instruct the client to continue taking steroidal anti-inflammatory drug d. he may take antitussive medication 6. Development of glaucoma is associated with the following factors EXCEPT: a. African- American race c. client with diabetes mallitus b. family history of glaucoma d. More common among young adults below 40 7. The most common complication of glaucoma is: a. damage to the retinal tissue b. damage to the optic nerve c. drying and scarring of the cornea d. displacement of the lens due to increased intraocular pressure 8. To constrict the pupil and to draw the smooth muscle of the iris away from the canal of schlemm thus permitting the aqueous humor to drain out, the physician will order: a. Midriatrics c. acetazolamide b. atropine sulfate d. miotics 9. To lessen the intraocular pressure by creating a channel to drain the fluid, the physician will perform which of the following procedures? a. iridotomy c. trabeculoplasty b. trabeculectomy d. cyclophotocoagulation Situation: A client was admitted in ER due to progressive loss of vision in one area. After laboratory procedures, the physician diagnosed the client to have retinal detachment. 10. During assessment, you will observe the following manifestations in a client with retinal detachment EXCEPT: a. showering of floaters in the visual field c. darkening of peripheral vision b. progressive blurring of vision d. presence of flashes of light 11. To correct the problem, scleral buckling was done to the client. Which of the following statements correctly describe scleral buckling? a. the vitreous humor is removed from the eye and replaced with a saline solution b. involves placing a silicone band around the eye to hold the retina in place. c. a small gas bubble is injected into the vitreous where it then rises and presses against the retina, thus, closing the tear. d. utilizes cryopexy to seal the detached retina 12. You are doing triage in ER. Among these clients with visual impairment, you will attend first to whom of the following? a. client with corneal inflammation c. client with corneal ulceration b. client with clouding of the cornea d. client with viral conjunctivitis

Situation: You are caring for an 8 year-old with chief complaints of fever and pain in the post-auricular area. In the laboratory, it shows elevation of WBC and with CT scan results of inflamed mastoid bone. 13. In routine assessment, alert yourself if you will observe which of the following manifestations in the client? a. stiffness of the neck c. positive drainage on the ear canal b. temperature of 40 C d. decrease urine output 14. In the clients health history, mastoiditis is most commonly associated with: a. middle ear infection c. upper respiratory tract infection b. CNS infection d. infection of the salivary gland Situation: Care of client with other auditory disorders. 15. The result of the otoscopic exam shows congestion in the middle ear. The physician ordered for a procedure to facilitate drainage of the middle ear. Which of the following procedures will most likely be performed? a. Tympanostomy c. myringotomy b. Tympanectomy d. tympanotomy 16. In caring for client with Menieres disease, the most characteristic manifestation is? a. Vertigo c. gradual hearing loss b. tinnitus d. nausea and vomiting 17. You are conducting health teaching to client with Menieres disease. To prevent exacerbation of the disease, you should include these information, EXCEPT: a. provide bed rest during attack c. provide low sodium diet b. provide dim and quiet environment d. provide stress therapy 18. A client was admitted with hearing impairment. CT scan revealed tumor in the left acoustic pathway which is conclusive of acoustic neuroma. In the assessment, you will observe which manifestation? a. unilateral hearing loss c. bilateral hearing loss b. severe tinnitus with nausea and vomiting d. loss of balance and dizziness Situation: A 28 year-old primigravida client was admitted to the medical ward due to vaginal bleeding with uterine cramping. 19. The most common cause of bleeding during the first trimester of pregnancy are the following, EXCEPT: a. Spontaneous abortion c. gestational throphoblastic disease b. ectopic pregnancy d. fetal death in uteru 20. In the ultrasound, the physician found absence of fetal heart rate and diagnosed the mother to have spontaneous abortion. The most common cause of spontaneous abortion is: a. chromosomal aberration c. germ plasma defect b. blighted ovum d. extreme maternal age 21. Another pregnant mother in 15th week gestation was admitted to the obstetric ward due to vaginal bleeding and uterine cramping. In the internal examination, it reveals 3-4 cm cervical dilation. With this finding, the mother is having which type of abortion? a. inevitable abortion c. complete abortion b. threatened abortion d. incomplete abortion 22. Which