PART I

NURSING PRACTICE IFoundation of Professional NursingPractice

TEST I - Foundation of Professional Nursing Practice
1.The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a client without checking the clients pulse. The standard
thatwould be used to determine if the nurse was negligent is:
a.The physicians orders.
b.The action of a clinical nurse specialist who is recognized expert inthe field.
c.The statement in the drug literature about administration of terbutaline.
d. The actions of a reasonably prudent nurse with similar educationand experience.
2.Nurse Trish is caring for a female client with a history of GI bleeding,sickle cell disease, and a platelet count of 22,000/l. The female client isdehydrated and
receiving dextrose 5% in half-normal saline solution at150 ml/hr. The client complains of severe bone pain and is scheduled toreceive a dose of morphine sulfate.
In administering the medication, NurseTrish should avoid which route?
A . I V
b I M
c . O r a l
d . S C
3. Dr. Garcia writes the following order for the client who has been recentlyadmitted Digoxin.125 mg P.O. once daily. To prevent a dosage error,how should the
nurse document this order onto the medicationadministration record?
a.Digoxin .1250 mg P.O. once daily
b.Digoxin 0.1250 mg P.O. once daily
c.Digoxin 0.125 mg P.O. once daily
d.Digoxin .125 mg P.O. once daily
4. A newly admitted female client was diagnosed with deep vein thrombosis.Which nursing diagnosis should receive the highest priority?
a.Ineffective peripheral tissue perfusion related to venous congestion.
b.Risk for injury related to edema.
c.Excess fluid volume related to peripheral vascular disease.
d.Impaired gas exchange related to increased blood flow.
5.Nurse Betty is assigned to the following clients. The client that the nursewould see first after endorsement?a.A 34 year-old post operative
appendectomy client of five hours whois complaining of pain.b.A 44 year-old myocardial infarction (MI) client who is complaining
of nausea.c.A 26 year-old client admitted for dehydration whose intravenous(IV) has infiltrated.d.A 63 year-old post operatives abdominal
hysterectomy client of three days whose incisional dressing is saturated withserosanguinous fluid.6.Nurse Gail places a client in a four-point
restraint following orders from thephysician. The client care plan should include:a.Assess temperature frequently.b.Provide diversional
activities.c.Check circulation every 15-30 minutes.d.Socialize with other patients once a shift.
7.

A male client who has severeburnsis receiving H2 receptor antagonisttherapy. The nurse In-charge knows the purpose of this therapy is to:a . P r e v e n t
s t r e s s u l c e r b.Block prostaglandin synthesisc . F a c i l i t a t e p r o t e i n s y n t h e s i s . d . E n h a n c e g a s e x c h a n g e 8.The doctor
orders hourly urine output measurement for a postoperativemale client. The nurse Trish records the following amounts of output for 2consecutive
hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts,which action should the nurse take?a.Increase the I.V. fluid infusion
rateb.Irrigate the indwelling urinary catheter c . N o t i f y t h e p h y s i c i a n d.Continue to monitor and record hourly
urine output9.Tony, a basketball player twist his right ankle while playing on the courtand seeks care for ankle pain and swelling. After the
nurse applies ice tothe ankle for 30 minutes, which statement by Tony suggests that iceapplication has been effective?a.My ankle looks less swollen
now.b . M y a n k l e f e e l s w a r m .
c . My an k le ap p ea rs re dd er n o w . d.I need something stronger for pain relief10.The physician prescribes a loop diuretic for a
client. When administeringthis drug, the nurse anticipates that the client may develop whichelectrolyte imbalance?
a . H y p e r n a t r e m i a b . H y p e r k a l e m i a c . H y p o k a l e m i a d . H y p e r v o l e m i a 11.She finds out that some managers have
benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely?a.Have condescending trust and
confidence in their subordinates.b.Gives economic and ego awards.c.Communicates downward to staffs.d.Allows decision
making among subordinates.12. Nurse Amy is aware that the following is true about functional nursinga.Provides continuous, coordinated
and comprehensive nursingservices.b.One-to-one nurse patient ratio.c.Emphasize the use of group
collaboration.d.Concentrates on tasks and activities. 13.Which type of medication order might read "Vitamin K 10 mg I.M. daily
3days?"a . S i n g l e o r d e r b . S t an da r d w ri t t en o rd er c . S t a n d i n g o r d e r d . S t a t o r d e r 14.A female client with a fecal
impaction frequently exhibits which clinicalmanifestation?a . I n c r e a s e d a p p e t i t e b . Lo ss o f u rg e to d ef ec a t ec .H ar d , b ro wn ,
fo rm ed s to o ls d. L iq u id o r sem i- li qu i d st o o l s
15.Nurse Linda prepares to perform an otoscopic examination on a femaleclient. For proper visualization, the nurse should position the client's
ear by:a.Pulling the lobule down and backb.Pulling the helix up and forward c . P u l l i n g t h e h e l i x u p a n d b a c k d.Pulling
the lobule down and forward
16.
Which instruction should nurse Tom give to a male client who is havingexternal radiation therapy:a.Protect the irritated skin from
sunlight.b.Eat 3 to 4 hours before treatment.c . W a s h t h e s k i n o v e r r e g u l a r l y . d.Apply lotion or oil to the radiated area when
it is red or sore.17.In assisting a female client for immediate surgery, the nurse In-charge isaware that she should:a.Encourage the client to void
following preoperative medication.b.Explore the clients fears and anxieties about the surgery.c.Assist the client in removing
dentures and nail polish.d.Encourage the client to drink water prior to surgery. 18. A male client is admitted and diagnosed with
acute pancreatitis after aholiday celebration of excessive food and alcohol. Which assessmentfinding reflects this diagnosis?a.Blood pressure above
normal range.b.Presence of crackles in both lung fields. c . H y p e r a c t i v e b o w e l s o u n d s d.Sudden onset of continuous
epigastric and back pain.
19.
Which dietary guidelines are important for nurse Oliver to implement incaring for the client withburns?a.Provide high-fiber, high-fat
dietb.Provide high-protein, high-carbohydrate diet.c.Monitor intake to prevent weight gain.d.Provide ice chips or water
intake.20.Nurse Hazel will administer a unit of whole blood, which priorityinformation should the nurse have about the client?a.Blood pressure and
pulse rate.

b . H e i g h t a n d w e i g h t . c . C a l c i u m a n d p o t a s s i u m l e v e l s d . H g b a n d H c t l e v e l s . 21. Nurse Michelle witnesses a female client

sustain a fall and suspects thatthe leg may be broken. The nurse takes which priority action?a . T a k e s a s e t o f v i t a l s i g n s . b.Call the radiology
department for X-ray.c.Reassure the client that everything will be alright.d.Immobilize the leg before moving the
client.22.A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. The nurse in-charge
wouldtake which priority action in the care of this client?a.Place client on reverse isolation.b.Admit the client into a private
room.c.Encourage the client to take frequent rest periods.d.Encourage family and friends to visit. 23.A newly admitted female
client was diagnosed with agranulocytosis. Thenurse formulates which priority nursing diagnosis?a . C o n s t i p a t i o n b . D i a r r h e a c . R i s k
f o r i n f e c t i o n d . D e f i c i e n t k n o w l e d g e 24.A male client is receiving total parenteral nutrition suddenly demonstratessigns and symptoms of an
air embolism. What is the priority action by thenurse?a . N o t i f y t h e p h y s i c i a n . b.Place the client on the left side in the Trendelenburg
position.c.Place the client in high-Fowlers position.d.Stop the total parenteral nutrition. 25.Nurse May attends an educational
conference on leadership styles. Thenurse is sitting with a nurse employed at a large trauma center who statesthat the leadership style at the trauma center is
task-oriented anddirective. The nurse determines that the leadership style used at thetrauma center is:a . A u t o c r a t i c . b . L a i s s e z - f a i r e .
c . D e m o c r a t i c . d . S i t u a t i o n a l 26.The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. Thenurse in-charge is going to hang a
500 cc bag. KCl is supplied 20 mEq/10cc. How many ccs of KCl will be added to the IV solution?a . . 5 c c b . 5
c c c . 1 . 5
c c d . 2 . 5 c c 27.A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift.The IV drip factor is 60. The IV rate that will
deliver this amount is:a . 5 0 c c / h o u r b . 5 5 c c / h o u r c . 2 4 c c / h o u r d . 6 6 c c / h o u r 28.The nurse is aware that the
most important nursing action when a clientreturns from surgery is:a.Assess the IV for type of fluid and rate of flow.b.Assess the client
for presence of pain.c.Assess the Foley catheter for patency and urine outputd.Assess the dressing for drainage.
29.
Which of the following vital sign assessments that may indicatecardiogenic shock after myocardial infarction?a.BP 80/60, Pulse 110
irregular b.BP 90 /50 , Pulse 50 regular c .BP 1 30/80, Pulse 100 regular d.BP 180/100, Pulse 90
irregular 30.Which is the most appropriate nursing action in obtaining a blood pressuremeasurement?a.Take the proper equipment, place the
client in a comfortableposition, and record the appropriate information in the clients chart.b.Measure the clients arm, if you are not sure of the
size of cuff touse.c.Have the client recline or sit comfortably in a chair with the forearmat the level of the heart
d.Document the measurement, which extremity was used, and theposition that the client was in during the measurement.31.Asking the
questions to determine if the person understands the healthteaching provided by the nurse would be included during which step of thenursing process?
a.
Assessment
b.
Evaluation
c.
Implementationd . P l a n n i n g a n d g o a l s 32.Which of the following item is considered the single most important factor in assisting the health
professional in arriving at a diagnosis or determining the persons needs?a.Diagn ostic test results b . B i o g r a p h i c a l d a t e c .History of
p res en t illness
d.
Physical examination33.In preventing the development of an external rotation deformity of the hipin a client who must remain in bed for any period of
time, the mostappropriate nursing action would be to use:a.Trochanter roll extending from the crest of the ileum to the mid-thigh.b.Pillows

