FORMATIVE 1

1. A professional nurse is a person who has completed a basic training education program and is licensed
in his or her country or state to practice professional nursing. Augustus Waters has recently passed the
nursing licensure exam. He understands that he is now a professional who must possess the following attributes,
except:
a. Self-directed
b. Concerned with quantity
c. Independent
d. Committed to spirit of inquiry

Rationale:
Answer: B. A professional nurse is concerned with quality and not quantity. He is always concerned with the
QUALITY of care rather than the quantity of care given.

Characteristics and Attributes of a Professional Person:
Is concerned with QUALITY
Is self-directed, responsible and accountable for his actions
Is able to make independent and sound judgment
Is dedicated to the improvement of human life
Is committed to the spirit of inquiry

Qualifications of a Professional Nurse:
Professional Preparation
o License to practice nsg in the country
o BSN graduate
o Be physically and mentally fit
Personal Qualities
o Interest and willingness to work
o Warm personality and concern for people
o Resourcefulness and creativity
o Initiative to improve self and service
o Competence in performing work
o Skill in decision making, communicating and relating with others
o Active participation in issues confronting nurses and nursing
(Venzon, 10
th
ed, pg 6)

2. The choice a nurse makes about how he or she defines his or her professional self affects not only his
or her morale but also the nature of care the patients receive. Augustus Waters, a newly registered nurse,
often wondered about what it takes to be called a professional. He was referred to Jahodas definition of
profession which includes all but one of the following:
a. It includes the application of special knowledge that has rules and standards.
b. It is altruistic.
c. It serves specific interest of a group.
d. Quality of work is of greater importance than economic benefits.

Rationale:
Answer: C. A profession should serve ALL OF SOCIETY and not specific interests of a group.
Marie Jahodas implies that a profession is an organization of an occupational group based on application of special
knowledge which establishes its own rules and standards for the protection of the public and the professionals. A
profession implies that the quality of work done by its members is of greater importance in its own eyes and the
society than the economic rewards they earn.

Criteria of a Profession:
1. Specialized Education
2. Body of Knowledge
3. Service Orientation (which is altruistic)
4. Ongoing Research
5. Code of Ethics
6. Autonomy in Decision making and practice
(Kozier, 8
th
ed, pg 16; ULG, pg 9)

3. According to Peter Drucker, management is a practice rather than a science or a profession so there is
no precise solution, and the ultimate test of management is achievement and performance. Hazel Grace
has been appointed as the nurse manager in the surgical department. She bears in mind that the characteristic
she must imbibe being the manager is to:
a. Do things right
b. Use person-to-person influence
c. Focus on the future
d. Focus on the people

Rationale:
LEADERS MANAGERS
Do the right thing Do things right
Focus on people Focus on systems and structures
Use person to person influence Use position to position (superior-subordinate)
influence
Take initiative to lead Are given a position
Inspire people to change Motivate people to comply with standards
Rely on trust Rely on control
Focus on the future Focus on the present
Emphasize philosophy, core values, and shared
goals
Emphasize tactics, structure and systems

(ULG, pg 423)

4. Planning is defined as pre-determining a course of action in order to arrive at a desired result. It is
always based and focused on the vision, mission, philosophy, and clearly defined objectives of the
organization. Hazel Grace is a new staff at Green Memorial Hospital (GMH) and she intends to figure out more
about the organizations vision. She correctly identifies which of the following statements as the vision of the
hospital:
a. The GMH is a center of excellence providing holistic approach to health care services in the next five
years.
b. The GMH, as a public, tertiary hospital is maintained as the peoples partner to provide accessible,
quality, cost effective, health care services to the general public.
c. The GMH aims to provide a patient-centered care in a total healing environment.
d. The GMH is guided by the belief that each individuals personal worth and dignity should be respected.

Rationale:
Answer: A. A vision is the statement that outlines the organizations future role and function. It refers to what the
institution wants to become within a particular period of time.
Option B refers to mission. It is a statement that outlines the agencys reason for existing, who the target clients are,
and what services will be provided.
Option C refers to the goal. Goals are general while objectives are specific. They are action commitments through
which an organizations mission and purpose will be achieved and the philosophy or belief sustained.
Option D refers the philosophy. Philosophy describes the vision. It is a statement of beliefs and values that direct
ones life or practice.
(Venzon, 3
rd
ed, pg 16)

5. A budget is the annual operating plan, a financial road map and plan which serves as an estimate of
future costs and a plan for utilization of manpower, material and other resources to cover capital
projects in the operating programs. Nurse Rhiannon is heading the budgetary control program of their
organization. She does not need further teaching if she includes the following in operating budget, except:
a. Medications for the shift
b. Salary of staff
c. In-service education
d. Purchase of MRI

Rationale:
Option D belongs to capital budget. Purchase of capital equipment is included in the capital budget. Capital budget
outlines the programmed acquisitions, disposals, and improvements in an institutions physical capacity. Operating
budget deals primarily with salaries, supplies, contractual services, employee benefits, laundry service, drugs and
pharmaceuticals, in-service educations (such as the fire safety program), travels to professional meetings, books,
repairs and maintenance. The operating budget is composed of the revenue and expense budget.
(Venzon, 3
rd
ed, pg 30)

6. Policies are broad guidelines that govern the action of workers and supervisors at all levels and are
intended to achieve pre-determined goals. Nurse supervisor Isaac is reviewing the policies of the surgical
department. He is aware that the nursing service policy manual has the following purposes, aside from:
a. A tool for orienting new staff
b. A tool in ensuring that a procedure will be done according to protocol
c. A reference when unexpected problems arise
d. A basis for developing administrative procedures

Rationale:
Option B is the purpose of Procedure Manuals. They are effective tools in ensuring that a procedure will be done
according to the agencys protocol. These manuals should be complete, up-to-date, and properly indexed to facilitate
easy referral.
The nursing service policy manual is an effective tool for orienting new employees, a reference when unexpected
problems arise, a basis for developing administrative procedures, and a firm basis for discussion when differences
occur. Departmental policies should be carefully made to define the scope of departmental responsibility within the
hospital so they would reflect the policies of the hospital.
(Venzon, 3
rd
ed, pg 33, 36)

7. Ethical codes are systematic guides for developing ethical behavior. They answer normative questions
of what beliefs and values should be morally accepted. Miley is a newly hired staff nurse. The training
coordinator emphasized during the orientation that nurses must be guided by ethico-moral principles during the
execution of their functions. Who among the following nurses fails to practice this provision?
a. Sarah who regularly attends seminars on nursing
b. Lavinia who delegates vital signs taking to the UAP
c. Lotty who refuses to go to clubs in her duty uniform
d. Doding who acts as an advocate by insisting his beliefs to the client

Rationale:
Option D- According to Code of Ethics Art III (Nurses and Practice), Sec 8- nurses are the advocates of the patients.
They uphold the clients rights when conflict arises regarding management of their care. The statement is wrong
because the nurse insisted his beliefs to the client when the client must have his own. The nurse merely supports the
clients decisions, and not imposes his own beliefs.
Option A- Article VI (Nurses and Profession) requires the nurse to commit to continual learning and active
participation in the development and growth of the profession
Option B- Article IV (Nurses and Co-Workers) encourages collegial and collaborative working relationship with
colleagues
Option C- Article III (Nurses and Practice) says that the nurses actions have professional, ethical, moral, and legal
dimensions. They strive to perform their work in the best interest of all concerned.
(ULG, pg 479)

8. The Nursing Code of Ethics guides the nurse in her decision making specifically in dealing with the
significant others. Nurse Matthew strives to abide by the nurses code of ethics. He is fully aware that
according to the nursing code of ethics, his first allegiance should be to the:
a. Client only
b. Client and family members
c. Physician
d. Hospital



Rationale:
The client is the center of care, thus the nurses allegiance remains with the client. According to the Nursing Code of
Ethics Art III Sec 8: registered nurses are the advocates of the clients, and they shall take appropriate steps to
safeguard their rights and privileges.
**Allegiance commitment, loyalty
(ULG, pg 481)

9. Evidence-based practice uses cutting edge research and best practices to make the most effective
decision about patient care. Nurse Billy is taking his time integrating evidence based practice in the clinical
area. He is positive that which of the following critical thinking competencies is not applicable to evidence-based
practice?
a. Develops a plan of care based on research findings
b. Identifies meaningful research evidence
c. Objectively critiques research findings
d. Integrates personal experience and beliefs into the process

Rationale:
EBP uses the best research to integrate with clinical experience and in getting the best research, objective data is
needed. Integrating ones personal experience and beliefs into the process will inhibit ones ability to be objective.
Option A- research findings are evidence based as the nurse provides the best care for the client
Option B- The ability to identify meaningful research finding is a key component of critical thinking
Option C- Objectively criticizing research findings eliminates personal biases and will enable the researcher to
evaluate objectively.
(Kozier, 8
th
ed, pg 35)

10. It is the nurses responsibility to be aware of findings published in the literature, to question practice so
it can be continuously improved, and to participate in investigating better ways to improve health.
Nurses assigned in the surgical unit are having trouble implementing waste disposal management. They plan to
initiate data gathering regarding this problem. With the information obtained and to promote evidence-based
practice the nurses should:
a. Apply findings based on own intuition
b. Make recommendation and apply it to waste disposal management in the unit
c. Conduct a pilot study in several units of the hospital
d. Communicate findings to nurses in the other units

Rationale:
After making generalizations on the new information obtained, the nurse should state recommendations based on the
findings and conclusions of the study. Interpreting the results, communicating the findings, and suggesting directions
for further study conclude the research process. However, in EBP, the nurse still integrates research findings with
clinical experience, the clients preferences, and available resources in implementing care. (Kozier 8
th
ed, pg 35)
Option A- EBP must be research-based, not intuition-based
Option C- There is no need to conduct pilot study since a research study has already been conducted and produced
results.
Option D- Findings are communicated to nurses in other units once it has been established on their own unit.

11. Much of the theoretical work in nursing focused on articulating relationships among four major
concepts: person, environment, health, and nursing. Many consider these four concepts to be central to
nursing. Who among the following nursing theorist postulated that caring is a nurturant way of responding to a
valued client towards whom the nurse feels a sense of commitment and responsibility?
a. Sister Callista Roy
b. Jean Watson
c. Lydia Hall
d. Martha Rogers

Rationale:
Jean Watsons theory is the Human Caring Model. She believes the practice of caring is central to nursing; it is the
unifying focus for practice.
Option A- Adaptation Model- Roy focuses on the individual as a biophysical adaptive system that employs a
feedback cycle of input (stimuli), throughput, and output or behaviors/ adaptive responses.
Option C- Care-Core Cure- Hall insisted that nursing is a participation in care, core, cure aspects of patient care,
where care is the sole function of the nurses.
Option D- Science of Unitary Human Beings- Rogers views the person as an irreducible whole, the whole being
greater than the sum of its parts
(Kozier, 8
th
ed, pg 45)

12. Client records are legal documents that provide evidence of a clients care. The nurse has a legal and
ethical duty to maintain confidentiality of the clients record. Dr. Burke writes the following order for the
client who has been recently admitted Digitalis .125 mg P.O. once daily. To prevent a dosage error, how should
Nurse Xtina document this order onto the medication administration record?
a. Digitalis .1250 mg P.O. once daily
b. Digitalis 0.1250 mg P.O. once daily
c. Digitalis 0.125 mg P.O. once daily
d. Digitalis .125 mg P.O. once daily

Rationale:
The nurse should always place a zero before a decimal point so that no one misreads the figure, which could result in
a dosage error. The nurse should never insert a zero at the end of a dosage that includes a decimal point because
this could be misread, possibly leading to a tenfold increase in the dosage.