of the following nursing diagnoses should be prioritized for a mother who is having an abortion? a. anticipatory grieving c. risk for infection b. fluid volume deficit d. ineffective labor process 23. In preparation for internal examination, you see umbilical cord protruding in the vaginal opening. The most appropriate nursing intervention for the nurse to do is? a. position the mother on left side lying position b. cover the cord with sterile cloth wet with NSS c. position the mother in knee-chest position d. instruct the mother to have complete bed rest Situation: You were the nurse on duty when a client was admitted due to vaginal bleeding with tissues passed out the vaginal orifice. An ultrasonography was ordered by the physician and the result showed retained of placenta and amniotic membranes. The physician ordered for dilation and curettage to prevent further bleeding. 24. With the information presented, the mother suffered from which type of abortion? a. incomplete abortion c. missed abortion b. complete abortion d. threatened abortion 25. Upon delivery of the product of conceptus, you will anticipate that the physician will order which of the following? a. administration of RhoGAM c. complete bed rest b. administration of oxytocin d. administration of Mg Sulfate

Situation: You are the rural health nurse in Brgy. XXX. Your concern is to implement one of the elements of primary healthcare which is maternal and child health. 26. You are conducting health education classes to pregnant mothers in the community. One of the mothers asked for ways to prevent abortion for those with history of it. The following are best responses EXCEPT: a. provide maximum time for bed rest b. instruct parents to avoid sexual activity while pregnant c. progesterone may be given to the mother d. regular internal examination is required to monitor for dilation of the cervix 27. One of the mothers verbalizes I had abortion last year when I lost my pregnancy during the 25th week of gestation. With this information, the most response of the nurse is: a. abortion occurs after 20th week of gestation b. abortion occurs before the 20th week of gestation c. abortion occurs after the age of viability d. abortion occurs anytime during pregnancy 28. In discussing family planning to the mothers, you included the physiology of menstruation. The normal blood loss during menstruation is? a. 30 to 50 cc of blood c. 50 to 80 cc of blood b. 80 to100 cc of blood d. 40 to 60 cc of blood 29. You are discussing ways in monitoring the fetal well being. Absence of fetal movement is an indication of fetal death in uteru. As a nurse, you will refer the client immediately if you observe which of the following? a. bleeding in the gums c. jaundice b. temperature of 39 C d. severe abdominal pain 30. A pregnant mother is telling that during the first trimester of her pregnancy, she had morning sickness associated with vomiting. To lessen the discomfort, the most appropriate nursing management for this is? a. monitor for electrolyte level b. monitor for I and O c. instruct mother to take soda biscuit d. instruct to be NPO temporarily to relax the stomach Situation: A mother war rushed to ER due to severe abdominal pain in the right lower quadrant. According to the mother, her LMP was 8 weeks ago. 31. With presenting manifestations, you will suspect the mother is having: a. throphoblastic tumor c. imminent abortion b. ectopic pregnanacy d. Uterine infection 32. After taking nursing health history, you found out that she was a prostitute before and was treated for gonorrhea. She has an IUD as a form of contraceptive and had her first intercourse when she was still 16 years old. Having this history, you will associate the development of the disease to: a. pelvic inflammatory disease c. use of IUD b. multiple partner d. early sexual activity 33. In doing you physical examination, the client complained for sudden knifelike pain that radiates to the shoulder. Which of the following findings will you most likely observed? a. scanty vaginal discharges c. severe vaginal bleeding b. periumbilical echimosis d. shocky manifestations Situation: A client was admitted to the OB ward due to generalized edema that includes the face and the upper extremities. The physician ordered for urinalysis. 34. As a nurse you will prepare which of the following at the bed side? a. padded tongue depressor c. padded side rails b. urinal to limit activity d. pillow to prevent head fall 35. Which of the following finding is indicative of pre-ecplampsia? a. edema, proteinuria and hypertension b. edema, toxemia and hypertension c. hypertension, edema in the lower extremities and proteinuria d. hypertension, edema and convulsion 36. After laboratory work-up, the physician diagnosed the client to have severe pre-eclampsia. Which of the following manifestations will support the diagnosis? a. BP of 160/110 mmHg, proteinuria of +3 to +4, and no edema noted b. BP of 160/110 mmHg, proteinuria of +2 to +3 with edema noted in the upper extremities c. BP of 180/120 mmHg, proteinuria of +3 to +4 and edema on the face d. BP of 180/120 mmHg, proteinura of +2 to +3 and no edema noted