und er the lower legs. c . F o o t b o a r d d.Hip-abductor p illo w 34.Which stage of pressure ulcer development does the ulcer extend into
thesubcutaneous tissue?a . S t a g e I b . S t a g e I I c . S t a g e I I I d . S t a g e I V 35.When the method of wound healing is one in
which wound edges are notsurgically approximated and integumentary continuity is restored bygranulations, the wound healing is termeda.Seco nd
inten tio n healingb.Prim ary inten tio n healingc.Third inten tio n healing
d .F irs t in ten tion healin g 36.An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver learns
that the client lives alone and hasnt beeneating or drinking. When assessing him for dehydration, nurse Oliver would expect to
find:a . H y p o t h e r m i a b . H y p e r t e n s i o n c . D i s t e n d e d n e c k v e i n s d . T a c h y c a r d i a 37.The physician prescribes meperidine
(Demerol), 75 mg I.M. every 4 hoursas needed, to control a clients postoperative pain. The package insert isMeperidine, 100 mg/ml. How many
milliliters of meperidine should theclient receive?a . 0 . 7 5 b . 0 . 6 c . 0 . 5 d . 0 . 2 5
38.
A male client withdiabetes mellitusis receiving insulin. Which statementcorrectly describes an insulin unit?a.Its a common measurement in the
metric system.b.Its the basis for solids in the avoirdupois system.c.Its the smallest measurement in the apothecary
system.d.Its a measure of effect, not a standard measure of weight or quantity.39.Nurse Oliver measures a clients temperature at 102 F. What
is theequivalent Centigrade temperature?a . 4 0 . 1 C b . 3 8 . 9 C c . 4 8 C d . 3 8 C 40.The nurse is assessing a 48-yearold client who has come to thephysicians office for his annual physical exam. One of the first physicalsigns of aging is:a.Accepting limitations
while developing assets.b.Increasing loss of muscle tone.c.Failing eyesight, especially close vision.
d.Having more frequent aches and pains.41.The physician inserts a chest tube into a female client to treat apneumothorax. The tube is
connected to water-seal drainage. The nursein-charge can prevent chest tube air leaks by:a.Checking and taping all connections.b.Checking
patency of the chest tube.c.Keeping the head of the bed slightly elevated. d.Keeping the chest drainage system below the level of
the chest.42.Nurse Trish must verify the clients identity before administeringmedication. She is aware that the safest way to verify identity is
to:a.Check the clients identification band.b.Ask the client to state his name.c.State the clients name out loud and wait a
client to repeat it.d.Check the room number and the clients name on the bed.43.The physician orders dextrose 5 % in water, 1,000 ml to be
infused over 8hours. The I.V. tubing delivers 15 drops/ml. Nurse John should run the I.V.infusion at a rate of:a . 3 0 d r o p s / m i n u t e b . 3 2
d r o p s / m i n u t e c . 2 0 d r o p s / m i n u t e d . 1 8 d r o p s / m i n u t e 44.If a central venous catheter becomes disconnected accidentally,
whatshould the nurse in-charge do immediately?a . C l a m p t h e c a t h e t e r b . C a l l a n o t h e r n u r s e c . C a l l t h e p h y s i c i a n d.Apply a
dry sterile dressing to the site.45.A female client was recently admitted. She has fever, weight loss, andwatery diarrhea is being admitted to the
facility. While assessing the client,Nurse Hazel inspects the clients abdomen and notice that it is slightlyconcave. Additional assessment should proceed
in which order:a.Palpation, auscultation, and percussion.b.Percussion, palpation, and auscultation.c.Palpation, percussion,
and auscultation.d.Auscultation, percussion, and palpation.
46. Nurse Betty is assessing tactile fremitus in a client with pneumonia. For this examination, nurse Betty should use
the:a . F i n g e r t i p s b . F i n g e r p a d s c.Dorsal surface o f the handd.Uln ar surfac e of th e hand 47. Which type of evaluation
occurs continuously throughout the teaching andlearning process?
a . S u m m a t i v e b . I n f o r m a t i v e c . F o r m a t i v e d . R e t r o s p e c t i v e 48.A 45 year old client, has no family history of breast cancer
or other riskfactors for this disease. Nurse John should instruct her to havemammogram how often?a . T w i c e p e r y e a r b . O n c e p e r
y e a r c . E v e r y 2 y e a r s d.On ce, to establish baselin e 49.A male client has the following arterial blood gas values: pH 7.30; Pao2
89mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on these values,Nurse Patricia should expect which condition?a.Res piratory
acidos is b.Resp iratory alkalosis c . M e t a b o l i c a c i d o s i s d . M e t a b o l i c a l k a l o s i s 50.Nurse Len refers a female client with terminal

cancer to a local hospice.What is the goal of this referral?a.To help the client find appropriate treatment options.b.To provide support
for the client and family in coping with terminalillness.c.To ensure that the client gets counseling regarding health carecosts.d.To teach
the client and family about cancer and its treatment.
51.When caring for a male client with a 3-cm stage I pressure ulcer on thecoccyx, which of the following actions can the nurse instituteindependently?
a.Massaging the area with an astringent every 2 hours. b.Applying an antibiotic cream to the area three times per day.c.Using
normal saline solution to clean the ulcer and applying aprotective dressing as necessary.d.Using a povidone-iodine wash on the ulceration
three times per day.52.Nurse Oliver must apply an elastic bandage to a clients ankle and calf. Heshould apply the bandage beginning at the
clients:a . K n e e b . A n k l e c . L o w e r t h i g h d . F o o t 53.A 10 year old child with type 1 diabetes develops diabetic
ketoacidosisand receives a continuous insulin infusion. Which condition represents thegreatest risk to this child?
a . H y p e r n a t r e m i a b . H y p o k a l e m i a c . H y p e r p h o s p h a t e m i a d . H y p e r c a l c e m i a 54.Nurse Len is administering sublingual
nitrglycerin (Nitrostat) to the newlyadmitted client. Immediately afterward, the client may experience:a.Throbbing headache or
dizzinessb.Nervousn ess or p aresthesia.c .Dro wsin ess or blurred vision .d.Tinn itus or d iplop ia. 55.Nurse Michelle hears
the alarm sound on the telemetry monitor. The nursequickly looks at the monitor and notes that a client is in a ventricular tachycardia. The nurse rushes
to the clients room. Upon reaching theclients bedside, the nurse would take which action first?a.Prep are for c ardiovers io n b.Prepare to
defibrillate the clientc . C a l l a c o d e d.Check the clients level of consciousness
56.Nurse Hazel is preparing to ambulate a female client. The best and thesafest position for the nurse in assisting the client is to stand:a.On the
unaffected side of the client.b.On the affected side of the client. c . I n f r o n t o f t h e c l i e n t . d . B e h i n d t h e c l i e n t . 57.Nurse
Janah is monitoring the ongoing care given to the potential organdonor who has been diagnosed with brain death. The nurse determinesthat the
standard of care had been maintained if which of the followingdata is observed?a.Urin e outp ut: 45 m l/hr b.Capillary refill: 5
s econ dsc . S e r u m p H : 7 . 3 2 d.Blo od pressure: 90 /48 mmH g
58.
Nurse Amy has an order to obtain aurinalysisfrom a male client with anindwelling urinary catheter. The nurse avoids which of the following,
whichcontaminate the specimen?a.Wiping the port with an alcohol swab before inserting the syringe.b.Aspirating a sample from the
port on the drainage bag.c.Clamping the tubing of the drainage bag.d.Obtaining the specimen from the urinary drainage
bag.59.Nurse Meredith is in the process of giving a client a bed bath. In themiddle of the procedure, the unit secretary calls the nurse on the
intercomto tell the nurse that there is an emergency phone call. The appropriatenursing action is to:a.Immediately walk out of the clients room
and answer the phonecall.b.Cover the client, place the call light within reach, and answer thephone call.c.Finish the bed bath before
answering the phone call.d.Leave the clients door open so the client can be monitored and thenurse can answer the phone call.60. Nurse
Janah is collecting a sputum specimen for culture and sensitivitytesting from a client who has a productive cough. Nurse Janah plans toimplement which
intervention to obtain the specimen?a.Ask the client to expectorate a small amount of sputum into theemesis basin.
b.Ask the client to obtain the specimen after breakfast.c.Use a sterile plastic container for obtaining the
specimen.d.Provide tissues for expectoration and obtaining the specimen.61. Nurse Ron is observing a male client using a walker. The
nursedetermines that the client is using the walker correctly if the client:a.Puts all the four points of the walker flat on the floor, puts weight
onthe hand pieces, and then walks into it.b.Puts weight on the hand pieces, moves the walker forward, andthen walks into it.c.Puts weight on
the hand pieces, slides the walker forward, and thenwalks into it.d.Walks into the walker, puts weight on the hand pieces, and thenputs all
four points of the walker flat on the floor.62.Nurse Amy has documented an entry regarding client care in the clientsmedical record. When checking the