Guidelines on Preventing Medication Errors in Hospitals
1. Nurses should review patients medications with respect to desired patient outcomes, therapeutic
duplications, and possible drug interactions. Adequate drug information should be obtained from
pharmacists, nurses, other health-care providers, the literature, and other means when there are
questions. There should be appropriate followup communication with the prescriber when this is
indicated.
2. All drug orders should be verified before medication administration.
3. Patient identity should be verified before the administration of each prescribed dose.
4. All doses should be administered at scheduled times unless there are questions or problems to be
resolved.
5. The administration of medication should be documented as soon as it is completed.
6. Nurses should talk with patients or caregivers to ascertain that they understand the use of their
medications and any special precautions or observations that might be indicated.
7. When a patient objects to or questions whether a particular drug should be administered, the nurse
should listen, answer questions, and (if appropriate) double check the medication order and
product dispensed before administering it to ensure that no preventable error is made
8. If a patient refuses to take a prescribed medication, that decision should be documented in the
appropriate patient records.
(Kozier, 8
th
ed, pg 258)

13. The client record should describe the clients ongoing status and reflect the full range of the nursing
process. Nurses document evidence of the nursing process on a variety of forms throughout the clinical
record. Kanye, a staff of the quality management system of the hospital, is auditing the charts for
incongruencies. He will report the following documentation errors to his superior, except:
a. Nurse Kim who drew a line through her mistake and wrote the word error above it
b. Nurse North West who used correcting fluid to cover her mistake and made a new entry
c. Nurse Kendall who drew a line through the blank spaces in the chart
d. Nurse Kylie who documented that he charted for a co-worker and signed his name on the entry

Rationale:
One guideline of documenting is to avoid leaving blank spaces for a colleague to chart later. If a blank appears in a
notation or chart, draw a line through the blank space so that no additional information can be recorded at any other
time or by any other person, and sign the notion.
Option A- When a recording mistake is made, draw a line through it and write the words mistaken entry above or next
to the original entry with your name or initials. Avoid writing the word error when recording a mistake has been
made. Some believe that the word error has a red flag for juries and can lead to the assumption that a clinical error
has caused the injury.
Option B- Do not erase, blot out or use correction fluid. The original entry must remain visible.
Option D- Do not chart for someone else. Whatever you did, you document by yourself.
(Kozier, 8
th
ed, pg 262)

14. The purpose of reporting is to communicate specific information to a person or group of people. A
report, whether oral or written, should be concise, including pertinent information but no extraneous
detail. Van Houten, assigned nurse for the night shift, is trying to contact his clients attending physician to report
a change in his clients status however, the physician is unable to take the call. His secretary called Nurse Van
Houten after several minutes and relayed the physicians verbal order. Nurse Van Houten is correct to do which
of the following:
a. Insist that he talk to the physician instead
b. Dont accept the order from the secretary
c. Note the verbal order and let the physician sign within 24 hrs
d. Transcribe the phone order and document appropriately

Rationale:
The order must come from the physician himself.
Guidelines for Telephone and Verbal Orders:
write the complete order and read it back to the physician
question for any ambiguous or unusual orders
indicate whether telephone or verbal order in the physicians order sheet
order countersigned by the physician within 24 hours

R- epeat order to the physician
E- mergency only or no opportunity
W- rite details of orders in physician order sheet
R- equire MD to co-sign within 24 hrs.
I- dentify client for whom the order is made
T- wo nurses verify/ listen to the order is safe
E-vening shifts usually

Never follow a voice-mail order. Call the prescriber for a client order. Write down and read it back for
confirmation.
(Kozier, 8
th
ed)

15. A change-of-shift report provides continuity of care for clients by providing the new caregivers a quick
summary of client needs and details of care to be given. It may be written or given orally, either in a face-
to-face exchange or by audiotape recording. Student Nurse Peeta observes endorsement in the ward. He
takes note that which of the following behaviors by the reporting nurse does not represent effective nursing
practice?
a. Speaks loudly when giving the report
b. States priorities of care that are due shortly after the report
c. States the time the client last received pain medication
d. Provides medical diagnosis of client

Rationale:
The nurse does not have to speak loudly for it violates client confidentiality if others hear protected information. Be
aware of where the shift report takes place in order to maintain client confidentiality. An area that is private and free
from interruption is best.
Option B- Clearly state priorities of care and care this due after the shift begins. Give this information at the end of the
clients report because memory is best for the first and last information given.
Option C- Include current nurse-prescribed and primary care provider prescribed orders
Option D- For new clients, provide the reason for admission or medical diagnosis, surgery, diagnostic tests, and
therapies in the past 24 hours.
(Kozier, 8
th
ed, pg 263)

16. A number of documentation systems are in current use: the source-oriented record, the problem-
oriented medical record, the PIE model, focus charting, charting by exception, computerized
documentation, and case management. Nurse Diana, a newly hired staff, noticed that the hospitals chart has
separate sections from the admission sheet, physicians order sheet, and nurses notes. She identifies that
information are scattered throughout the chart and its a bit difficult to monitor clients progress. Based on her
observations, the hospital is most likely using which documentation system?
a. PIE model
b. Focus Charting
c. Problem-Oriented Medical Record
d. Source-Oriented Medical Record

Rationale:
The traditional client record is a source-oriented record. Each person or department makes notations in a separate
section of the clients chart. For example, the admissions department has admission sheet, the physician has
physicians order sheet and progress notes, nurses use the nurses notes, etc. In this type of record, information
about a particular problem is distributed throughout the record.
SOMR are convenient because care providers from each discipline can easily locate the forms on which to record
date and it is easy to trace the information specific to the discipline. The disadvantage is that information about a
particular client problem is scattered throughout the chart, so it is difficult to find chronological information on a
clients problems and progress. This can lead to decreased communication among the health team, an incomplete
picture of the clients care, and a lack of coordination of care.
Option A- The PIE documentation model groups information into three categories. It is an acronym for Problems,
Interventions, and Evaluation of nursing care. This system consists of a client care assessment flow sheet and
progress notes.
Option B- Focus charting is intended to make the client and client concerns and strength the focus of care. 3 columns
for recording are usually used: date and time, focus, and progress notes.
Option C- POMR is arranged according to the problems the client has rather than the source of the information.
Plans for each active or potential problem are drawn up and progress notes are recorded for each problem.
(Kozier, 8
th
ed, pg 247)

17. A balance of fluids, electrolytes, acids, and bases in the body is necessary for health and life. Fluids and
electrolytes move among the body compartments by osmosis, diffusion, filtration, and active transport.
Nurse Alaska assesses a 65-year-old woman admitted at the emergency department. Client history states that
she has refused to eat or drink anything for 3 days now. Nurse Alaska is accurate to observe which of the
following in her client:
a. BP of 160/100 mmHg
b. HR of 135 bpm that is weak and thready
c. Moist mucous membranes
d. Jugular vein distention

Rationale:
A client who has not eaten or drunk anything for several days would be experiencing fluid volume deficit. Signs and
symptoms include a low BP, dry mucous membranes, flat neck veins or collapsed veins, and weak and rapid pulse
rate.
A, C, and D are indicative of fluid volume excess.
(Kozier, 8
th
ed)

18. Potassium influences both skeletal and muscle activity. Serum potassium levels and ECG changes are
crucial to the diagnosis of hypokalemia. Nurse Giovanna is reviewing the laboratory results of her client and
notes that the potassium level is 3 mEq/L. Which of the following would Nurse Giovanna expect in the ECG
reading as a result of this laboratory value?
a. Tall tented T waves
b. Elevated ST segment
c. Absent P waves
d. U waves

Rationale:
Normal levels of potassium is 3.5- 5 mEq/L. The patient has hypokalemia. Common manifestations are: Fatigue,
anorexia, nausea and vomiting, muscle weakness, polyuria, decreased bowel motility, ventricular asystole or
fibrillation, paresthesias, leg camps, BP, ileus, abdominal distention, hypoactive reflexes,
ECG changes: flattened T waves, prominent U waves, ST depression, prolonged PR interval.
Option A- tall tented T wave is found in hyperkalemia along with prolonged PR interval and QRS duration, absent P
waves, and ST depression.
(Brunner, 11
th
ed, pg 316)

19. Identification of the specific acid-base imbalance is important in identifying the underlying cause of the
disorder and determining appropriate treatment. Upon admission of a client, Nurse Hermione observed rapid
respirations, confusion, and signs of dehydration. ABG was taken and the values are as follows: pH of 7.27;
HCO3 of 20mEq/L; and PaCO2 of 33mmHg. Nurse Hermione accurately interprets these values as:
a. Metabolic Alkalosis
b. Metabolic Acidosis
c. Respiratory Alkalosis
d. Respiratory Acidosis

Rationale:
Metabolic acidosis is a clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma
bicarbonate concentration. Chronic metabolic acidosis is usually seen with chronic renal failure. The cardinal feature
of metabolic acidosis is a decrease in the serum bicarbonate level. Hyperventilation decreases the CO2 level as a
compensatory action which is responsible for the drop in PaCO2.
To determine acid-base balance disturbance:
a. Label the pH. Is it acid or base?
b. Find the cause. Is it metabolic or respiratory?
c. Determine compensation. Is it uncompensated (either HCO3 or PaCO2 is normal), partially compensated (all
are abnormal), or fully compensated (only pH is normal)?
(Brunner, 11
th
ed, pg 335; ULG)

20. Blood gas analysis is often used to identify the specific acid-base disturbance and the degree of
compensation that has occurred. A client has an order of ABG analysis. Nurse Lana knows that Allens test
must be performed first before ABG specimen is drawn. She is positive that Allens test checks the patency of
the:
a. Ulnar artery
b. Radial artery
c. Carotid artery
d. Brachial artery

Rationale:
Allens Test is a test used in medicine prior to arterial blood gas collection in order to determine normal patency of the
ulnar artery.
To perform an Allens test:
1. The patients hand should be elevated above his or her heart;
2. The patients should be asked to make a fist;
3. Pressure should be applied to both the radial and the ulnar artery until distal blood flow is occluded;
4. While maintaining the elevated hand position, the patient should then open the hand. The hand should
appear pale and have limited capillary refills;
5. The ulnar arterial pressure should be released (while maintaining enough pressure to occlude the radial
artery).
6. The hand should return to normal color within 5-7 seconds.
If the patients hand returns to normal color within 3-7 seconds the Allens test is said to be negative and the patient
has normal dual blood supply. If the patients hand returns to normal after 7 seconds, the Allens test is said to be
negative and the patient does not have dual blood supply to the hand (or if he or she does, it is very small).
When the Allens test is positive (meaning that the patient does not have dual blood supply to the hand), he or she
will often have a negative result for the other hand. Therefore, to reduce the risk of ischemia to that hand, it is
important to perform the cannulation or arterial blood gas collection from the hand with dual blood supply.
(Emergency Medical Paramedic, 2013)

21. Restraint is the direct application of physical force to a person, without his or her permission, to restrict
his or her freedom of movement. The physical force may be human, mechanical, or both. Nurse Bellamy
is caring for a client with a four-point restraint as ordered by the physician. He is correct to prioritize which of the
following in the client care?
a. Frequently assess the temperature
b. Have him socialize with other clients once per shift
c. Check circulation every 15-30 minutes
d. Provide diversional activities

Rationale:
Restraints encircle the limbs, which place the client at risk for circulation being restricted to the distal areas of the
extremities. Checking the clients circulation every 15-30 minutes will allow the nurse to adjust the restraints before
injury from decreased blood flow occurs.
The five criteria when using restraints:
1. It restricts the client movement as little as possible. If a client needs to have one arm restrained, do
not restrain the entire body.
2. It does not interfere with the client's treatment or health problem.
3. It is readily changeable.
4. It is safe for the particular client.
5. It is the least obvious to others. Both clients and visitors are often embarrassed by a restraint, even
though they understand why it is being used.
(Kozier, 8
th
ed)

22. Hazards to safety occur at all ages and vary according to the age and development of the individual.
Nurses need awareness of what constitutes a safe environment for specific individuals and for groups of
people in the home, community, and workplace. Nurse Hotch is caring for a 65-year-old confused elderly.
Bearing in mind that his client is at risk for falls, Nurse Hotch puts priority in which of the following nursing
interventions?
a. Administer anxiolytics as prescribed.
b. Keep side rails up all the time.
c. Place the client farthest from the nursing station.
d. Place the bed in the lowest position.




Rationale:
Falls are the leading cause of injuries among older adults. Placing the bed in the lowest position results in a client
falling the shortest distance. When a client falls, the nurses first duty is to the client. First, assess for injuries. Then,
notify the physician.
Option A- Independent actions first before dependent.
Option B- side rails are a form of restraints and restraints should be given as a last option. Putting up side rails
without putting the bed at its lowest position can cause injuries from falls because the client may fall from a higher
distance while trying to get over the rail.
Option C- the client should be placed near the nurses station so that if an injury occurs, the nurse can immediately
intervene. The nurse must also instruct the client on how to use call bells when he needs assistance in his activities.
(Kozier, 8
th
ed, pg 723)

23. The nurse who prepares the medication administers it and must never leave a prepared medication
unattended. The nurse always identifies the client appropriately before administering a medication and
stays with the client until the medication is taken. Nurse Fantine is about to administer a tablet to her client,
Mr. Valjean, when the client says, This doesnt look like the drug I usually take. Which of the following is the
best response by Nurse Fantine?
a. This is it Mr. Valjean. You must have seen wrong.
b. Maybe your doctor ordered a different medication.
c. Ill recheck your medication orders.
d. Let me leave the tablet here while I check with your doctor, Mr. Valjean.