37. The physician ordered magnesium sulfate to be given IM on the buttocks. Before administering the medication, the nurse must prepare which medication at bedside? a. aluminum hydroxide c. calcium gluconate b. protamine sulfate d. epinephrine 38. You are about to give the next dose of magnesium sulfate. Which of the following findings will warn you to withhold the medication? a. hypoactivity of the patellar reflex c. urine output of 20 cc/hour b. respiratory rate of 10 bpm d. BP of 90/70 39. To prevent convulsive attack, the nurse must include all in the intervention plan EXCEPT? a. do clustering of activity c. allow family visit to provide support b. provide dim light d. promote complete bed rest 40. Which of the following diagnoses should be prioritized for client with pre-eclampsia? a. fluid volume excess c. altered cerebral tissue perfusion b. risk for injury d. anticipatory grieving th Situation: A client who is on the 7 month of her pregnancy was admitted in the OB ward due to severe bleeding. In the history, you found out that she was diagnosed to have placental previa. 41. Which of the following is the classical manifestation of placental previa? a. Painless uterine contraction with bright red vaginal bleeding b. Painful uterine contraction dark red vaginal bleeding c. severe abdominal pain d. dropping of coagulation factor 42. In the delivery room, the physician performed an internal examination. With this procedure, you will anticipate to prepare which of the following? a. delivery pack c. D and C pack b. operating room d. oxytocin in case of uterine atony 43. Another client was admitted with the same complain of sever vaginal bleeding. In physical examination, you observed a board-like abdomen. With this assessment finding, you suspected that the client has? a. placental previa c. uterine atony b. abruptio placenta d. pathologic retraction ring 44. A pregnant client who is on the 3rd trimester of pregnancy went to the hospital with chief complaint of constipation. History revealed that she had placenta previa. The physician ordered to give castor oil to relieve the client from constipation. Your main nursing consideration for this order is? a. question the physician order b. instruct the mother to take the medication before going to bed c. tell the mother to save a part of the stool for laboratory examination d. instruct the mother to increase fluid intake to replace the GI losses 45. A pregnant client went to hospital for scheduled elective C-S delivery. During the operation, the physician made a classical vertical incision on the clients fundus. The advantages of this procedure includes the following EXCEPT: a. vaginal delivery is possible for the next pregnancy b. there is lesser blood loss and possibility of adhesion c. it allows the delivery of the fetus regardless of the presentation d. it bypasses the lower uterine abnormalities such as varicosities and myomas 46. A parturian mother went to the labor room in preparation for delivery. While shaving the perineal, you noticed lesions on the vaginal wall. You then suspect she may have herpes infection. With this assessment finding, your nursing consideration is: a. prepare the mother for C-S delivery b. obtain specimen for culture and sensitivity c. perform catheterization to allow the descend of the fetus d. discontinue the shaving for you may scraped the lesions Situation: You were the nurse on duty when a client was admitted due to massive bleeding. Your vital signs show shock manifestations. 47. Which of the following findings indicate that the client is developing shock? a. BP of 150/80 mm Hg, RR of 24 bpm, PR of 106 bpm b. BP of 80/70 mm Hg, RR of 25 bpm, HR of 115 bpm c. BP of 120/100 mm Hg, RR of 20 bpm, HR of 100 bpm d. All of the above 48. The physician ordered for Dopamine to be given as side drip. During the rounds, which assessment finding indicates referral to the physician? a. BP of 160/100 mm Hg c. RR of 11 bpm b. PR of 50 bpm d. Difficulty of breathing

49. Base on the findings, which of the following nursing interventions is most appropriate for the client? a. Position the client on left side lying to promote drainage b. Position the client in trendelenburg position c. Position the client in supine position d. Position the client in knee chest position 50. During vital sings taking, you noted that the client assumes the temperature of the environment. With this, you assume that the client is developing? a. Hypovolemic shock c. Cardiogenic shock b. Nuerogenic shock d. Septic shock .