entry, the nurse realizes that incorrectinformation was documented. How does the nurse correct this error?a.Erases the error and writes in the
correct information.b.Uses correction fluid to cover up the incorrect information andwrites in the correct information.c.Draws one line
to cross out the incorrect information and theninitials the change.d.Covers up the incorrect information completely using a black
penand writes in the correct information63.Nurse Ron is assisting with transferring a client from the operating roomtable to a stretcher. To provide
safety to the client, the nurse should:a.Moves the client rapidly from the table to the stretcher. b.Uncovers the client completely before
transferring to the stretcher.c.Secures the client safety belts after transferring to the stretcher.d.Instructs the client to move self from the
table to the stretcher.64.Nurse Myrna is providing instructions to a nursing assistant assigned togive a bed bath to a client who is on contact
precautions. Nurse Myrnainstructs the nursing assistant to use which of the following protectiveitems when giving bed bath?a . G o w n a n d
g o g g l e s b . G o w n a n d g l o v e s c.Gloves and sho e p rotec to rs d . G l o v e s a n d g o g g l e s
65. Nurse Oliver is caring for a client with impaired mobility that occurred as aresult of a stroke. The client has right sided arm and leg weakness.
Thenurse would suggest that the client use which of the following assistivedevices that would provide the best stability for ambulating?
a . C r u t c h e s b.Sin gle straight-legged c an e c . Q u a d c a n e d . W a l k e r 66.A male client with a right pleural effusion noted
on a chest X-ray is beingprepared for thoracentesis. The client experiences severe dizziness whensitting upright. To provide a safe environment, the nurse
assists the clientto which position for the procedure?a.Prone with head turned toward the side supported by a pillow.b.Sims position with
the head of the bed flat.c.Right side-lying with the head of the bed elevated 45 degrees.d.Left side-lying with the head of the bed
elevated 45 degrees.67.Nurse John develops methods for data gathering. Which of the followingcriteria of a good instrument refers to the ability of the
instrument to yieldthe same results upon its repeated administration?
a . V a l i d i t y b . S p e c i f i c i t y c . S e n s i t i v i t y d . R e l i a b i l i t y 68.Harry knows that he has to protect the rights of human research
subjects.Which of the following actions of Harry ensures anonymity?a.Keep the identities of the subject secretb.Obtain in formed
con sent c.Provide equal treatment to all the subjects of the study.d.Release findings only to the participants of the
study69.Patients refusal to divulge information is a limitation because it is beyondthe control of Tifanny.What type of research is appropriate for this
study?a.D esc riptiv e- co rrelatio nal b . E x p e r i m e n t c . Q u a s i - e x p e r i m e n t d . H i s t o r i c a l
70.Nurse Ronald is aware that the best tool for data gathering is?a . I n t e r v i e w s c h e d u l e b . Q u e s t i o n n a i r e c . U s e o f l a b o r a t o r y
d a t a d . O b s e r v a t i o n 71.Monica is aware that there are times when only manipulation of studyvariables is possible and the elements of control or
randomization are notattendant. Which type of research is referred to this?a . F i e l d s t u d y b . Q u a s i - e x p e r i m e n t c .Solomon -Fo ur
gro up des ignd .Po st-test o nly design 72.Cherry notes down ideas that were derived from the description of aninvestigation written by the
person who conducted it. Which type of reference source refers to this?a . F o o t n o t e b . B i b l i o g r a p h y c . P r i m a r y
s o u r c e d . E n d n o t e s 73.When Nurse Trish is providing care to his patient, she must remember thather duty is bound not to do doing any action
that will cause the patientharm. This is the meaning of the bioethical principle:a . N o n m a l e f i c e n c e b . B e n e f i c e n c e c . J u s t i c e d . S o l i d a r i t y 74.When a nurse in-charge causes an injury to a female patient and the
injurycaused becomes the proof of the negligent act, the presence of the injuryis said to exemplify the principle of:a . F o r c e
m a j e u r e b.Resp ondeat sup erio r c . R e s i p s a l o q u i t o r d . H o l d o v e r d o c t r i n e
75.Nurse Myrna is aware that the Board of Nursing has quasi-judicial power.An example of this power is:a.The Board can issue rules and
regulations that will govern thepractice of nursingb.The Board can investigate violations of the nursing law and code of ethicsc.The Board
can visit a school applying for a permit in collaborationwith CHEDd.The Board prepares the board examinations
76.
When the license of nurse Krina is revoked, it means that she:a.Is no longer allowed to practice the profession for the rest of her lifeb.Will
never have her/his license re-issued since it has been revokedc.May apply for re-issuance of his/her license based on certainconditions

stipulated in RA 9173d.Will remain unable to practice professional nursing77.Ronald plans to conduct a research on the use of a new
method of painassessment scale. Which of the following is the second step in theconceptualizing phase of the research process?a.Formulating the
research hypothesisb.Rev iew related literature c.Formulating and delimiting the research problemd.Design the
theoretical and conceptual framework
78.
The leader of the study knows that certain patients who are in aspecialized research setting tend to respond psychologically to theconditions of the study.
This referred to as :a . C a u s e a n d e f f e c t b . H a w t h o r n e e f f e c t c . H a l o e f f e c t d . H o r n s e f f e c t 79.Mary finally decides to use
judgment sampling on her research. Which of the following actions of is correct?a.Plans to include whoever is there during his
study.b.Determines the different nationality of patients frequently admittedand decides to get representations samples from each.c.Assigns
numbers for each of the patients, place these in a fishbowland draw 10 from it.
d. Decides to get 20 samples from the admitted patients
80.
The nursing theorist who developed transcultural nursing theory is: a.Floren ce Nightin galeb.Madeleine Lein in ger c . A l b e r t
M o o r e d . S r . C a l l i s t a R o y 81.Marion is aware that the sampling method that gives equal chance to allunits in the population to get picked
is: a . R a n d o m b . A c c i d e n t a l c . Q u o t a d . J u d g m e n t 82.John plans to use a Likert Scale to his study to determine
the: a.Degree of agreement and disagreementb.Compliance to expected standards c .Lev el o f s atisfactio nd .D egree of
accep tan ce 83.Which of the following theory addresses the four modes of adaptation?a.Madelein e Leininger b . S r . C a l l i s t a
R o y c . F l o r e n c e N i g h t i n g a l e d . J e a n W a t s o n 84.Ms. Garcia is responsible to the number of personnel reporting to her. Thisprinciple
refers to:a . S p a n o f c o n t r o l b . U n i t y o f c o m m a n d c .Do wn ward communic ation d . L e a d e r 85.Ensuring that there is an
informed consent on the part of the patientbefore a surgery is done, illustrates the bioethical principle
of:a . B e n e f i c e n c e b . A u t o n o m y c . V e r a c i t y d . N o n - m a l e f i c e n c e
86.Nurse Reese is teaching a female client with peripheral vascular diseaseabout foot care; Nurse Reese should include which instruction?a.Avoid
wearing cotto n socks. b.Avoid using a nail clipper to cut toenails.c .Avoid wearin g c anv as s hoes. d.Avoid using
cornstarch on feet.87.A client is admitted with multiple pressure ulcers. When developing theclient's diet plan, the nurse should include:a . F r e s h
o r a n g e s l i c e s b . S t e a m e d b r o c c o l i c . I c e c r e a m d . G r o u n d b e e f p a t t i e s 88.The nurse prepares to administer a cleansing
enema. What is the mostcommon client position used for this procedure?a . L i t h o t o m y b . S u p i n e c . P r o n e d . S i m s l e f t
l a t e r a l 89.Nurse Marian is preparing to administer a blood transfusion. Which actionshould the nurse take first?a.Arrange for typing and cross
matching of the clients blood.b.Compare the clients identification wristband with the tag on the unitof blood.c.Start an I.V. infusion
of normal saline solution.d.Measure the clients vital signs. 90.A 65 years old male client requests his medication at 9 p.m. instead of
10p.m. so that he can go to sleep earlier. Which type of nursing interventionis required?
a . I n d e p e n d e n t b . D e p e n d e n t c . I n t e r d e p e n d e n t d . I n t r a d e p e n d e n t 91.A female client is to be discharged from an acute
care facility after treatment for right leg thrombophlebitis. The Nurse Betty notes that theclient's leg is pain-free, without redness or edema. The nurse's
actionsreflect which step of the nursing process?
a . A s s e s s m e n t b . D i a g n o s i s c . I m p l e m e n t a t i o n d . E v a l u a t i o n 92.Nursing care for a female client includes removing elastic
stockings onceper day. The Nurse Betty is aware that the rationale for this intervention?a.To increase blood flow to the heartb.To observe
the lower extremitiesc.To allow the leg muscles to stretch and relaxd.To permit veins in the legs to fill with blood. 93.Which