Rationale:
If there is any doubt about the medication administered, the medication administration process must be interrupted
until the question is clarified. Medication should never be left unattended. Listen to the client. Find out any other
information the client may have about a certain medication. Review the chart to make sure there is no discrepancy
between the physicians order and the medication administration record.
When administration medications the nurse observes specified rights to ensure accurate administration. When
preparing medications, the nurse checks the medication container label against the medication administration record
for three times.
(Kozier, 8
th
ed, pg 899)

24. The drug order has seven essential parts: full name of the client, date and time the order is written, name
of the drug to be administered, dosage of the drug, frequency of administration, route, and signature of
the person writing the order. The physician ordered Ampicillin 13 g, PO, BID. Ampicillin is available as 2,000
mg tablets. How many tablets will Nurse Marcus administer per day?
a. 6 tablets
b. 6 tablets
c. 12 tablets
d. 13 tablets

Rationale:
1. Convert 2,000 mg to g: 2,000mg / 1,000 = 2 g
2. Formula: Desired / Hand x vol or tab 13 g / 2 g x 1 tab = 6.5 or 6 tablets
3. Tablets / day: order: BID 6.5 tabs x 2 = 13 tablets per day

25. A safety issue that affects the nurse is to ensure that clients receive the appropriate medications and
dosages on admission, during transfer, and at discharge. Nikko, 10 yrs old, was admitted due to persistent
diarrhea. Nikko is to receive 400cc of D5W in an 8-hour shift. The physician ordered the fluid to be administered
via a microset. Nurse Lea is aware that the IV rate that will deliver this amount is:
a. 12.5 cc/hr
b. 40 cc/hr
c. 50cc/hr
d. 60 cc/hr

Rationale:
IV rate is the mL/hr.
Total infusion volume / total insfusion time = mL/hr
400 cc / 8 hrs = 50cc/hr

26. Public health refers to the health status of a defined group of people and the governmental actions and
conditions to promote, protect and preserve their health. Eponine wants to become a public health nurse in
her community. Before she can become one, she has to bear in mind that which of the following is the most
prominent feature of public health nursing?
a. Public health nursing focuses on preventive, not curative, services.
b. It involves providing home care to sick people who are not confined in the hospital.
c. The public health nurse functions as part of a team providing public health nursing services.
d. Services are provided free of charge to people within the area.

Rationale:
Public health nursing according to C.E. winslow is the science and art of preventing disease, prolonging life,
promoting health and efficiency through organized community effort, the core of which is prevention.
Option B- PHN is universal and it extends even to people in the hospital, both sick and well.
Option C- is a correct statement but is not the most prominent feature of PHN
Option D- services are not totally free but are affordable.
(Reyala, pg 4)

27. Public health is a core element of governments attempts to improve and promote the health and welfare
of their citizens. The classic definition of public health comes from C.E. Winslow. Nurse Eponine
comprehends that according to C. E. Winslow, the goal of public health is:
a. For promotion of health and prevention of disease
b. For people to have access to basic health services and free services
c. For people to attain their birthrights of health and longevity
d. For people to be organized in their health efforts to prevent disease

Rationale:
According to C.E. Winslow, Public Health is the Science and art of preventing disease, prolonging life, promoting
health and efficiency, through organized community effort for the sanitation of the environment, control of
communicable diseases, the education of individuals in personal hygiene, the organization of medical and nursing
services for the early diagnosis and preventive treatment of disease, and the development of the social machinery to
ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to
enable every citizen to realize his birthright of health and longevity goal.
Option A- according to WHO
Option C- wrong because public health services are affordable rather than free
Option D- community organization is aimed at promoting health rather than preventing disease
(Reyala, pg 5)

28. Millenium Development Goals are based on the fundamental values of freedom, equality, solidarity,
tolerance, health, respect for nature, and shared responsibility. The Department of Health and the public
health system strives to reach the first of the millennium development goals which is to:
a. Reduce child mortality
b. Improve maternal health
c. Develop a global partnership for development
d. Eradicate extreme poverty and hunger

Rationale:
Except for goals 2 and 3, all the MDGs are health or health-related. Health is essential to the achievement of these
goals and is a major contributor to the overarching goal of poverty reduction. The 8 MDGs are the following:
1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria, and other diseases
7. Ensure environmental sustainability
8. Develop a global partnership for development
(Reyala, pg 3)

29. The core business of public health cannot be achieved without the proper delivery of essential public
health functions which were described as a set of fundamental activities that address the determinants
of health, protect a populations health, and treat a disease. The following are essential public health
functions, aside from:
a. Technology appropriate in community
b. Health situation monitoring and analysis
c. Epidemiological surveillance
d. Health promotion, social participation and empowerment

Rationale:
Option A- is a part of strategies of primary health care (REMOTE OL)
Strategies of PHC:
Reorientation & reorganization
Effective prep & enabling process
Mobilization of people
Organization of community
Technology appropriate in community
Emphasizing partnership
Opportunities for participation
Linkages with different sectors

Essential public health functions are:
1. Health situation monitoring and analysis
2. Epidemiological surveillance/ disease prevention and control
3. Development of policies and planning in public health
4. Strategic management of health systems and services for population health gain
5. Regulation and enforcement to protect public health
6. Human resources development and planning in public health
7. Health promotion, social participation and empowerment
8. Ensuring the quality of personal and population based health services
9. Research, development and implementation of innovative public health solutions.
(Reyala, pg 6)

30. Public health nursing and community health nursing have been interchangeable used in the Philippines.
Who among the following coined the term public health nursing and noted this as a service that was available to
all people?
a. World Health Organization
b. C.E. Winslow
c. Lillian Wald
d. Ruth B. Freeman

Rationale:
PHN was coined by Lillian Wald to denote a service that was a service that was available to all people.
WHO defines PHN as a special field in nursing that combines skills of nursing, public health and some phrases of
social assistance and functions as a part of the total public health program for the promotion of health, the
improvement of conditions in the social and physical environment, rehabilitation of illness and disability.
C.E. Winslow defines Public Health is the science and art of preventing disease, prolonging life, promoting health and
efficiency, through organized community effort for the sanitation of the environment, control of communicable
diseases, the education of individuals in personal hygiene, the organization of medical and nursing services for the
early diagnosis and preventive treatment of disease, and the development of the social machinery to ensure
everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable
every citizen to realize his birthright of health and longevity.
Ruth Freeman did not define PHN but CHN. CHN according to her refers to a service rendered by a professional
nurse with communities, groups, families, individuals at home, etc. for the PROMOTION OF HEALTH, PREVENTION
OF ILLNESS, CARE OF THE SICK AT HOME, and REHABILITATION.
(Reyala, pg 7)

31. Various categories of health workers make up the primary health care team. The types vary in different
communities depending upon: available health manpower resources, local health needs and problems,
and political and financial feasibility. Nurse Dan Howell is conducting an orientation to the new staff nurses
deployed in the Rural Health Unit. He asks the novice nurses where they belong among the levels of primary
health care workers. Who among the following do not need further teaching:
a. Charlie says Intermediate level health worker
b. Finn says Manager of the RHU
c. Jack says Low level health worker
d. Phil says Liaison person of the community

Rationale:
Types of Primary Health Care Workers:
1. Village or Barangay Health Workers (BHWs)
Trained community health workers or health auxillary volunteer or traditional birth attendant or
healer
2. Intermediate level health workers
General medical practitioners or their assistants
Public health nurse, rural sanitary inspectors and midwives
(Reyala, 2007, pg 32)

32. Public health nurses are found in various health settings and occupying various positions in the
hierarchy. Under the restructured health care delivery system, the following comprise the basic primary health
care team EXCEPT:
a. doctor
b. public health nurse
c. midwife
d. barangay health worker

Rationale:
The PHC team consists of the physician, nurses, midwives, nurse auxillaries, locally trained community health
workers, traditional birth attendants and healers. In the Philippines, under the restructured health care delivery
system, a physician, a public health nurse, and midwives compose the basic primary health care team.
(Reyala, 2007, pg 32)

33. Public health nurses have broad roles and functions. Emphasis given on specific role and function is
dependent on the position description of the public health nurse in the hierarchy of the health care
system. In carrying out the program in her barangay, Nurse Cossette monitors and evaluates the performance
of midwives assigned to her. Therefore, Nurse Cossette is performing the role of:
a. Supervisor
b. Health Provider
c. Manager
d. Coordinator

Rationale:
Roles of the Public Health Nurse:
Manager- organize the nursing service; responsible for the delivery of services provided
Supervisor- supervises midwives and other health workers; formulates supervisory plan and conducts
supervisory visits
Nursing Care Provider- inherent function; cares for clientele toward health promotion and disease prevention
Collaborator and Coordinator- brings activities or group activities into proper relation and harmony with each
other
Health Promoter and Educator- provides information that allows clients to make healthier choices and practices
Trainer- formulation of staff development and training of midwives and health workers
Researcher- participates in the conduct of research
(ULG by Balita, pg 7)

34. The Public Health Nurse uses various tools and procedures necessary for her to properly practice her
profession and deliver basic health service. Nurse Ted functions as a manager in the RHU. You will not
include which of the following as Nurse Teds tasks as a manager, except:
a. He brings activities into proper relation and harmony with each other.
b. He is responsible for the delivery of services provided.
c. He formulates staff development and training.
d. He formulates supervisory plans.

Rationale:
The Manager is responsible for organizing the nursing service and for the delivery of services provided.
Option A- Collaborator/ Coordinator
Option C- Trainer
Option D- Supervisor
**Functions Item no. 33
(ULG, pg 7)

35. Occupational Health Nursing is the specialty practice that provides for and delivers health care services
to workers and worker populations. Gino has been working as an occupational health nurse in Liwayway
Factory. He understands that all of the following are true about his line of work, except:
a. Independent nursing judgments characterize his practice.
b. He focuses on the promotion, protection and restoration of the workers health.
c. He is not professionally accountable to workers and employers.
d. He is the key to the coordination of health services.

Rationale:
Option C- Occupational health nurses are professionally accountable to workers (their primary responsibility),
employers, their own profession, and themselves.
All other options are correct.
Occupational health nurses focus on the promotion, protection, and restoration of workers health within the
context of a safe and healthy work environment
Autonomy and independent nursing judgments characterize the practice of occupational health nursing
With a research-based foundation, occupational health nursings theoretical, conceptual, and factual
framework is multidisciplinary.
Occupational health nurses are advocates for workers and encourage and enable individuals to make
informed decisions about health care concerns.
Through collaborative practice with other occupational health and safety professionals, occupational health
nurses are key to the coordination of a holistic approach to the delivery of quality, comprehensive
occupational health services.
The essential elements of occupational health and safety services are defined by the Standards of
Occupational Health Nursing Practice.
(Reyala, pg 108)

36. School nursing is a type of public health nursing that focuses on the promotion of health and wellness
of the pupils/students, teaching and non-teaching personnel of the schools. Nurse Francis has been newly
appointed as a school nurse in an elementary school. In order to give quality care, he must be aware of his
health care provider functions which includes:
a. Taking remedial action on an accident hazard in the school playground
b. Conducting rapid classroom inspection during a measles epidemic
c. Requesting for BCG from the RHU for school entrant immunization
d. Observing places in the school where pupils spend their free time

Rationale:
Option B- Rapid classroom inspection is assessment of pupils/students and teachers for signs of a health problem
prevalent in the community. This is the priority of a health care provider. One of the goals of rapid classroom
inspection is to detect cases of communicable diseases. During epidemics, special attention must be given to signs
and symptoms peculiar to the disease in question.
Option A- is the primary task of a clinic teacher
Option C- is not mandatory for school nurses
Option D- is not a priority

Functions of a School Nurse:
1. School Health and Nutrition survey
2. Putting up a functional school clinic
3. Health Assessment
4. Standard Vision Testing for School Children
5. Ear Examination
6. Nutritional Status Determination
7. Medical Referrals
8. Attendance to Emergency cases
9. Student Health Counseling
10. Communicable Disease Control
11. Rapid Classroom Inspection
12. Home Visitation
(Reyala, pg 95)

37. School nurses are the front liners in the provisions of health and nutrition programs in school. The
primary role of the school nurse is to support student learning and ensure that educational potential is
not hampered by unmet health needs. As the acting school nurse of Hopia Elementary School, Nurse
Vanessa performs health assessment to every school child. You will correct Nurse Vanessa if she does which of
the following during health assessment, aside from:
a. She asks the child to inform parents about the findings.
b. She performs deworming after school feeding programs if child is malnourished.
c. She privately examines each child in a separate room.
d. She examines every school child once a year.

Rationale:
Every school child should be examined once a year and as the need arises during epidemics.
Option A- The nurse should inform the parents of the child about the findings herself. The child has limited
understanding about the assessment.
Option B- Deworming is a pre-requisite BEFORE feeding programs. Parental consent is a must before deworming is
done.
Option C- If the health personnel is of the opposite sex, assessment must be done in the presence of other school
personnel preferable of the SAME SEX.
(Reyala, pg 93)

38. Home visitation is necessary in the effective implementation of the total school program. Due to lack of
time and personnel, however, the nurses will have to use a great deal of judgment, for not all cases can
be followed up and all homes visited. Lancelot, a school nurse, would give priority in performing a home visit
in which of the following children, except:
a. Detty who suffers from malnutrition
b. Nerry whose parents wont consent to a much needed surgery
c. Ejay who is recovering from chickenpox
d. Elsa who is frequently absent because of her lolos death

Rationale:
The following are cases needing home visitation:
1. Pupils whose parents are afraid of some medical procedures (Option B)
2. Pupils who get re-infected because of home conditions
3. Pupils suffering from communicable diseases (Option C)
4. Pupils who are absent frequently because of sickness.
5. Pupils who are malnourished. (Option A)
(Reyala, pg 97)

39. World Health Organization defines mental health as a state of well being where a person can realize his
or her own abilities to cope with normal stresses of life and work productively. Nurse Carrie is well
informed about the four facets of mental health problems as a public health burden. Her co-worker asked what
undefined burden is. Nurse Carrie correctly refers to which of the following as undefined burden:
a. Stigma that accompanies mental illness
b. Financial burden on family members
c. Emotional burden on the person with mental illness
d. Violation of human rights that comes from mental illness

Rationale:
Undefined burden is the portion of the burden relating to the impact of mental health problems to persons other than
the individual directly affected. Mental illness is disabling and lasts for many years. It puts a tremendous burden on
the emotional and socio-economic capabilities of relatives who care for the patient, especially when the health
system cannot offer treatment and support at an early age.
Option A & D- Hidden Burden. It refers to the stigma and violations of human rights. Stigma is a mark of shame,
disgrace or disapproval that results in a person being shunned or rejected by others
Option C- Defined Burden refers to the burden currently affecting persons with mental disorders and is measured in
terms of prevalence and other indicators such as quality of life indicators.
Future Burden refers to the burden in the future resulting from the aging of the population, increasing social problems
and unrest inherited from the existing burden.
(Reyala, pg 228)

40. The process of attaining and maintaining mental well-being across the life cycle through the promotion
of healthy lifestyle with emphasis on coping with psychosocial issues. Tyler, diagnosed with
Schizophrenia, is ready to be discharged in the community. During the first week of his integration in the
community, children have been pointing fingers at him and saying hes crazy. This is what type of burden?
a. Defined burden
b. Undefined burden
c. Future burden
d. Hidden burden

Rationale:
Hidden Burden refers to the stigma and violations of human rights. Stigma is a mark of shame, disgrace or
disapproval that results in a person being shunned or rejected by others. The stigma associated with all forms of
mental illness is strong but generally increase the more a persons behavior differs from that of the norm.
(Reyala, pg 228)

41. The epidemiologic triangle of disease causation consists of three components- host, environment, and
agent. A change in any of the component will alter an existing equilibrium to increase or decrease the
frequency of disease. Nurse Detty, a public health nurse in Barangay Hopia, is interested in teaching the
students about the elements of the ecologic triad. She appropriately informs them by saying which of the
following, except:
a. TB is caused by the agent tubercle bacilli.
b. The host of schistosomiasis is the snail oncomelania quadrasi.
c. The vector of dengue is the day-biting Aedes Egypti.
d. Extrinsic factors include occupation.

Rationale:
The epidemiologic triangle or the ecologic triad are:
AGENT- any element, substance, or force, either animate or inanimate, the presence or absence of which
may serve as stimulus to initiate a disease process.
o Ex: Biological (viruses, bacteria, fungus, parasite), Chemical (insecticide, lead), Physical,
Mechanical, Nutritive (vitamins, proteins)
HOST (instrinsic)- influences exposure, susceptibility, or response to agents; HUMAN is the host organism
o Ex: Immunologic experience, Age, Nonspecific resistance (intact skin, coughing, other reflexes),
Human behavior (hygiene, food handling)
ENVIRONMENT (extrinsic)- influences existence of the agent, exposure, or susceptibility to agent
o Ex: Physical environment (geology, climate), Biologic environment (sources of food, vectors such
as vertebrates and other sources of agents), Socio-economic environment (occupation,
urbanization, disruption)
Option A- The snail is not the host but the vector of the disease. Vectors are part of environmental factors.
(Reyala, pg 64- 65)

42. Communicable disease transmission is a complicated but well-studied process that is best understood
through a conceptual model known as the chain of infection. Julia is studying the chain of infection. She will
not be corrected if she identifies the following as a reservoir, except:
a. A perfectly healthy human
b. Salmonella
c. Human suffering from TB
d. A flock of birds

Rationale:
Option B is an agent or a causative agent. Salmonella is the causative agent of typhoid fever.
The reservoir of an infectious agent is the habitat in which the agent normally lives, grows, and multiplies. Reservoirs
include humans, animals, and the environment. The reservoir may or may not be the source from which an agent is
transferred to a host. For example, the reservoir of Clostridium botulinum is soil, but the source of most botulism
infections is improperly canned food containing C. botulinum spores. Reservoirs can be humans (sick or well),
animals, and the environment.
(Center for Disease Control and Prevention, www.cdc.gov)

43. The chain of infection is a process that begins when an agent leaves its reservoir or host through a
portal of exit, and is conveyed by some mode of transmission, then enters through an appropriate portal
of entry to infect a susceptible host. Nurse Ariel is positive that the most effective way to break the chain of
infection is by:
a. Wearing gloves
b. Placing clients in isolation
c. Practicing good hand hygiene
d. Providing private rooms for clients

Rationale:
Good hand hygiene / hand washing is the single most effective way to break the chain of infection.
Wearing gloves can help in decreasing disease transmission, but clean hands are required for it to be truly effective.
Placing clients in isolation is costly and often unnecessary, and clients can be psychologically harmed by isolation.
Even providing private rooms for clients will not be effective if health care workers do not follow good hand hygiene
practices.
(Center for Disease Control and Prevention, www.cdc.gov)

44. An infectious agent may be transmitted from its natural reservoir to a susceptible host in different ways.
There are different classifications for modes of transmission. Nurse Harry is reviewing updates in CDC that
he can apply in their unit. The following statements reflect the current trend in the directives from the Centers for
Disease Control and Prevention (CDC) for minimizing risks of infection, aside from:
a. Gown and gloves should be removed after leaving the room of the client
b. Do not wear the same gown for the care of more than one client.
c. Do not recap syringes or break needles off before discarding into sharps containers.
d. None of the above

Rationale:
Option A- Remove PPE before leaving the exam room or client environment (except respirators which should be
removed after exiting the room). Gloves should be removed first, followed by gowns, facemask, and googles. Hand
hygiene should be done afterwards.
Option B- Use one gown per client to prevent cross-contamination.
Option C- Needles are not to be recapped or cut because of the increased risk of experiencing puncture wounds
while doing so.
(Center for Disease Control and Prevention, www.cdc.gov)

45. Knowledge of the portals of exit and entry and modes of transmission provides a basis for determining
appropriate control measures. In general, control measures are usually directed against the segment in
the infection chain that is most susceptible to intervention. Nurse Freya has just admitted 32-year-old Niall
to rule out active hepatitis B. Niall is confused, spitting and scratching everyone who enters the room. Nurse
Freya is correct to do which of the following?
a. Wait an hour until Niall calms down and then use gloves when touching him.
b. Use gloves, mask, face shield, and gown when entering the room to perform the initial assessment.
c. Administer a sedative and then perform the assessment after he is asleep; no precautions would be
needed.
d. Realize that isolation equipment might further confuse him and avoid using a face mask and shield but
use gown and gloves.

Rationale:
Hepatitis virus is a blood-borne virus, but the client is increasing the risk of cross contamination by spitting (saliva can
be a source of bacterial contamination) and scratching others, which can break the skin and become a source of risk.
All of the barriers listed would minimize cross contamination from the client to the nurse.
Even though gloves may be all that is needed because of limited contact with the client, after an hour the client will
remain confused and may not understand. The client may become aggressive again and spit or scratch, and other
barriers are needed to stop that source of possible risks. A sedative may be given if needed, but trying to perform an
assessment when the client is asleep is not appropriate and will prevent the nurse from successfully establishing
rapport with the client. Although masks and shields might be frightening to some confused clients, if the client is
spitting and body fluids could be exchanged, a barrier should still be used.
(Center for Disease Control and Prevention, www.cdc.gov)

46. The female internal reproductive organs are the vagina, uterus, fallopian tubes, cervix and ovary. The
external components include the mons pubis, pudendal cleft, labia majora, labia minora, Bartholin's
glands, and clitoris. Nurse Amy March is providing information to a client on the female reproductive system.
While discussing the uterus and its different layers, Nurse Amy understands that the myometrium has unique
muscle fibers that make it ideally suited for the birth process. She would describe this layer to the client as:
a. The inner layer of muscle that is in the uterus
b. The middle layer of thick muscle in the uterus
c. The functional layer that lies above the basal layer of the uterus
d. The outer layer of muscle that covers most of the uterus

Rationale:
The myometrium is the middle layer of thick muscle in the uterus. These muscles assist the birth process by expelling
the fetus, ligating blood vessels after birth, and controlling the opening of the cervical os.
Option A- Endometrium
Option D- Perimetrium/ Epimetrium
(Saunders, 5
th
ed)

47. The menstrual cycle is the series of changes a woman's body goes through to prepare for a pregnancy.
The average menstrual cycle is 28 days. Andrea, 30 years old, has been attempting to become pregnant. She
and her husband sought information from Nurse Minerva as to the optimum timing of intercourse during her
cycle. She stated that she has a 35-day menstrual cycle. Nurse Minerva would know that the counseling was
effective when the couple states that they should have intercourse on the:
a. 12
th
day of the cycle
b. 14
th
day of the cycle
c. 21
st
day of the cycle
d. 25
th
day of the cycle

Rationale:
Ovulation occurs 14 days before menstruation. In a 35-day cycle, ovulation may occur as late as the 21
st
day.
35-14= 21
(Mosby, 5
th
ed)

48. Infertility primarily refers to the biological inability of a person to contribute to conception. It may also
refer to the state of a woman who is unable to carry a pregnancy to full term. Fifi has been taking
clomiphene citrate (Clomid) for three months now to treat anovulatory cycles. She visits the health clinic and
complains to the nurse of vaginal dryness. She says that penetration during intercourse is becoming difficult. An
appropriate response by the nurse would be:
a. I know that you are concerned about this Fifi, but this is only temporary.
b. This is good news! This means that you are probably beginning to ovulate.
c. This is a common side effect; use a water-soluble lubricant to ease penetration.
d. Stop Clomid immediately. Well have to report this to your physician.

Rationale:
Vaginal dryness is a common and expected side effect of Clomid. The nurses response shows understanding and it
also offers a possible solution.
The side effect continues as long as the drug is continued, it is not only temporary.
Clomiphene citrate (Clomid)
Therapeutic Class: female reproductive agent
Action: Antiestrogen that binds with estrogen receptors to trigger FSH and LH release.
Side Effects: Patients may experience ovarian enlargement, vasomotor flushes, abdominal distention, nausea and
vomiting, breast tenderness, blurred vision, headache, pelvic pain, abnormal uterine bleeding. May cause multiple
ovulation.
(Mosby, 5
th
ed)

49. Primary infertility refers to couples who have not become pregnant after at least 1 year of unprotected
sex (intercourse). Secondary infertility refers to couples who have been pregnant at least once, but
never again. Because an infertility check-up involves both partners, Mr. Brad Pritt decided to have a semen
analysis. As a part of his instructions, Nurse Gelina should tell him to do which of the following?
a. Use a condom to collect the semen specimen
b. Make sure that the semen is collected as soon as he awakens
c. Collect specimen after 48 to 72 hours of abstinence and bring it to the clinic within 2 hours
d. Refrigerate the specimen until it can be delivered to the laboratory

Rationale:
Semen or sperm analysis, where the semen is freshly ejaculated, is the most important diagnostic tool in the initial
investigation of male fertility. For the semen analysis result to be most valuable, proper collection of the specimen is
essential. The semen analysis is performed on a fresh specimen within 2 hours of collection. Before testing, a period
of 2 to 5 days of abstinence from ejaculation is recommended. It can be collected at home provided the sample is
rapidly transported (within 1 hour) and kept at body temperature.
(Pillitteri, 5
th
ed)

50. Abortion is the termination of pregnancy by the removal or expulsion from the uterus of a fetus or
embryo prior to viability. Sophie, 10 weeks AOG, arrives at the hospital with some vaginal spotting and
abdominal cramping. Nurse Sarry performs vaginal examination and reveals that her cervix is 2cm dilated.
Based on the manifestations, Nurse Sarry would conclude that Sophie is having a/an:
a. Complete abortion
b. Threatened abortion
c. Inevitable abortion
d. Incomplete abortion

Rationale:
Once cervical dilation has begun, the abortion is classified as inevitable.
Option A- the products of conception have been completely expelled in a complete abortion
Option B- bleeding and cramping may be present but the cervix is still closed in a threatened abortion
Option D- The products of conception have been partially expelled with an incomplete abortion
(Mosby, 5
th
ed)

51. The most common cause of spontaneous abortion during the first trimester is chromosomal
abnormalities of the embryo or fetus. Jessy, 10

weeks pregnant, comes to the hospital because she
experiences spotting and abdominal cramping. Upon internal examination by the midwife, her cervix is 0cm
dilated. What would be the best intervention that Nurse Matteo should implement or advise her?
a. Rest at home, and do not move until bleeding stops. Complete bed rest can stop bleeding. Save and
count the number of pads saturated with blood.
b. Avoid sexual intercourse for 2 weeks
c. Administer Misoprostol as prescribed. Avoid strenuous activities for 1 week.
d. Support the mother emotionally. Explain fully the main intervention which is dilatation and curettage.