nursing intervention takes highest priority when caring for a newlyadmitted client who's receiving a blood transfusion?a.Instructing the client to
report any itching, swelling, or dyspnea.b.Informing the client that the transfusion usually take 1 to 2 hours.c.Documenting blood
administration in the client care record.d.Assessing the clients vital signs when the transfusion ends.94.A male client complains of
abdominal discomfort and nausea whilereceiving tube feedings. Which intervention is most appropriate for thisproblem?a.Give the feedings at
room temperature.b.Decrease the rate of feedings and the concentration of the formula.c.Place the client in semi-Fowler's
position while feeding.d.Change the feeding container every 12 hours. 95.Nurse Patricia is reconstituting a powdered medication in a
vial. After adding the solution to the powder, she nurse should:a . D o n o t h i n g . b.Invert the vial and let it stand for 3 to 5
minutes.c.Sh ake the vial vigoro usly. d.Roll the vial gently between the palms.96.Which intervention should the nurse Trish use
when administering oxygenby face mask to a female client?a.Secure the elastic band tightly around the client's head.b.Assist the client to the
semi-Fowler position if possible.c.Apply the face mask from the client's chin up over the nose.
d.Loosen the connectors between the oxygen equipment andhumidifier.97.The maximum transfusion time for a unit of packed red blood cells
(RBCs)is:a . 6 h o u r s b . 4 h o u r s c . 3 h o u r s d . 2 h o u r s 98.Nurse Monique is monitoring the effectiveness of a client's
drug therapy.When should the nurse Monique obtain a blood sample to measure thetrough drug level?a.1 hour before administering the next
dose.b.Immediately before administering the next dose.c.Immediately after administering the next dose.d.30 minutes
after administering the next dose.99.Nurse May is aware that the main advantage of using a floor stock systemis:a.The nurse can
implement medication orders quickly.b.The nurse receives input from the pharmacist.c.The system minimizes
transcription errors.d.The system reinforces accurate calculations. 100.Nurse Oliver is assessing a client's abdomen. Which
finding should thenurse report as abnormal?a.Dullness over the liv er. b.Bowel sounds occurring every 10 seconds.c.Shifting
dullness over the abdomen.d.Vascular sounds heard over the renal arteries
TEST II - Community Health Nursing and Care of the Mother and Child
1.May arrives at the health care clinic and tells the nurse that her lastmenstrual period was 9 weeks ago. She also tells the nurse that a
homepregnancy test was positive but she began to have mild cramps and isnow having moderate vaginal bleeding. During the physical examination
of the client, the nurse notes that May has a dilated cervix. The nursedetermines that May is experiencing which type of abortion?
a . I n e v i t a b l e b . I n c o m p l e t e c . T h r e a t e n e d d . S e p t i c 2.Nurse Reese is reviewing the record of a pregnant client for
her firstprenatal visit. Which of the following data, if noted on the clients record,would alert the nurse that the client is at risk for a spontaneous
abortion?a . A g e 3 6 y e a r s b . H i s t o r y o f s y p h i l i s c.H isto ry of genital herp esd .H is tory of diabetes m ellitus 3.Nurse
Hazel is preparing to care for a client who is newly admitted to thehospital with a possible diagnosis of ectopic pregnancy. Nurse Hazeldevelops a
plan of care for the client and determines that which of thefollowing nursing actions is the priority?a . M o n i t o r i n g w e i g h t b . A s s e s s i n g f o r
e d e m a c.Mon ito ring apical p ulsed.Mo nito ring temperature 4.Nurse Oliver is teaching a diabetic pregnant client about
nutrition andinsulin needs during pregnancy. The nurse determines that the clientunderstands dietary and insulin needs if the client states that the
secondhalf of pregnancy require:a.Decreased calo ric in takeb.In creased calo ric in take c . D e c r e a s e d I n s u l i n d . I n c r e a s e
Insulin
5.Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is
unassociatedwith this condition?a.Excessive fetal activ ity. b.Larger than normal uterus for gestational age.c . V a g i n a l
b l e e d i n g d.Elevated levels of human chorionic gonadotropin.6.A pregnant client is receiving magnesium sulfate for severe
pregnancyinduced hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is:a.Urin ary output 90
cc in 2 ho urs.b.Absent patellar reflex es. c.Rapid respiratory rate above 40/min.d .Rapid rise in bloo d

p res sure. 7.During vaginal examination of Janah who is in labor, the presenting part isat station plus two. Nurse, correctly interprets it
as:a.Presenting part is 2 cm above the plane of the ischial spines.b.Biparietal diameter is at the level of the ischial
spines.c.Presenting part in 2 cm below the plane of the ischial spines.d.Biparietal diameter is 2 cm above the ischial
spines.8.A pregnant client is receiving oxytocin (Pitocin) for induction of labor. Acondition that warrant the nurse in-charge to discontinue
I.V. infusion of Pitocin is:a.Contractions every 1 minutes lasting 70-80 seconds. b.Matern al temperature 101.2 c.Early
decelerations in the fetal heart rate.d.Fetal heart rate baseline 140-160 bpm. 9.Calcium gluconate is being administered to a
client with pregnancyinduced hypertension (PIH). A nursing action that must be initiated as theplan of care throughout injection of the drug
is:a.V en tilator assistanc e b . C V P r e a d i n g s c . E K G t r a c i n g s d . C o n t i n u o u s C P R
10. A trial for vaginal delivery after an earlier caesareans, would likely to begiven to a gravida, who had:a.First low transverse cesarean was for active
herpes type 2infections; vaginal culture at 39 weeks pregnancy was positive.b.First and second caesareans were for cephalopelvic
disproportion.c.First caesarean through a classic incision as a result of severe fetaldistress.d.First low transverse caesarean was for
breech position. Fetus inthis pregnancy is in a vertex presentation.11.Nurse Ryan is aware that the best initial approach when trying to take acrying
toddlers temperature is:a.Talk to the mother first and then to the toddler.b.Bring extra help so it can be done
quickly.c.Encourage the mother to hold the child.d.Ignore the crying and screaming. 12.Baby Tina a 3 month old infant just had a
cleft lip and palate repair. Whatshould the nurse do to prevent trauma to operative site?a.Avoid touching the suture line, even when
cleaning.b.Place the baby in prone position.c.Giv e the baby a pac ifier. d.Place the infants arms in soft elbow restraints.
13.
Which action should nurse Marian include in thecare planfor a 2 monthold with heart failure?a.Feed the in fant wh en he cries . b.Allow the
infant to rest before feeding.c.Bathe the infant and administer medications before feeding.d.Weigh and bathe the infant
before feeding.14.Nurse Hazel is teaching a mother who plans to discontinue breast feedingafter 5 months. The nurse should advise her to include
which foods in her infants diet?a.Skim milk an d baby food.b.Whole milk an d baby fo od.c.Iron -rich fo rm ula on ly. d.Ironrich formula and baby food.15.Mommy Linda is playing with her infant, who is sitting securely alone onthe floor of the clinic. The mother hides a
toy behind her back and the
infant looks for it. The nurse is aware that estimated age of the infantwould be:a . 6 m o n t h s b . 4 m o n t h s c . 8 m o n t h s d . 1 0
m o n t h s 16.Which of the following is the most prominent feature of public healthnursing?a.It involves providing home care to sick people who
are not confinedin the hospital.b.Services are provided free of charge to people within thecatchments area.c.The public health nurse
functions as part of a team providing apublic health nursing services.d.Public health nursing focuses on preventive, not curative,
services.17.When the nurse determines whether resources were maximized inimplementing Ligtas Tigdas, she is
evaluatinga . E f f e c t i v e n e s s b . E f f i c i e n c y c . A d e q u a c y d . A p p r o p r i a t e n e s s 18.Vangie is a new B.S.N. graduate. She wants to
become a Public HealthNurse. Where should she apply?a.Dep artment of Healthb.Prov inc ial Health Offic ec.Region al Health
Offic ed . R u r a l H e a l t h U n i t 19.Tony is aware the Chairman of the Municipal Health Board is: a . M a y o r b. Municip al Health
Offic er c . P u b l i c H e a l t h N u r s e d. Any qualified physic ian 20.Myra is the public health nurse in a municipality with a total
population of about 20,000. There are 3 rural health midwives among the RHUpersonnel. How many more midwife items will the RHU need?
a.1b. 2c. 3d. The RHU does not need any more midwife item. 21.According to Freeman and Heinrich, community health nursing is
adevelopmental service. Which of the following best illustrates thisstatement?a.The community health nurse continuously develops
himself personally and professionally.b.Health education and community organizing are necessary inproviding community health

services.c.Community health nursing is intended primarily for health promotionand prevention and treatment of disease.d.The goal of
community health nursing is to provide nursing servicesto people in their own places of residence.22.Nurse Tina is aware that the disease declared
through PresidentialProclamation No. 4 as a target for eradication in the Philippines is?a . P o l i o m y e l i t i s b . M e a s l e s c . R a b i e s d .
N e o n a t a l t e t a n u s 23.May knows that the step in community organizing that involves training of potential leaders in the community
is:a . I n t e g r a t i o n b. Comm un ity o rgan ization c . C o m m u n i t y s t u d y d. Co re gro up formatio n 24.Beth a public health nurse
takes an active role in community participation.What is the primary goal of community organizing?a.To educate the people regarding community
health problemsb.To mobilize the people to resolve community health problemsc.To maximize the communitys resources in dealing
with healthproblems.d.To maximize the communitys resources in dealing with healthproblems.
25.Tertiary prevention is needed in which stage of the natural history of disease?a . P r e p a t h o g e n e s i s b . P a t h o g e n e s i s c . P r o d r o m a l d . T e r m i n a l 26.The nurse is caring for a primigravid client in the labor and
delivery area.Which condition would place the client at risk for disseminatedintravascular coagulation (DIC)?a.I ntrauterine fetal
d eath. b . P l a c e n t a a c c r e t a . c . D y s f u n c t i o n a l l a b o r . d.Premature rupture of the membranes.27.A fullterm client is in labor.
Nurse Betty is aware that the fetal heart ratewould be:a.80 to 100 beats/minuteb.1 00 to 120 beats /m in utec .1 20 to 160
beats/minuted.1 60 to 180 beats/minute 28.The skin in the diaper area of a 7 month old infant is excoriated and red.Nurse Hazel should
instruct the mother to:a.Change the diaper more often . b.Apply talc powder with diaper changes.c.Wash the area vigorously
with each diaper change.d.Decrease the infants fluid intake to decrease saturating diapers.29.Nurse Carla knows that the common cardiac
anomalies in children withDown Syndrome (tri-somy 21) is:a.A trial septal defect b . P u l m o n i c s t e n o s i s c .V en tric ular s eptal
d efectd.End ocardial cushion defect 30.Malou was diagnosed with severe preeclampsia is now receiving I.V.magnesium sulfate. The adverse
effects associated with magnesiumsulfate is:a . A n e m i a
b.D ec reas ed urin e output c . H y p e r r e f l e x i a d.I ncreased resp irato ry rate 31.A 23 year old client is having her menstrual period
every 2 weeks that lastfor 1 week. This type of menstrual pattern is bets defined
by:a . M e n o r r h a g i a b . M e t r o r r h a g i a c . D y s p a r e u n i a d . A m e n o r r h e a 32.Jannah is admitted to the labor and delivery unit.
The critical laboratoryresult for this client would be:a . O x y g e n s a t u r a t i o n b.I ro n bindin g capacity c . B l o o d t y p i n g d . S e r u m
C a l c i u m 33.Nurse Gina is aware that the most common condition found during thesecond-trimester of pregnancy is:a . M e t a b o l i c
a l k a l o s i s b.Respirato ry acido sis c . M a s t i t i s d . P h y s i o l o g i c a n e m i a 34.Nurse Lynette is working in the triage area of an
emergency department.She sees that several pediatric clients arrive simultaneously. The clientwho needs to be treated first is:a.A crying 5 year old
child with a laceration on his scalp.b.A 4 year old child with a barking coughs and flushed appearance.c.A 3 year old child with
Down syndrome who is pale and asleep inhis mothers arms.d.A 2 year old infant with stridorous breath sounds, sitting up in hismothers
arms and drooling.35.Maureen in her third trimester arrives at the emergency room with painlessvaginal bleeding. Which of the following conditions is
suspected?a . P l a c e n t a p r e v i a b . A b r u p t i o p l a c e n t a e c . P r e m a t u r e l a b o r d.Sexually transmitted disease
36.A young child named Richard is suspected of having pinworms. Thecommunity nurse collects a stool specimen to confirm the diagnosis. Thenurse
should schedule the collection of this specimen for:a . J u s t b e f o r e b e d t i m e b.A fter the child has been bath e c . A n y t i m e d u r i n g
t h e d a y d . E a r l y i n t h e m o r n i n g 37.In doing a childs admission assessment, Nurse Betty should be alert tonote which signs or symptoms of
chronic lead poisoning?a.Irritability and seizuresb.Dehydratio n an d diarrheac.Bradycardia an d
h ypoten sion d.Petec hiae an d hem aturia 38.To evaluate a womans understanding about the use of diaphragm for family planning, Nurse
Trish asks her to explain how she will use theappliance. Which response indicates a need for further health teaching?a.I should check the diaphragm

carefully for holes every time I use itb.I may need a different size of diaphragm if I gain or lose weightmore than 20 poundsc.The
diaphragm must be left in place for atleast 6 hours after intercoursed.I really need to use the diaphragm and jelly most during
the middleof my menstrual cycle.39.Hypoxia is a common complication of laryngotracheobronchitis. NurseOliver should frequently assess a child with
laryngotracheobronchitis for:a . D r o o l i n g b . M u f f l e d v o i c e c . R e s t l e s s n e s s d . L o w - g r a d e f e v e r 40.How should Nurse
Michelle guide a child who is blind to walk to theplayroom?a.Without touching the child, talk continuously as the child walksdown the
hall.b.Walk one step ahead, with the childs hand on the nurses elbow.c.Walk slightly behind, gently guiding the child
forward.d.Walk next to the child, holding the childs hand.
41.When assessing a newborn diagnosed with ductus arteriosus, NurseOlivia should expect that the child most likely would have an:a.Loud,
machinery-like murmur.b.Bluish co lor to the lip s. c.Decreased BP reading in the upper extremitiesd.Increased BP
reading in the upper extremities.42.The reason nurse May keeps the neonate in a neutral thermalenvironment is that when a newborn becomes
too cool, the neonaterequires:a.Less oxygen, and the newborns metabolic rate increases.b.More oxygen, and the newborns metabolic rate
decreases.c.More oxygen, and the newborns metabolic rate increases. d.Less oxygen, and the newborns metabolic rate
decreases.43.Before adding potassium to an infants I.V. line, Nurse Ron must be sureto assess whether this infant has:a.Stable bloo d
p res sure b . P a t a n t f o n t a n e l l e s c . M o r o s r e f l e x d . V o i d e d 44.Nurse Carla should know that the most common causative factor
of dermatitis in infants and younger children is:a . B a b y o i l b . B a b y l o t i o n c . L a u n d r y d e t e r g e n t d.Po wd er with
co rns tarch 45.During tube feeding, how far above an infants stomach should the nursehold the syringe with formula?a . 6 i n c h e s b . 1 2
inchesc.18 inchesd.24 inches
46.
In a mothers class, Nurse Lhynnete discussed childhood diseases suchas chicken pox. Which of the following statements aboutchicken poxiscorrect?
a.The older one gets, the more susceptible he becomes to thecomplications of chicken pox.b. A single attack of chicken pox will prevent
future episodes,including conditions such as shingles.c. To prevent an outbreak in the community, quarantine may beimposed by health
authorities.d. Chicken pox vaccine is best given when there is an impendingoutbreak in the community.47.Barangay Pinoy had an outbreak of
German measles. To preventcongenital rubella, what is the BEST advice that you can give to women inthe first trimester of pregnancy in the barangay
Pinoy?a.Advice them on the signs of German measles. b.Avoid crowded places, such as markets and movie houses.c.Consult at the
health center where rubella vaccine may be given.d.Consult a physician who may give them rubella immunoglobulin.48.Myrna a public
health nurse knows that to determine possible sources of sexually transmitted infections, the BEST method that may be undertakenis:a . C o n t a c t
t r a c i n g b . C o m m u n i t y s u r v e y c . M a s s s c r e e n i n g t e s t s d. In terv iew o f susp ects 49.A 33-year old female client came for
consultation at the health center withthe chief complaint of fever for a week. Accompanying symptoms weremuscle pains and body malaise. A week after
the start of fever, the clientnoted yellowish discoloration of his sclera. History showed that he wadedin flood waters about 2 weeks before the onset of
symptoms. Based onher history, which disease condition will you suspect?
a.
Hepatitis A
b.
Hepatitis Bc . T e t a n u s
d.
Leptospirosis50.Mickey a 3-year old client was brought to the health center with the chief complaint of severe diarrhea and the passage of rice water
stools. Theclient is most probably suffering from which condition?a . G i a r d i a s i s