Rationale:
She only experiences threatened abortion, which is manifested by vaginal bleeding with slight cramping but without
cervical dilatation. Coitus is usually restricted for 2 weeks after the bleeding episode to prevent infection and avoid
further bleeding.
Complete bed rest is usually not indicated. It can only stop bleeding while woman is lying, but will not totally stop
bleeding especially when woman starts to ambulate.
Misoprostol (Cytotec) must not be administered because it can dilate the cervix and cause preterm labor. It is only
administered when patient had missed miscarriage. Strenuous activities must be avoided for 1-2 daysthis is the
key intervention.
Dilatation and curettage is performed in incomplete miscarriage when fragments of the fetus have already been
expelled.
(Pilliteri. 5
th
ed. pp. 402-406)

52. Vaginal bleeding is a deviation from the normal that may occur at any point during pregnancy. Vaginal
bleeding should always be investigated for, as its occurrence in sufficient amounts can significantly
impair the outcome of the pregnancy and the womans health. Blair Bass, a 30 year old G4P3, has just
been admitted because of excessive vaginal bleeding. Her husband found her asleep, with blood pooling
beneath her. Priority nursing action for Blair is to:
a. Place her on bed rest in a side lying position
b. Perform abdominal examination
c. Elevate the clients legs using a firm pillow
d. Place her on a modified trendelenburg position

Rationale:
In cases of excessive vaginal bleeding, the woman is placed in a side lying or lateral position, not supine, to prevent
pressure on the vena cava and additional interference with fetal circulation. However, if this is not possible, position
her on her back, with a wedge under one hip to minimize uterine pressure on the vena cava and to prevent blood
from being trapped in the lower extremities (supine hypotension syndrome). Any form of vaginal bleeding in a
pregnant woman, no matter how small, needs to be evaluated.
(Pillitteri, 5
th
ed, pg 402, 416)

53. Worldwide, breast cancer accounts for 22.9% of all cancers (excluding non-melanoma skin cancers) in
women. Prognosis and survival rates for breast cancer vary greatly depending on the cancer type, stage,
treatment, and geographical location of the patient. 38-year-old Shakira is admitted for a biopsy of a lump in
her right breast. Nurse Teddy recognizes that the finding that could indicate malignancy would be:
a. A soft mass that is movable and tender
b. A hard, hot reddened area that is tender and painful
c. Multiple bilateral lesions, well defined, and movable
d. A single lesion in the upper, outer quadrant poorly delineated and nonmovable

Rationale:
Most breast malignancies are painless, fixed, and in the upper outer quadrant; painful, mobile lesions are usually
benign.
Option A- benign; suggestive of a lipoma
Option B- suggestive of a breast abscess from lactation
Option C- suggestive of fibrocystic benign tumors
(Mosby, 5
th
ed)

54. Breast cancer screening refers to testing otherwise-healthy women for breast cancer in an attempt to
achieve an earlier diagnosis under the assumption that early detection will improve outcomes. A number
of screening test have been employed including: clinical and self breast exams, mammography, genetic
screening, ultrasound, and magnetic resonance imaging. To perform breast-self examination correctly,
Nurse Jo teaches a premenopausal female that the best time to examine her breasts is:
a. When she ovulates
b. The first of every month
c. The day her menses begin
d. Three to seven days after the menses ends

Rationale:
During this time, the least amount of breast engorgement occurs, limiting lumps that may occur because of fluid
accumulation.
Option A & C- Breast engorgement begins before ovulation and does not subside until several days after menses
ends. The engorgement interferes with accurate palpation
Option B- Inaccurate assessment could result because examination would occur at different times of the menstrual
cycle. Accurate comparisons could not be made from month to month. This is only appropriate for
POSTMENOPAUSAL women.
(Mosby, 5
th
ed)

55. Healthcare professionals suggest safer sex, such as the use of condoms, as the most reliable way of
decreasing the risk of contracting sexually transmitted diseases during sexual activity, but safer sex
should by no means be considered an absolute safeguard. Nurse Lea is assessing a female client
suspected of having primary syphilis. She needs further teaching if she expects which of the following early
symptoms in her client, except:
a. Flat wart-like plaques around the vagina and anus
b. An indurated painless nodule on the vulva that begins to drain
c. Glistening patches in the mouth covered with a yellow exudates
d. A maculopapular rash on the palms of the hands and soles of the feet

Rationale:
Option B pertains to a chancre sore which is the initial and characteristic sign of syphilis.
Option A- called condylomata lata which are typical of the secondary stage of syphilis
Option C- this is typical of the secondary stage of systemic involvement, which occurs from 2-4 years after the
disappearance of the chancre)
Option D- typical of the secondary stage of syphilis
(Mosby, 5
th
ed)

56. The Apgar score is a numerical expression of the neonates well-being and is done at 1 minute and 5
minutes after birth. Five minutes after birth, the newborn is pale, has irregular and slow respirations, heart rate
of 120 bpm, and displays minimal flexion of the extremities and minimal reflex responses. Nurse Hook should
expect the newborns APGAR score and status to be reported as:
a. 2,
b. 3
c. 5
d. 8

Rationale:
The parameters for assessing the Apgar score are: heart rate, respiratory effort, muscle tone, reflex irritability, and
color. According to the Apgar scoring system, the newborn received 2 points for heart rate, 0 for color, 1 for
respiratory effort, 1 for muscle tone, and 1 for reflex irritability.
(Maternal-Child Nursing Care, Ward & Hisley, 2009, p. 566)

57. Reflexes help identify a baby's normal brain and nerve activity. Some reflexes occur only in specific
periods of development. Nurse Mariah recognizes that a positive Babinski reflex in a newborn infant is a result
of which of the following:
a. Neurologic impairment
b. Hypoxia during labor and delivery
c. Immaturity of the CNS
d. Hyperreflexia of the muscular system

Rationale:
Positive Babinskis sign is normal for the newborn. The newborns immature neuromuscular development, when
stimulated, causes dorsiflexion of the big toe and fanning of the remaining toes.
Option A- Negative Babinski indicates neurologic impairment
Option B- also indicates negative Babinski
Option D- Hyperreflexia is an abnormal increase in reflexes; it is not related to the Babinskis reflex.
(Mosby, 5
th
ed)

58. A complete physical examination is an important part of newborn care. Each body system is carefully
examined for signs of health and normal function. The physician also looks for any signs of illness or
birth defects. An assessment of a newborn includes the differentiation between cephalhematoma and caput
succedaneum. When making this assessment, Nurse Ariel understands that caput succedaneum is
characterized by which of the following?
a. Edema crosses the suture line
b. Swelling increases within 24 hrs
c. Area surrounding the swelling will be tender
d. Scalp over the swelling becomes ecchymotic

Rationale:
This is the sign that differentiates between these two conditions; with caput succedaneum, the swelling crosses the
suture line and it does not with cephalhematoma.
Option B- the swelling decreases in size; if the swelling increases, the newborn would have for signs of increased
intracranial pressure
Option C- pain is not associated with either condition
Option D- bruising can occur with either condition
(Mosby, 5
th
ed)

59. The first stool of the newborn is usually passed within 24 hours after birth and it is called meconium.
Nurse Amelia is caring for a 1-week-old infant who is frequently breast-fed by his mother. The nurse can assume
that by this time the infants stools are:
a. thick, black-green, sticky stools
b. light yellow, sweet-smelling stools
c. green and loose stools
d. bright yellow, foul-smelling stools

Rationale:
By the fourth day of life, breast-fed babies pass three or four light yellow, sweet-smelling stools per day.
The thick, black-green, sticky stool is meconium which is usually passed within 24-48 hours after birth. Green and
loose stool is transitional stool which is passed about the second or third day of life. Bright yellow, foul-smelling stool
is formula stool which is also passed by the fourth day of life, but differs in appearance compared to stools of breast-
fed babies.
(Maternal and Child Health Nursing, Pillitteri, 2007, p. 685)

60. A baby's birth weight is an important indicator of health. Babies are weighed daily in the nursery to
assess growth, fluid, and nutrition needs. The nurse is caring for a 2-day-old newborn in the nursery. She is
preparing the newborn to be roomed-in to her mother. The mother holds her newborn and says, What
happened to my baby? She wasnt this light the first time I carried her. The nurse responds to the mother my
saying:
a. This is a normal change in your baby. She will regain her lost weight in a few days.
b. I understand that this is not normal. We better seek the advice of your physician on this one.
c. Its abnormal and its because she doesnt receive enough nutrition.
d. This is abnormal and is a result of poor nutrition during pregnancy.

Rationale:
The neonate loses 5-10% of birth weight during the first few days after birth. The weight loss occurs due to loss of
extracellular fluid through stools and urine. Most likely it is also due to minimal nutritional intake and the loss of
maternal hormones from newborns body. Any weight loss is regained by 7-10 days of life.
Other options state that this is abnormal when it is actually a normal transition.
(Pillitteri, 5
th
ed)

61. A newborn should have a thorough evaluation performed within 24 hours of birth to identify any
abnormality that would alter the normal newborn course or identify a medical condition that should be
addressed. The nurse is doing a thorough physical examination on a neonate. The circumference of the
neonates head and chest when compared at birth is normally:
a. Head equals chest circumference.
b. Head circumference is 2 cm larger than the chest.
c. Head circumference is 2 cm smaller than the chest.
d. None of the above.



Rationale:
At birth, the neonates head circumference is approximately 2 cm larger than the chest circumference. Head
circumference 33-35 cm (13-14 inches), Chest circumference 30-33 cm (12-13 inches) body length 44-55 cm (18-22
inches).
(Pillitteri, 5
th
ed; ULG)

62. Thermoregulation is critical for newborn because of the inability of the newborn to shiver. Prompt action
should be given by the nurse to prevent heat loss. The nurse is trying to prevent heat loss in the newborn
through evaporation. She can do this by:
a. Providing a warm environment
b. Wiping the face, head, body and extremities of the newborn
c. Moving the newborn far from a cold surface
d. Covering the newborn with a warmed blanket

Rationale:
Evaporation it is the loss of heat through conversion of liquid to a vapor. Heat loss is minimized when newborn is
dried. Providing a warm environment is preventing heat loss through convection. Convection refers to heat loss from
the newborns body to cooler surrounding air. Moving the newborn far from a cold surface is preventing heat loss
through radiation. Radiation is the transfer of body heat to a cooler solid object not in contact with the baby. Covering
the newborn with a warmed blanket is preventing heat loss through conduction. Conduction is the transfer of body
heat to a cooler solid object in contact with the baby.
Convection is the flow of heat from the newborns body surface to cooler surrounding air. The effectiveness of
convection depends on the velocity of the flow (a current of air cools faster than nonmoving air). Eliminating drafts
from windows or air conditioners reduces convection heat loss.
(Pillitteri, 5
th
ed)

63. Heat loss occurs immediately after birth to below normal due to immature heat regulating system. Nurse
Shawie recognizes that in a healthy, full-term neonate heat production is accomplished by which of the following:
a. Oxidizing fatty acids
b. Shivering vigorously
c. Breaking down brown fat
d. Increasing muscular activity

Rationale:
This metabolic process releases energy and increases heat production in the newborn.
Option A- fatty acids are byproducts of the breakdown of brown fat
Option B- shivering is the mechanism of heat production for the adult, not for the newborn
Option D- this will not be successful unless plentiful of brown fat is present
(Mosby, 5
th
ed)

64. The whole key to the management of the newborn infant lies in a proper assessment of the baby at birth.
This necessitates obtaining certain basic information in relation to two different individuals, the mother
and the baby, and obtained in two completely different ways, by the history and by the physical
examination. When teaching cord care, Nurse Natalie should explain to the parents about the appearance of
the cord. Her health teaching should include:
a. Swabbing the base of the cord daily with alcohol at each diaper change.
b. Taping a gauze over the umbilicus to protect it until the cord dries and falls off
c. Applying antibiotic ointment to the base of the cord with each diaper change
d. Placing the diaper over the umbilical cord to prevent infection and to protect the cord from injury until it
falls off

Rationale:
Alcohol helps to dry the cord and facilitate its falling off.
Option B- Putting gauze/ dressing over the cord is ineffective and could promote infection because the air circulation
needed to promote drying is decreased.
Option C- If no infection is present, antibiotic ointment is not used
Option D- The warm, moist environment inside a diaper is a good medium for bacterial growth; the diaper should be
turned down below the umbilicus.
(Mosby, 5
th
ed)

65. Newborns are usually kept in either a birthing room or a nursery in the first few hours of life. During this
period, certain principles of care always apply. After the birth of her son, Mrs. Grey states to Nurse Lexie, I
was told that my baby has to have an injection of Vitamin K. Im worried; shes so little to be getting a shot. Why
does she have to have it? Nurse Lexies most appropriate response would be:
a. Your baby needs the injection to develop mature RBCs.
b. An injection of vitamin K will help to prevent your baby from having yellowish discoloration of the skin.
c. Newborns are deficient of vitamin K. This treatment protects your baby from bleeding.
d. A newborns blood clots faster than it should. This injection helps decrease the clotting time.