b.
Cholera
c.
Amebiasis
d . D y s e n t e r y 51.The most prevalent form of meningitis among children aged 2 months to 3years is caused by which
microorganism? a.H emop hilus in fluen zae b . M o r b i l l i v i r u s c. Steptococc us pneumo niaed . Neis seria
meningitidis 52.The student nurse is aware that the pathognomonic sign of measles isKopliks spot and you may see Kopliks spot by inspecting
the:a . N a s a l m u c o s a b . B u c c a l m u c o s a c . S k i n o n t h e a b d o m e n d . S k i n o n n e c k 53.Angel was diagnosed as having
Dengue fever. You will say that there isslow capillary refill when the color of the nailbed that you pressed does notreturn within how many seconds?a . 3
s e c o n d s b . 6 s e c o n d s c . 9 s e c o n d s d . 1 0 s e c o n d s 54.In Integrated Management of Childhood Illness, the nurse is aware
thatthe severe conditions generally require urgent referral to a hospital. Whichof the following severe conditions DOES NOT always require
urgentreferral to a hospital?a . M a s t o i d i t i s b . S e v e r e d e h y d r a t i o n c . S e v e r e p n e u m o n i a d.Severe febrile d is ease 55.Myrna
a public health nurse will conduct outreach immunization in abarangay Masay with a population of about 1500. The estimated number of infants in the
barangay would be:a . 4 5 i n f a n t s b . 5 0 i n f a n t s c . 5 5 i n f a n t s d . 6 5 i n f a n t s
56.The community nurse is aware that the biological used in ExpandedProgram on Immunization (EPI) should NOT be stored in the freezer?
a . D P T b . O r a l p o l i o v a c c i n e c . M e a s l e s v a c c i n e d . M M R 57.It is the most effective way of controlling
schistosomiasis in an endemicarea?a.Use of mollusc icidesb.Buildin g of foo t bridges c.Prop er us e of sanitary
toilets d.Use of protective footwear, such as rubber boots58.Several clients is newly admitted and diagnosed with leprosy. Which of
thefollowing clients should be classified as a case of multibacillary leprosy?a.3 skin lesions, negative slit skin smear b.3 skin lesions,
positive slit skin smear c.5 skin lesions, negative slit skin smear d.5 skin lesions, positive slit skin smear 59.Nurses are aware
that diagnosis of leprosy is highly dependent onrecognition of symptoms. Which of the following is an early sign of leprosy?a . M a c u l a r
l e s i o n s b.In ability to c lose eyelidsc.Thic kened pain ful n erv esd.Sin king of th e nos ebridge 60.Marie brought her 10 month
old infant for consultation because of fever,started 4 days prior to consultation. In determining malaria risk, what willyou do?a.Perform a
tourn iquet test.b.Ask where the family resides.c.Get a spec imen for blood sm ear. d.Ask if the fever is present
everyday.61.Susie brought her 4 years old daughter to the RHU because of cough andcolds. Following the IMCI assessment guide, which of the
following is adanger sign that indicates the need for urgent referral to a hospital?
a . I n a b i l i t y t o d r i n k b . H i g h g r a d e f e v e r c .Signs o f severe dehydratio nd.Cough for mo re than 30 d ays 62.Jimmy a
2-year old child revealed baggy pants. As a nurse, using theIMCI guidelines, how will you manage Jimmy?a.Refer the child urgently to a
hospital for confinement.b.Coordinate with the social worker to enroll the child in a feedingprogram.c.Make a teaching plan for the
mother, focusing on menu planning for her child.d. Assess and treat the child for health problems like infections andintestinal
parasitism.63.Gina is using Oresol in the management of diarrhea of her 3-year oldchild. She asked you what to do if her child vomits. As a
nurse you will tellher to: a.Bring the child to the nearest hospital for further assessment.b.Bring the child to the health center for
intravenous fluid therapy.c.Bring the child to the health center for assessment by the physician.d.Let the child rest for 10 minutes then
continue giving Oresol moreslowly.64.Nikki a 5-month old infant was brought by his mother to the health center because of diarrhea for 4 to 5 times
a day. Her skin goes back slowly after a skin pinch and her eyes are sunken. Using the IMCI guidelines, you willclassify this infant in which category?
a.No s igns of dehydratio n b . S o m e d e h y d r a t i o n c . S e v e r e d e h y d r a t i o n d. Th e data is ins uffic ient. 65.Chris a 4-month

old infant was brought by her mother to the health center because of cough. His respiratory rate is 42/minute. Using the IntegratedManagement of Child
Illness (IMCI) guidelines of assessment, hisbreathing is considered as: a . F a s t b . S l o w c . N o r m a l d . I n s i g n i f i c a n t
66.Maylene had just received her 4th dose of tetanus toxoid. She is awarethat her baby will have protection against tetanus for a . 1 y e a r b . 3
y e a r s c . 5 y e a r s d . L i f e t i m e 67.Nurse Ron is aware that unused BCG should be discarded after howmany hours of reconstitution?
a . 2 h o u r s b . 4 h o u r s c . 8 h o u r s d . A t t h e e n d o f t h e d a y 68.The nurse explains to a breastfeeding mother that breast
milk is sufficientfor all of the babys nutrient needs only up to: a . 5 m o n t h s b . 6 m o n t h s c . 1 y e a r d . 2
y e a r s 69.Nurse Ron is aware that the gestational age of a conceptus that isconsidered viable (able to live outside the womb) is:
a.
8 weeks
b.
12 weeks
c.
24 weeks
d.
32 weeks70.When teaching parents of a neonate the proper position for the neonatessleep, the nurse Patricia stresses the importance of placing the
neonateon his back to reduce the risk of which of the following?
a.
Aspiration
b.
Sudden infant death syndrome (SIDS)
c.
Suffocation
d.
Gastroesophageal reflux (GER)71.Which finding might be seen in baby James a neonate suspected of having an infection?
a.
Flushed cheeks
b.
Increased temperature
c.
Decreased temperature
d.
Increased activity level72.Baby Jenny who is small-for-gestation is at increased risk during thetransitional period for which complication?
a.
Anemia probably due to chronic fetal hyposia
b.
Hyperthermia due to decreased glycogen stores
c.

Hyperglycemia due to decreased glycogen stores

d.
Polycythemia probably due to chronic fetal hypoxia73.Marjorie has just given birth at 42 weeks gestation. When the nurseassessing the neonate, which
physical finding is expected?
a.
A sleepy, lethargic baby
b.
Lanugo covering the body
c.
Desquamation of the epidermis
d.
Vernix caseosa covering the body74.After reviewing the Myrnas maternal history of magnesium sulfate duringlabor, which condition would nurse
Richard anticipate as a potentialproblem in the neonate?
a.
Hypoglycemia
b.
Jitteriness
c.
Respiratory depression
d.
Tachycardia75.Which symptom would indicate the Baby Alexandra was adaptingappropriately to extra-uterine life without difficulty?
a.
Nasal flaring
b.
Light audible grunting
c.
Respiratory rate 40 to 60 breaths/minute
d.
Respiratory rate 60 to 80 breaths/minute76. When teaching umbilical cord care for Jennifer a new mother, the nurseJenny would include which
information?
a.
Apply peroxide to the cord with each diaper change
b.
Cover the cord with petroleum jelly after bathing
c.
Keep the cord dry and open to air
d.
Wash the cord with soap and water each day during a tub bath.77.Nurse John is performing an assessment on a neonate. Which of thefollowing findings
is considered common in the healthy neonate?

a.
Simian crease
b.
Conjunctival hemorrhage
c.
Cystic hygroma
d.
Bulging fontanelle78.Dr. Esteves decides to artificially rupture the membranes of a mother whois on labor. Following this procedure, the nurse Hazel
checks the fetalheart tones for which the following reasons?a.To determine fetal well-being.b.To as sess fo r pro laps ed cordc.To
ass es s fetal positio n d.To prepare for an imminent delivery.79.Which of the following would be least likely to indicate anticipated
bondingbehaviors by new parents?a.The parents willingness to touch and hold the new born. b.The parents expression of interest
about the size of the new born.c.The parents indication that they want to see the newborn.d.The parents interactions with
each other.80.Following a precipitous delivery, examination of the client's vagina revealsa fourth-degree laceration. Which of the following would
becontraindicated when caring for this client?a.Applying cold to limit edema during the first 12 to 24 hours.b.Instructing the client to use two
or more peripads to cushion thearea.c.Instructing the client on the use of sitz baths if ordered. d.Instructing the client about the
importance of perineal (kegel)exercises.81. A pregnant woman accompanied by her husband, seeks admission to thelabor and delivery area. She
states that she's in labor and says she attended thefacility clinic for prenatal care. Which question should the nurse Oliver ask her first?a.Do you have
any chronic illnesses?b.Do you hav e an y allergies? c.What is your expected due date?d.Who will be with you
during labor?82.A neonate begins to gag and turns a dusky color. What should the nursedo first?
a . C a l m t h e n e o n a t e . b.Notify the physic ian . c.Provide oxygen via face mask as orderedd.Aspirate the neonates nose and
mouth with a bulb syringe.
83.
When a client states that her "water broke," which of the following actionswould be inappropriate for the nurse to do?a.Observing the pooling of
straw-colored fluid.b.Checking vaginal discharge with nitrazine paper. c.Conducting a bedside ultrasound for an amniotic fluid
index.d.Observing for flakes of vernix in the vaginal discharge. 84. A baby girl is born 8 weeks premature. At birth, she has no
spontaneousrespirations but is successfully resuscitated. Within several hours she developsrespiratory grunting, cyanosis, tachypnea, nasal flaring, and
retractions. She'sdiagnosed with respiratory distress syndrome, intubated, and placed on aventilator. Which nursing action should be included in the
baby's plan of care toprevent retinopathy of prematurity?a.Cover his eyes while receiving oxygen.b.Keep her body temperature
low.c.Monitor partial pressure of oxygen (Pao2) levels. d.Humidify the ox ygen . 85. Which of the following is normal newborn
calorie intake?a.110 to 1 30 calo ries per kg. b.30 to 40 calories per lb of body weight.c.A t leas t 2 ml per feed in gd .9 0 to
100 c alories per kg 86. Nurse John is knowledgeable that usually individual twins will growappropriately and at the same rate as singletons until
how many weeks?a . 1 6 t o 1 8 w e e k s b . 1 8 t o 2 2 w e e k s c . 3 0 t o 3 2 w e e k s d . 3 8 t o 4 0 w e e k s 87. Which of the
following classifications applies to monozygotic twins for whomthe cleavage of the fertilized ovum occurs more than 13 days after fertilization?
a . c o n j o i n e d t w i n s b.diam niotic dicho rion ic twins
c .d iamn io tic monochorion ic twin d.monoamniotic monochorionic twins88. Tyra experienced painless vaginal bleeding has just been
diagnosed ashaving a placenta previa. Which of the following procedures is usually performedto diagnose placenta previa?

a . A m n i o c e n t e s i s b.Digital or speculum examinationc.Ex tern al fetal monito ring d . U l t r a s o u n d 89. Nurse Arnold knows
that the following changes in respiratory functioningduring pregnancy is considered normal:a.I ncreased tid al vo lumeb.Inc reas ed
exp iratory vo lum e c.Decreased inspiratory capacityd.Decreased oxygen consumption 90. Emily has gestational diabetes and it is
usually managed by which of thefollowing therapy?a . D i e t b.Lon g-ac ting in sulin c . O r a l h y p o g l y c e m i c d.Oral hypoglycemic
drug and insulin91. Magnesium sulfate is given to Jemma with preeclampsia to prevent which of the following condition?
a . H e m o r r h a g e b.Hypertensionc . H y p o m a g n e s e m i a d.Seizure92. Cammile with sickle cell anemia has an increased risk for having a sickle
cellcrisis during pregnancy. Aggressive management of a sickle cell crisis includeswhich of the following measures?a.A ntih yp ertens iv e
agen ts b . D i u r e t i c a g e n t s c . I . V . f l u i d s d.Acetaminophen (Tylenol) for pain
93. Which of the following drugs is the antidote for magnesium toxicity?a.Calcium gluconate (Kalcinate)b.H yd ralazine
(Ap reso line) c . N a l o x o n e ( N a r c a n ) d.Rho (D) immune globulin (RhoGAM)94. Marlyn is screened for tuberculosis during her first
prenatal visit. Anintradermal injection of purified protein derivative (PPD) of the tuberculin bacilli isgiven. She is considered to have a positive test for
which of the following results?a.An indurated wheal under 10 mm in diameter appears in 6 to 12 hours.b.An indurated wheal over 10 mm
in diameter appears in 48 to 72 hours.c.A flat circumcised area under 10 mm in diameter appears in 6 to 12hours.d.A flat circumcised
area over 10 mm in diameter appears in 48 to 72hours.95. Dianne, 24 year-old is 27 weeks pregnant arrives at her physicians officewith
complaints of fever, nausea, vomiting, malaise, unilateral flank pain, andcostovertebral angle tenderness. Which of the following diagnoses is most likely?
a.Asymptom atic bacteriuriab.Bacterial v agin osis c.Pyelonephritisd.Urinary tract infection (UTI)96. Rh isoimmunization in a
pregnant client develops during which of thefollowing conditions?a.Rh-positive maternal blood crosses into fetal blood, stimulating
fetalantibodies.b.Rh-positive fetal blood crosses into maternal blood, stimulatingmaternal antibodies.c.Rh-negative fetal blood crosses into
maternal blood, stimulatingmaternal antibodies.d.Rh-negative maternal blood crosses into fetal blood, stimulating fetalantibodies.97. To
promote comfort during labor, the nurse John advises a client to assumecertain positions and avoid others. Which position may cause
maternalhypotension and fetal hypoxia?a . L a t e r a l p o s i t i o n b . S q u a t t i n g p o s i t i o n c . S u p i n e p o s i t i o n
d . S t a n d i n g p o s i t i o n 98. Celeste who used heroin during her pregnancy delivers a neonate. Whenassessing the neonate, the nurse Lhynnette
expects to find:a.Lethargy 2 days after birth. b.Irritability and poor sucking.c.A flattened nose, small eyes, and thin
lips.d.Congenital defects such as limb anomalies. 99. The uterus returns to the pelvic cavity in which of the following time frames?
a.
7
th
to 9
th
day postpartum.b . 2 w e e k s p o s t p a r t u m .
c.
End of 6
th
week postpartum.d.When the lochia changes to alba.100. Maureen, a primigravida client, age 20, has just completed a difficult,forceps-assisted
delivery of twins. Her labor was unusually long and requiredoxytocin (Pitocin) augmentation. The nurse who's caring for her should stay
alertfor:a . U t e r i n e i n v e r s i o n b . U t e r i n e a t o n y c . U t e r i n e i n v o l u t i o n d . U t e r i n e d i s c o m f o r t