Rationale:
Newborns are given vitamin K since they are prone for bleeding disorders during the first week of life. However, they
cannot produce it by themselves yet since their gastrointestinal tracts are sterile at birth and unable to produce
vitamin K, which is necessary for blood coagulation.
Option A- Vitamin K has no effect on erythropoiesis
Option B- Vitamin K is important in the synthesis of clotting factor in the lover but it will not prevent jaundice
Option D- Newborns have blood coagulation deficiency. The blood clots more slowly, not more quickly.
(Maternal and Child Health Nursing, Pillitteri, 2007, p. 714)

66. Coronary artery disease is the most prevalent type of cardiovascular disease in adults. For this reason,
it is important for nurses to become familiar with various manifestations of coronary artery diseases.
Rebecca Wilson, 35 years old, came to the out-patient department for a general check-up. She asked Nurse
Carrie of her probability to develop a heart disease. Nurse Carrie appropriately enumerates the risk factors of
heart diseases, except for:
a. Elevated high-density lipoprotein cholesterol
b. Blood pressure of 140/100 taken in two visits
c. Waist circumference of 45 inches
d. Diagnosed with diabetes mellitus

Rationale:
HDL cholesterol is known as the good cholesterol and is not a predisposing factor. One of the factors include
dyslipidemia (triglycerides more than 150 mg/dL, HDL less than 50 mg/dL in women, less than 40 mg/dL in men).
Elevated LDL cholesterol, also known as the bad cholesterol is the primary target of cholesterol-lowering therapy.
Option B- Hypertension is a risk factor
Option C- obesity is a risk factor (abdominal obesity refers to waist circumference more than 35 inches in women and
more than 40 inches in men)
Option D- Diabetes mellitus is a risk factor
(Brunner, 11
th
ed, pg 861)

67. Angina pectoris is a clinical syndrome usually characterized by episodes or paroxysms of pain or
pressure in the anterior chest. The cause is insufficient coronary blood flow wherein the need for
oxygen exceeds the supply. Dan Howell, 50 years old, is admitted to the hospital for management of chest
pain. His physician lists a probable diagnosis of chronic stable angina. Nurse Phil educates Dan Howell that one
characteristic of his type of angina is:
a. Increased progressively in frequency and duration.
b. Incapacitating
c. Relieved by rest and is predictable
d. Usually occurring at night and may be relieved by sitting upright

Rationale:
Stable angina is predictable and consistent pain that occurs on exertion and is relieved by rest.
Option A- refers to unstable angina which is also called a preinfarction angina.
Option B- refers to intractable or refractory angina which is severe incapacitating chest pain
Option D- refers to variant or Prinzmetals angina which is pain at rest, especially at night, with reversible ST-
segment elevation. It is thought to be caused by coronary artery vasospasm.
(Brunner, 11
th
ed, pg 867)

68. Nitrates remain the mainstay treatment of angina pectoris. The objectives of the medical management of
angina are to decrease the oxygen demand of the myocardium and to increase the oxygen supply. Nurse
Alaska is teaching a client who receives sublingual nitroglycerin for the relief of chest pain. Which instruction
should nurse Alaska emphasize?
a. Repeat the dose of sublingual nitroglycerin every 15 minutes for three doses.
b. Store the drug in a cool, well-lit place.
c. Restrict alcohol intake to two drinks per day.
d. Lie down or sit in a chair for 5-10 minutes after taking the drug.

Rationale:
Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which
makes the client dizzy and weak. Nitrates are taken at the first sign of chest pain and before activities that might
induce chest pain.
Sublingual NTG is taken every 5 minutes for three doses. If the pain persists, the client should seek medical
assistance immediately. Nitrates must be stored in a dark place in a closed container. Sunlight causes the medication
to lose its effectiveness. And alcohol is prohibited because nitrates may enhance the effects of alcohol.
(Brunner, 11
th
ed., p. 867, 869-870)

69. Myocardial infarction is usually caused by reduced blood flow in a coronary artery due to rupture of an
atherosclerotic plaque and occlusion of the artery by a thrombus. Diagnostic tests and procedures are
used to confirm the data obtained by the history and physical assessment. Dan Howell is rushed to the
emergency room due to a crushing substernal pain that is unrelieved by NTG and rest. Nurse Charlie suspects
AMI and expects which of the following diagnostic test to be drawn that would be most specific to his suspicion:
a. Troponin I
b. Myoglobin
c. CK-MB
d. LDH

Rationale:
Creatining kinase (CK) and its isoenzyme CK-MB are the most specific enzymes analyzed in acute MI, and they are
the first enzyme levels to increase. Lactic dehydrogenase and its isoenzymes may also be analyzed but only in select
patients who have delayed seeking medical attention, because blood levels of these substances peak in 2-3 days,
much later than CK levels. Myoglobin is not used alone to diagnose MI because variations can occur in patients with
renal or musculoskeletal disease. Troponin tests are reliable markers that can be detected within 3- 4 hours after
myocardial injury.
(Brunner, 11
th
ed, pg 805)

70. The ECG waveform represents the function of the hearts conduction system, which normally initiates
and conducts the electrical activity, in relation to the lead. The ECG offers important information about
the electrical activity of the heart. Chuck Bass experienced severe chest pain unrelieved by rest. The
physician ordered STAT ECG for him. A section of the reading shows a T-wave inversion. Nurse Blair correctly
concludes that:
a. It is a zone of ischemia.
b. It is a zone of infarction.
c. It is a zone of injury.
d. It is a zone of necrosis.

Rationale:
Myocardial ischemia causes inversion of the T wave because of delayed and altered repolarization. Cardiac muscle
injury causes elevation of the ST segment. The injured myocardial cells depolarize normally but repolarize more
rapidly than normal cells, causing the ST segment to rise at least 1 mm above the isoelectric line. Later, Q waves
develop because of the absence of depolarization current from the necrotic tissue and opposing currents from other
parts of the heart (infarction).
(Brunner, 11
th
ed, pg 875)

71. Heart failure, often referred to as congestive heart failure, is the inability of the heart to pump sufficient
blood to meet the needs of the tissues for oxygen and nutrients. A patient with chronic left-sided heart
failure has been admitted in the ICU for close observation. In preparing for assessment, Nurse Kellan would
expect to find which signs and symptoms in the patient?
a. Distended neck veins
b. Pitting edema on both legs
c. Enlarged liver upon palpation
d. Pink frothy sputum

Rationale:
Signs and symptoms of left-sided heart failure include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and
pulmonary congestion. It is also accompanied by pulmonary edema once it becomes chronic. Pulmonary edemas
characteristic sign is pink, frothy sputum.
Signs and symptoms of right-sided heart failure include hepatomegaly, edema, ascites, and distended neck veins.
(Brunner, 11
th
ed, pg 950)

72. Digoxin, a cardiac glycoside derived from digitalis, is used for patients with systolic heart failure, atriall
fibrillation, and atrial flutter. It improves cardiac function by increasing the force of contraction, slowing
cardiac conduction, and promoting dieresis. Nurse Park is caring for a client receiving digoxin (Lanoxin).
Upon assessment of the client, which of the following findings would alert Nurse Park for possible digoxin
toxicity?
a. Client experiences constipation
b. Potassium of 3.5 mEq/L
c. Increase in appetite
d. Client complains of double vision

Rationale:
Visual disturbances are a common symptom of digoxin toxicity. Other symptoms include fatigue, anorexia, blurred or
double vision, nausea, confusion, bradycardia, irregular heart rhythm and dysrryhtmias. Constipation, hyperkalemia
and increased hunger are not symptoms of digoxin toxicity.
(Brunner, 11
th
ed, pg 956)

73. Iron deficiency anemia is the most common type of anemia overall and it has many causes. RBCs often
appear hypochromic (paler than usual) and microcytic (smaller than usual) when viewed with a
microscope. Anne, a post gastrectomy client, is prescribed with Ferrous sulfate 325mg once a day, per orem.
Nurse Jasmine provides appropriate care for the client when she does which of the following?
a. Allowing Anne to eat breakfast before taking the medication.
b. Giving the medication to Anne 3 hrs after dinner just before she goes to bed.
c. Letting Anne take the medication just before going to bed after a light snack.
d. Assisting Anne to take the medication after arising just before breakfast.

Rationale:
Taking iron at bedtime helps to avoid GI upset. Taking it with water on an empty stomach promotes optimal
absorption.
Guidelines in administering Iron:
Take iron on an empty stomach (1 hour before or 2 hours after a meal). Iron absorption is reduced with
food, especially dairy products.
To prevent gastrointestinal distress, the following schedule may work better if more than one tablet a day is
prescribed:
Start with only one tablet per day for a few days, then increase to two tablets per day, then three tablets per
day. This method permits the body to adjust gradually to the iron.
Increase the intake of vitamin C (citrus fruits and juices, strawberries, tomatoes, broccoli), to enhance iron
absorption.
Eat foods high in fiber to minimize problems with constipation.
Remember that stools will become dark in color.
Liquid forms of iron supplementation may be better tolerated than solid forms, although they are more
expensive. The liquid forms can discolor teeth. Use a straw or place the spoon at the back of the mouth to
take the supplement; rinse mouth thoroughly afterward.
(Kee, Hayes, and McCuisition 2006, p. 799, Lippincott review series MS, p. 503, Brunner 10
th
ed)

74. In polycythemia vera, the bone marrow is hypercellular, and the RBC, WBC, and platelet counts in the
peripheral blood are elevated. It is characterized by bone marrow overactivity. Nurse America is teaching a
24-year-old client diagnosed with polycythemia vera about ways of preventing complications of the disease.
Which of the following teachings made by Nurse America would require further teaching?
a. You should drink 500mL of fluids or less each day.
b. You should wear support stockings when you ambulate.
c. You should use electric razor for shaving.
d. You should eat foods low in iron.

Rationale:
The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per
day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. The objective of
management is to reduce the high blood cell mass. Phlebotomy is an important part of therapy and can be performed
repeatedly to keep the hematocrit within normal range.
Option B- The use of elastic stockings prevents emboli formation and promotes venous return.
Option C- Electric razors are much safer because they prevent injury thus decreasing the risk of bleeding
Option D- Low iron in diet is essential to further red blood cell formation
(Brunner, 11
th
ed, pg 895)

75. Neutropenia (neutrophils less than 200/mm
3
) results from decreased production of neutrophils and or
increased destruction of these cells. Neutrophils are essential in preventing and limiting bacterial
infection. Nurse Edith is developing a plan of care for her client who is immunocompromised and will be placed
on neutropenic precaution. She shares the planned interventions to her co-worker, Agnes. Agnes will agree if
Nurse Edith plans to do which of the following, except?
a. Insert indwelling urinary catheters using strict aseptic technique.
b. Change IV tubings daily.
c. Do not allow the patient to work with houseplants.
d. Do not reuse cups or glasses without washing.

Rationale:
The use of indwelling catheters should be avoided because it can be a potential source of infection. Changing the IV
tubings daily is needed to prevent infection. The patient should not be allowed to come in contact with litter boxes or
work in the garden or with house plants as these as potential sources of infection. Cups or glasses that the patient is
using should not be reused without washing them first to prevent infection.
(p. 497, Medical-Surgical Nursing by Ignatavicius and Workman 5
th
edition, 2006)

76. Thrombocytopenia can result from various factors: decreased production of platelets within the bone
marrow, increased destruction of platelets, or increased consumption of platelets. Bleeding and
petechiae usually do not occur in platelet counts greater than 50,000/mm
3
. Nurse Crissy is caring for an 8-
year-old with Idiopathic Thrombocytopenic Purpura. She wants to prevent bleeding as much as possible by
doing all of the following, except:
a. Discourage vigorous coughing.
b. Avoid flossing of teeth and commercial mouthwashes.
c. Use lower-numbered gauge in needles when performing venipuncture.
d. Lubricate lips with water-soluble lubricant.

Rationale:
Lower-numbered gauges in needles are large-bored or have larger holes in them. If the client is at risk for bleeding,
higher-numbered gauges should be used such as gauge 24 and above.
Nursing Interventions to Prevent Complications:
Avoid aspirin and aspirin-containing medications or other medications known to inhibit platelet function, if
possible.
Do not give intramuscular injections.
Do not insert indwelling catheters.
Take no rectal temperatures; do not give suppositories, enemas.
Use stool softeners, oral laxatives to prevent constipation.
Use smallest possible needles when performing venipuncture.
Apply pressure to venipuncture sites for 5 min or until bleeding has stopped.
Permit no flossing of teeth and no commercial mouthwashes.
Use only soft-bristled toothbrush for mouth care.
Use only toothettes for mouth care if platelet count is <10,000/mm3, or if gums bleed.
Lubricate lips with water-soluble lubricant every 2 hr while awake.
Avoid suctioning if at all possible; if unavoidable, use only gentle suctioning.
Discourage vigorous coughing or blowing of the nose.
Use only electric razor for shaving.
Pad side rails as needed.
Prevent falls by ambulating with patient as necessary.
(Brunner, 11
th
ed, pg 902)

77. Most patients with hemophilia are diagnosed as children. They often require assistance in coping with
the condition because it is chronic, places restrictions in their lives, and is an inherited disorder that can
be passed to future generations. A mother went to the clinic to seek advice from Nurse Crissy regarding
implementing health promotion strategies to her 7-year-old son who has hemophilia A. Which of the following
statements made by the mother indicates a need for further teaching?
a. Our backyard is fenced in so I let my son and his friends play outside while I do the housework.
b. When my son has a joint pain, I dont give him Ibuprofen to relieve the pain.
c. When my son falls, I immobilize the injured area and apply ice immediately.
d. I taught my son to always check his urine for signs of bleeding.

Rationale:
Prevention of injury is the most important intervention with these children so outdoor activities or outside play should
always be supervised despite the safety precautions implemented.
Ibuprofen is not ordered as an analgesic because it may prolong bleeding. Ice compress and immobilization are done
immediately after the injury to prevent bleeding. In addition, checking for any evidence of bleeding is a must in order
to render appropriate and timely management.
(Pillitteri, 5
th
ed, p. 1406-1408)

78. An aneurysm is a localized sac or dilation formed at a weak point in the wall of the artery. The most
common cause of abdominal aortic aneurysm is atherosclerosis. Nurse Eleanor is caring for Park, 50 years
old, who is scheduled for surgical repair of an abdominal aortic aneurysm (AAA). Before surgery, nursing
assessment is guided by anticipating a rupture. Nurse Eleanor stays alert for which of the following impending
signs of rupture of an AAA?
a. Constant, severe back pain
b. Rising blood pressure
c. Pulsating mass in the abdomen
d. Systolic bruit upon auscultation

Rationale:
Signs of impending rupture include severe back pain or abdominal pain, which may be persistent or intermittent and
is often localized in the middle or lower abdomen to the left of the midline. Low back pain may also be present
because of pressure of the aneurysm on the lumbar nerves. This is a serious symptom, usually indicating that the
aneurysm is expanding rapidly and is about to rupture. Indications of a rupturing abdominal aortic aneurysm include
constant, intense back pain; falling blood pressure; and decreasing hematocrit.
Options C and D are normal manifestations of a patient with AAA.
(Brunner, 11
th
ed, pg 1000)

79. Buergers disease is characterized by recurring inflammation of the intermediate and small arteries and
veins of the lower and upper extremities. Nurse Angela is knowledgeable that a patient with Buergers
disease will manifest with all of the following, except:
a. Arterial thrombus formation and occlusion
b. Lipid deposits in the arteries
c. Redness or cyanosis in the limb when it is dependent
d. Episodic spasm of small arteries

Rationale:
Episodic spasm of small arteries and arterioles due to exposure to cold and emotional stress is a characteristic sign
of Raynauds disease.
Buergers disease is characterized by thrombotic and inflammatory occlusions of small arteries and veins among
smokers. Although it is different from atherosclerosis, it may be accompanied by atherosclerosis (lipid deposits) of
the larger vessels. Pain is the outstanding symptom of Buergers disease. Physical signs include intense rubor
(reddish-blue discoloration) of the foot.
(Brunner, 11
th
ed, pg 996)

80. Although the exact cause of venous thrombosis remains unclear, three factors known as the Virchows
triad are believed to play a significant role in its development: venous stasis, vessel wall injury, and
altered blood coagulation. Nurse Blair is teaching her client Dorota, who was recently diagnosed with DVT, on
how to use antiembolic stockings. Which of the following reflects correct teaching by Blair?
a. Removing the stocking every other day to prevent further thrombosis.
b. Putting on the stocking before getting out of the bed in the morning.
c. Wearing the stocking in the evening and remove it in the morning.
d. Putting on the stocking only when exercising.

Rationale:
Any type of stocking, including the elastic type, can inadvertently become a tourniquet if applied incorrectly. In such
instances, the stockings produce stasis rather than prevent it. For ambulatory patients, elastic compression stockings
are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning.
(Brunner, 11
th
ed, pg 1008)

81. Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that
is not fully reversible. Nurse Will caring for a client diagnosed with chronic bronchitis 2 years ago is reviewing
the clients laboratory results. Which of the following results shall Nurse Will not expect?
a. Hypercapnia
b. Polycythemia
c. Leukopenia
d. None of the above

Rationale:
COPD is characterized by a decrease in oxygen and increase in carbon dioxide so hypoxemia and hypercapnia are
expected. Polycythemia or an increase in RBCs also occurs as a compensatory effort to maintain tissue oxygenation.
It is frequently seen as PaO2 levels fall below 55 mm Hg. Leukopenia or less than normal amount of WBCs in
circulation is not an expected finding, usually there is leukocytosis.
(Brunner, 11
th
ed)

82. Cystic Fibrosis is a disease in which there is generalized dysfunction of the exocrine glands. Nurse
Charles is caring for 18-year-old Cornelia diagnosed with cystic fibrosis. Cornelia has been admitted to the
hospital to receive treatment for exacerbation of a lung infection. She has a number of questions about her future
and the consequences of the disease. Which statements about the course of cystic fibrosis are true?
1. Only males carry the gene for the disease
2. Pregnancy and child bearing arent affected
3. Cornelia is at risk for developing diabetes
4. Normal sexual relationships can be expected
5. Breast development is frequently delayed
6. By age 20, Cornelia should be able to decrease the frequency of respiratory treatment

a. 1,4,6
b. 2,4,5
c. 3,4,5
d. 4,5,6

Rationale:
(5) Cystic fibrosis delays growth and onset of puberty. Children with cystic fibrosis tend to be smaller than average
size and develop secondary sex characteristics later in life. (3) In addition, they are at risk for developing diabetes
mellitus because the pancreatic duct becomes obstructed as pancreatic tissues are destroyed. (4) They can also
expect to have normal sexual relationships, (2) but fertility becomes difficult because thick secretions obstruct the
cervix and block sperm entry. (6) Pulmonary disease commonly progresses as the client ages, requiring additional
respiratory treatmentnot less.
(Maternal and Child Health Nursing, Pillitteri, 2007, p. 1269-1273; Maternal-Child Nursing Care, Ward & Hisley, 2009,
p. 758-761)

83. Asthma is characterized by reversible obstructive condition of bronchi/bronchioles in response to
certain biochemical, immunological, and psychological factors. Caulder, 8 years old, has had frequent
exacerbations of his asthma attack. Nurse Lake is carefully assessing him for any signs of immediate danger.
Which of the following findings should Nurse Lake report without delay?
a. Circumoral cyanosis
b. Absence of wheezing
c. Non-productive cough
d. Prolonged expiratory phase

Rationale:
All of the following are assessment findings in patients with asthma. However, the most reportable sign is absence of
wheezing because it poses danger to the life of the child.
In asthma, as constriction becomes acute, the sound of wheezing may decrease because so little air can leave the
alveoli. When blood gases show and increased PCO2 level and the sound of wheezing suddenly stops, respiratory
failure is imminent.
(Pillitteri, 5
th
ed, pg 1260)

84. Emphysema is a form of COPD in which recurrent pulmonary inflammation damages and eventually
destroys the alveolar walls, creating large air spaces. This breakdown leaves the alveoli unable to recoil
normally after expanding, and, upon expiration, results in bronchial collapse. Nurse Dawn assists Richard,
her client diagnosed with advanced emphysema, to the bathroom. Richard becomes extremely short of breath
while returning to bed. Nurse Dawn needs further teaching is she does which of the following, aside from?
a. Increase his nasal O2 to 6 LPM
b. Place him in lateral Sims position
c. Encourage pursed-lip breathing
d. Have him breathe into a paper bag

Rationale:
Pursed lip breathing helps the client to blow of carbon dioxide and to keep air passages open. This is the desired
breathing technique for clients with emphysema. It prevents airway collapse.
Option A- Giving too high a concentration of oxygen to a client with emphysema may remove his stimulus to breathe.
Option B- the client should sit forward with his hands on his knees or an overbed table and with shoulders elevated.
Option D- Covering the face of the client extremely short of breath may cause anxiety and further cause dyspnea
(Davis, 3
rd
ed)

85. Pulmonary embolism is the obstruction of the pulmonary arterial bed. It results from a mass (commonly
a thrombus) that lodges in the main pulmonary artery or branch. Andi just delivered a healthy baby and was
transferred in the postpartum unit. Hours later, she complained of sudden sharp chest pain. She is noted to be
tachycardic and tachypneic. Nurse Luis suspects pulmonary embolism and would be correct to do which of the
following initially?
a. Initiate an intravenous line
b. Assess her blood pressure
c. Prepare to administer morphine sulfate
d. Administer oxygen at 8-10 LPM by face mask

Rationale:
If pulmonary embolism is suspected, oxygen should be administered at 8 to 10 L/min by face mask. Oxygen is used
to decrease hypoxia. ABCs, establish airway first before other interventions.
The woman also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate
may be prescribed for the client, but this action would not be the initial nursing action. An intravenous line also will be
required, and vital signs need to be monitored, but these actions would follow the administration of the oxygen.
(Saunders, 4
th
ed)

86. No single, universal definition of mental health exists. Generally a persons behavior can provide clues
to his or her mental health. Jasper, a psychiatric nurse, accurately defines Mental Health as:
a. The ability to distinguish what is real from what is not.
b. A state of well-being where a person can realize his own abilities can cope with normal stresses of life
and work productively.
c. Is the promotion of mental health, prevention of mental disorders, nursing care of patients during illness
and rehabilitation
d. Absence of mental illness

Rationale:
Mental Health is a state of well-being where a person can realize his own abilities can cope with normal stresses of
life and work productively. Mental health is a state of emotional and psychosocial well being. A mentally healthy
individual is self aware and self directive, has the ability to solve problems, can cope with crisis without assistance
beyond the support of family and friends fulfill the capacity to love and work and sets goals and realistic limits.
Option A- This describes the ego function reality testing.
Option C- This is the definition of Psychiatric mental health Nursing.
Option D- Mental health is not just the absence of mental illness.
(Videbeck, 5
th
ed, pg 3)

87. A mental illness is a health problem that significantly affects how a person thinks, behaves and interacts
with other people. Mental illness results from complex interactions between the mind, body and
environment. After lecturing about the characteristics of a mentally healthy person according to Marie Jahoda,
Mr. Chen asked his students to identify which client can be categorized as mentally healthy:
a. Snow who distracts herself from the board exam results by applying for a job
b. Charming who lives alone and often hears voices
c. Regina who cannot act on her own but can be easily commanded what to do.
d. Henry who hoards plastic bottles and describes them as treasure


Rationale:
Mental health is a state of emotional, psychological, and social wellness evidenced by satisfying interpersonal
relationships, effective behavior and coping, positive self-concept, and emotional stability. Snow is able to manage
whats causing her stress in an acceptable way.
Option B- shows a problem with reality orientation (cannot distinguish real world from dream, fact from fantasy)
Option C- lacks the component of being autonomous and independent
Option D- shows a problem with reality orientation

Components of a mentally healthy person:
Autonomy and independence
Maximization of ones potential
Tolerance of lifes uncertainties
Self- esteem
Mastery of environment
Reality orientation
Stress management
(Videbeck, 5
th
ed, pg 3)

88. The DSM-IV-TR is a multiaxial classification system that describes all mental disorders, outlining
specific diagnostic criteria for each based on clinical experience and research. You are a psychiatric nurse
caring for Peyton who was diagnosed with borderline personality disorder as well as regression. You are well
aware that these findings are found on which axis of the DSM-IV-TR?
a. Axis I
b. Axis II
c. Axis III
d. Axis IV

Rationale:
The DSM-IV-TR allows the practitioner to identify all the factors that relate to a persons condition.
Axis I- All major psychiatric disorders except mental retardation and personality disorders
Axis II- Mental retardation and personality disorders as well as prominent maladaptive personality features
and defense mechanisms
Axis III- current medical conditions
Axis IV- Psychosocial and environmental problems such as the social environment, education, occupation,
housing, economics, access to health care, and the legal system
Axis V- Global Assessment of Functioning
(Videbeck, 4
th
ed, pg 5)

89. The psychiatric nurse is usually one of the first people a patient will see when he is admitted to a mental
hospital. He or she will be monitoring most of the patient's plan of care and implementing doctors'
orders. Nurse Stefan is performing the role of a nurse technician if he does which of the following activities?
a. Administers medications to a schizophrenic patient.
b. Feeds and bathes a catatonic client
c. Coordinates diverse aspects of care rendered to the patient
d. Disseminates information about alcohol and its effects.

Rationale:
Administration of medications and treatments, assessment, documentation are the activities of the nurse as a
technician.
Option B- Activities as a parent surrogate.
Option C- Refers to the ward manager role.
Option D- Role as a teacher.
Other roles of nurses according to Peplau are:
Resource person: providing specific answers to questions within a larger context
Teacher: helping the client to learn formally or informally
Leader: offering direction to the client or group
Surrogate: serving as a substitute for another such as a parent or sibling
Counselor: promoting experiences leading to health for the client such as expression of feelings
Stranger: offers the client the same acceptance and courtesy that the nurse would to any stranger. It
provides an accepting climate that builds trust.
(Videbeck, 5
th
ed, pg 56; ULG by Balita pg 137)

90. An interdisciplinary (or multi-disciplinary) team approach is most useful in dealing with the multi-faceted
problems of clients with mental illnesses, as they can meet the clients needs more effectively by
collaborating. The team member that usually conducts therapy and interprets psychological tests is the:
a. Psychiatrist
b. Psychologist
c. Psychiatric Nurse
d. Advanced Practice Nurse

Rationale:
The clinical psychologist has a doctorate in clinical psychology and is prepared to practice therapies, conduct
research and interpret psychological tests. They may also participate in the design of therapy programs for groups or
individuals. This team member is different from the psychiatrist.
Option A is a physician certified in psychiatry and whose main function is diagnosis of mental disorders and
prescription of medical treatments.
Option C- The psychiatric nurses function mainly involves roles in health promotion, illness prevention, and
rehabilitation. If the psychiatric nurse obtains a masters degree in mental health, he or she may become certified as
a clinical specialist or an advanced practice nurse (Option D). They are usually licensed to prescribe medications.
(Videbeck, 4
th
ed., pp. 77-78)

91. According to Freud's structural theory of the mind, the id, the ego and the superego function in different
levels of consciousness. There is a constant movement of memories and impulses from one level to
another. Nurse Alex interviews a teenager in the ward. When asked about the foods she ate last week, the
teenager answered, Wait a minute give me 5 minutes to recall the foods I ate last week. Nurse Alex is aware
that the teenager is operating on her:
a. Subconscious
b. Conscious
c. Unconscious
d. Ego

Rationale:
Subconscious refers to the materials that are partly remembered partly forgotten but these can be recalled
spontaneously and voluntarily.
Option B- This functions when one is awake. One is aware of his thoughts, feelings actions and what is going on in
the environment.
Option C- The largest portion of the mind that contains the memories of ones past particularly the unpleasant. It is
difficult to recall the unconscious content.
Option D- The conscious self that deals and tests reality.
(Videbeck, 4
th
ed)

92. The purpose of the psychosocial assessment is to construct a picture of the clients current emotional
state, mental capacity, and behavioral function. Nurse Groo is caring for Agnes, a 69-year-old female client
who underwent hip repair two days ago. During assessment, Agnes tells the nurse that she is a young girl who is
still living with her father and her siblings. She believes that the nurse is her deceased mother. Nurse Groo
records this finding as manifestations of impaired:
a. Insight
b. Orientation
c. Judgment
d. Memory

Rationale:
Orientation refers to the clients recognition of person, place, and time; that is, knowing who and where he or she is
and the correct day, date, and year. The waxing and waning of the patients orientation is a hallmark of organic
mental disturbances.
Insight is the ability to understand the true nature of ones situation and accept some personal responsibility for the
situation.
Judgment refers to the ability to interpret ones environment and situation correctly and adapt ones decision and
behavior accordingly.
(ULG pg 126)

93. Thought process refers to how the client thinks. The nurse can infer a clients thought process from
speech and speech patterns. A 19-year-old Japanese female client admitted in the psychiatric ward was seen
crying. She tells Nurse Merida that the earthquake and tsunami that destructed her hometown was her fault
because she was wishing for a reason not to go back in Japan. The nurse knows that this is an example of:
a. Though broadcasting
b. Loose associations
c. Nihilism
d. Magical thinking

Rationale:
Magical thinking is normal in young children and is present in people affected by a variety of psychiatric conditions.
Magical thinking is the belief that specific thoughts, words, or gestures can directly lead to the fulfillment of wishes.
Such thinking is due to an unrealistic understanding of the relationship between cause and effect.
Thought broadcasting is the delusional belief that others can hear or know what the client is thinking.
Loose associations are disorganized thinking that jumps from one idea to another with little or no evidence between
the thoughts.
Nihilism is extreme skepticism according to which nothing in the world has a real existence.
(ULG, pg 125)

94. The mental status examination is an important part of the clinical assessment process in psychiatric
practice. It is a structured way of observing and describing a clients current state of mind. Carly Rae has
been admitted to the psych unit with the diagnosis of Schizophrenia. During interaction with the nurse, she said,
Yes, its March. March is Little Women. Thats literal you know. The nurse takes not that these statements
illustrates:
a. Echolalia
b. Neologisms
c. Flight of Ideas
d. Looseness of associations

Rationale:
Loose associations are thoughts that are presented without the logical connections usually necessary for the listener
to interpret the message.
Echolalia is the purposeless repetition of words spoken by others or repetition of overheard sounds.
Neologisms are new meaningless words coined by the client, or new meanings given to old words.
Flight of ideas is the rapid skipping from one thought to another; thoughts usually have only superficial or chance
relationships.
(Mosby, 5
th
ed)

95. The purpose of mental status exam is to obtain a comprehensive cross-sectional description of the
clients mental state, which, when combined with the biographical and historical information, allows the
clinician to make an accurate diagnosis and formulation. Nurse Aura is assessing Clarks affect. Which
question is she most likely to ask the client?
a. Are you angry or sad?
b. Why do you think you always get into fights?
c. You look upset, are you?
d. How are you feeling?

RATIONALE:
Affect is the external or outward expression of emotion manifested by the client.
Mood is the clients pervasive and enduring emotional state.
(Videbeck, 5
th
ed, pg 161)

96. The CNS is composed of the brain, the spinal cord, and associated nerves that control voluntary acts.
Structurally the brain is divided into the cerebrum, cerebellum, brain stem, and limbic system. An
emergency psychiatric client presents with amnesia, hyperthermia and unexplained loss of appetite.
Accompanying family members state that he suffered a head injury while falling from a ladder several days ago.
Nurse Jess concludes that the clients symptoms are consistent with trauma to which area of the brain?
a. Thalamus
b. Cerebrum
c. Cerebellum
d. Hypothalamus

Rationale:
The client probably has trauma to the hypothalamus since hypothalamus regulates appetite and temperature. It also
regulates the anterior and posterior lobes of the pituitary gland.
The thalamus integrates all sensory input (except smell) and is involved with emotions and mood.
The cerebrum is divided into two hemispheres where all lobes and structures are found in both halves of the brain
except for the pineal gland which is located in between.
The cerebellum is involved with involuntary movement, such as muscular tone and coordination and the maintenance
of posture and equilibrium.
(Townsend, 5
th
ed, pg 34- 37)

97. Thought process refers to how the client thinks. The nurse can infer a clients thought process from
speech and speech patterns. Nurse Ellie initiated an interaction with Mr. Pringles who said, I played in a band
once. Our bands name is Kill Me Now. The name actually means, but stopped abruptly and does not
continue the statement. He did this multiple times. Nurse Ellie would document this as:
a. Thought withdrawal
b. Tangentiality
c. Circumstantial thinking
d. Thought blocking

Rationale:
Thought blocking is stopping abruptly in the middle of a sentence or train of thought, sometimes unable to continue
the idea.
Thought withdrawal is a delusional belief that others are taking the clients thought away and the client is powerless
to stop it.
Tangentiality is wandering off topic and never providing the information requested.
Circumstantial thinking is when a client eventually answers the question but only after giving excessive unnecessary
detail.

Other disorders in thought process & content:
Delusion: a fixed false belief not based in reality
Flight of ideas: excessive amount and rate of speech composed of fragmented or unrelated ideas
Ideas of reference: clients inaccurate interpretation that general events are personally directed to him or
her, such as hearing a speech on the news and believing the message had personal meaning
Loose associations: disorganized thinking that jumps from one idea to another with little or no evident
relation between the thoughts
Thought broadcasting: a delusional belief that others can hear or know what the client is thinking
Thought insertion: a delusional belief that others are putting ideas or thoughts into the clients headthat
is, the ideas are not those of the client
Word salad: flow of unconnected words that convey no meaning to the listener.
(Videbeck, 4
rd
ed., p. 155)

98. Hallucinations can involve the five senses and bodily sensations. Auditory hallucinations (hearing
voices) are the most common. Nurse Charlie is interviewing Bryarly, a client on the psychiatric unit. Bryarly tilts
her head to the side, stops talking midsentence, and listens intently. Nurse Charlie recognizes these behaviors
as a symptom of the clients illness. The most appropriate nursing intervention for this symptom is to:
a. Ask the client to describe his physical symptoms.
b. Ask the client to describe what he is hearing.
c. Administer a dose of antipsychotic.
d. Call the physician for additional orders.

Rationale:
If these behaviors are observed, ask client, Are you hearing the voices again?
Encourage the client to share the content of the hallucinations. This is important for early intervention in case the
content contains commands to harm self or others.
It is important for the nurse to focus on what is real and to help shift the clients response toward reality. Initially, the
nurse must determine what the client is experiencingwhat the voice is saying or what the client is seeing, especially
for command hallucinations. Knowledge about the content of the hallucination can alert the health-care providers in
implementing safety precautions to protect the client as necessary. However, if the voices are non-commanding, the
nurse should proceed to acknowledging, presenting reality, and distracting the client from the hallucinations.
(Videbeck, 5
th
ed, pg 314)

99. Neurotransmitters are the chemical substances manufactured in the neuron that aid in the transmission
of information throughout the body. They either excite or stimulate an action in the cells (excitatory) or
inhibit or stop an action (inhibitory). Student nurse Beyonce is aware that which of the following
neurotransmitter disturbances has been implicated to have caused Alzheimers Disease?
a. Increased Acetylcholine
b. Decreased Acetylcholine
c. Increased Serotonin
d. Decreased Serotonin

Rationale:
A relative deficiency of acetylcholine is associated with this disorder. The drugs used in the early stages of
Alzheimers disease will act to increase available acetylcholine in the brain.
Option A- causes depression
Option C- causes anxiety and mania
Option D- causes depression
(ULG, pg 144)

100. The absence, lack, or excess of neurotransmitters have a great influence in brain diseases and
behavioral disorders. Nurse Lyka is knowledgeable that which of the following statements show the correct
pairing of the neurotransmitter imbalance and the condition it is associated to?
a. Norepinephrine is increased in depression.
b. Serotonin is decreased in panic disorder.
c. GABA is increased in epilepsy.
d. Dopamine is decreased in Parkinsons.

Rationale:
Serotonin increase has been implicated in schizophrenia and anxiety states. However, decreased levels of the
neurotransmitter have been associated with depression.
Norepinephrine increase is associated to several anxiety disorders as well as mania. Decreased norepinephrine is
associated with depression.
Dopamine increase is associated with mania and schizophrenia, while it is decreased in Parkinsons and depression.
GABA decrease is attributed to anxiety disorders, Huntingtons, and various forms of epilepsy.
(Townsend, 5
th
ed, pg 39- 40)