TEST III - Care of Clients with Physiologic and Psychosocial Alterations

1.Nurse Michelle should know that the drainage is normal 4 days after asigmoid colostomy when the stool is:a . G r e e n l i q u i d b . S o l i d
f o r m e d c . L o o s e , b l o o d y d . S e m i f o r m e d 2.Where would nurse Kristine place the call light for a male client with aright-sided
brain attack and left homonymous hemianopsia?a.On the c lien ts right sideb.On the clients left sidec .D irec tly in fron t of the
c lien td .Where the client like 3.A male client is admitted to the emergency department following anaccident. What are the first nursing
actions of the nurse?a.Check respiration, circulation, neurological response.b.Align the spine, check pupils, and check for
hemorrhage.c.Check respirations, stabilize spine, and check circulation.d.Assess level of consciousness and
circulation.4.In evaluating the effect of nitroglycerin, Nurse Arthur should know that itreduces preload and relieves angina
by:a.Increasing contractility and slowing heart rate.b.Increasing AV conduction and heart rate.c.Decreasing contractility
and oxygen consumption.d.Decreasing venous return through vasodilation. 5.Nurse Patricia finds a female client who is postmyocardial infarction (MI)slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action?a.Call for
help and note the time.b . C l e a r t h e a i r w a y c.Give two sharp thumps to the precordium, and check the
pulse.d .Ad minister two quick blo ws. 6.Nurse Monett is caring for a client recovering from gastro-intestinalbleeding. The nurse
should:
a.Plan care so the client can receive 8 hours of uninterrupted sleepeach night.b.Monitor vital signs every 2 hours.c.Make sure that the
client takes food and medications at prescribedintervals.d.Provide milk every 2 to 3 hours.7.A male client was on warfarin
(Coumadin) before admission, and hasbeen receiving heparin I.V. for 2 days. The partial thromboplastin time(PTT) is 68 seconds. What should
Nurse Carla do?a.Stop the I.V. infusion of heparin and notify the physician.b.Continue treatment as ordered.c.Expect the warfarin
to increase the PTT.d.Increase the dosage, because the level is lower than normal.8.A client undergone ileostomy, when should the
drainage appliance beapplied to the stoma?a.24 hours later, when edema has subsided.b.I n th e operating room . c.After the
ileostomy begin to function.d.When the client is able to begin self-care procedures. 9.A client undergone spinal anesthetic, it
will be important that the nurseimmediately position the client in:a.On the side, to prevent obstruction of airway by tongue.b . F l a t o n
b a c k . c.On the back, with knees flexed 15 degrees.d.Flat on the stomach, with the head turned to the side. 10.While
monitoring a male client several hours after a motor vehicleaccident, which assessment data suggest increasing intracranialpressure?a.Blood
pressure is decreased from 160/90 to 110/70.b.Pulse is increased from 87 to 95, with an occasional skipped beat.c.The client is
oriented when aroused from sleep, and goes back tosleep immediately.d.The client refuses dinner because of anorexia. 11.Mrs. Cruz,
80 years old is diagnosed with pneumonia. Which of thefollowing symptoms may appear first?a.Altered mental status and dehydration
b . F e v e r a n d c h i l l s c.H emop tysis and Dysp nea d.Pleuritic chest pain and cough12. A male client has active tuberculosis (TB).
Which of the following symptomswill be exhibit?a.Chest an d lo wer back p ain b.Chills, fever, night sweats, and hemoptysisc.Fever
of more than 104F (40C) and nausead.Headache an d photophobia 13. Mark, a 7-year-old client is brought to the emergency
department. Hestachypneic and afebrile and has a respiratory rate of 36 breaths/minute and hasa nonproductive cough. He recently had a cold. Form
this history; the client mayhave which of the following conditions?a . A c u t e a s t h m a b.Bronc hial pn eum onia c.Chronic obstructive
pulmonary disease (COPD)d . E m p h y s e m a 14. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4
breaths/minute. If action isnt taken quickly, she might havewhich of the following reactions?a . A s t h m a a t t a c k b . R e s p i r a t o r y
a r r e s t c . S e i z u r e d . W a k e u p o n h i s o w n 15. A 77-year-old male client is admitted for elective knee surgery. Physicalexamination

reveals shallow respirations but no sign of respiratory distress.Which of the following is a normal physiologic change related to aging?a.Increased
elastic recoil of the lungsb.Increased number of functional capillaries in the alveolic .Decreased residual vo lum ed .D ec reas ed
v ital c apacity 16. Nurse John is caring for a male client receiving lidocaine I.V. Which factor isthe most relevant to administration of this medication?
a.Decrease in arterial oxygen saturation (SaO2) when measured with apulse oximeter.b.Increase in systemic blood pressure
c.Presence of premature ventricular contractions (PVCs) on a cardiacmonitor.d.Increase in intracranial pressure (ICP).17. Nurse Ron
is caring for a male client taking an anticoagulant. The nurseshould teach the client to:a.Rep ort incidents of diarrhea.b.Avo id fo ods h igh
in vitamin K c.Use a straight razor when shaving.d.Take asp irin to p ain relief. 18. Nurse Lhynnette is preparing a site for the
insertion of an I.V. catheter. Thenurse should treat excess hair at the site by:a.Leaving the hair intact b . S h a v i n g t h e a r e a c .Clipping
the h air in the area d.Removing the hair with a depilatory.19. Nurse Michelle is caring for an elderly female with osteoporosis.
Whenteaching the client, the nurse should include information about which major complication:a . B o n e f r a c t u r e b . L o s s o f
e s t r o g e n c .Negative c alcium balanc e d . D o w a g e r s h u m p 20. Nurse Len is teaching a group of women to perform BSE. The nurse
shouldexplain that the purpose of performing the examination is to discover:a . C a n c e r o u s l u m p s b.Areas of thickness or
fullnessc.Changes from previous examinations.d . F i b r o c y s t i c m a s s e s 21. When caring for a female client who is being treated for
hyperthyroidism, it isimportant to:a.Provide extra blankets and clothing to keep the client warm.b.Monitor the client for signs of
restlessness, sweating, and excessiveweight loss during thyroid replacement therapy.c.Balance the clients periods of activity and
rest.d.Encourage the client to be active to prevent constipation.
22. Nurse Kris is teaching a client with history of atherosclerosis. To decreasethe risk of atherosclerosis, the nurse should encourage the client
to:a.Avo id focusin g on his weight.b.Inc rease his ac tivity lev el. c . F o l l o w a r e g u l a r d i e t . d.Continue leading a highstress lifestyle.23. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a clientfollowing
a:a . L a m i n e c t o m y b . T h o r a c o t o m y c . H e m o r r h o i d e c t o m y d . C y s t e c t o m y . 24. A 55-year old client underwent cataract
removal with intraocular lens implant.Nurse Oliver is giving the client discharge instructions. These instructions shouldinclude which of the following?
a.Avoid lifting objects weighing more than 5 lb (2.25 kg).b.Lie on your abdomen when in bedc.Keep roo ms brigh tly
lit. d.Avoiding straining during bowel movement or bending at the waist.25. George should be taught about testicular examinations
during:a.when sex ual activity starts b . A f t e r a g e 6 9 c . A f t e r a g e 4 0 d . B e f o r e a g e 2 0 . 26. A male client undergone a
colon resection. While turning him, wounddehiscence with evisceration occurs. Nurse Trish first response is to:a . C a l l t h e p h y s i c i a n b.Place a
saline-soaked sterile dressing on the wound.c.Take a blo od pressure and pulse.d .Pull th e d ehiscence c los ed. 27. Nurse
Audrey is caring for a client who has suffered a severecerebrovascular accident. During routine assessment, the nurse notices Cheyne-Strokes
respirations. Cheyne-strokes respirations are:a.A progressively deeper breaths followed by shallower breaths withapneic periods
b.Rapid, deep breathing with abrupt pauses between each breath.c.Rapid, deep breathing and irregular breathing without
pauses.d.Shallow breathing with an increased respiratory rate.28. Nurse Bea is assessing a male client with heart failure. The breath
soundscommonly auscultated in clients with heart failure are:a . T r a c h e a l b . F i n e c r a c k l e s c . C o a r s e c r a c k l e s d . F r i c t i o n
r u b s 29. The nurse is caring for Kenneth experiencing an acute asthma attack. Theclient stops wheezing and breath sounds arent audible. The reason
for thischange is that:a . T h e a t t a c k i s o v e r . b.The airways are so swollen that no air cannot get through.c.Th e swellin g h as
d ecreased. d.Crackles have replaced wheezes.30. Mike with epilepsy is having a seizure. During the active seizure phase, thenurse
should:a.Place the client on his back remove dangerous objects, and insert abite block.b.Place the client on his side, remove dangerous
objects, and insert abite block.c.Place the client o his back, remove dangerous objects, and hold downhis arms.d.Place the client on his

side, remove dangerous objects, and protect hishead.31. After insertion of a cheat tube for a pneumothorax, a client becomeshypotensive with neck
vein distention, tracheal shift, absent breath sounds, anddiaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred.What cause of
tension pneumothorax should the nurse check for?a.I nfectio n of the lun g. b.Kinked or obstructed chest tubec.Excessive water in
the water-seal chamber d.Excessive chest tube drainage32. Nurse Maureen is talking to a male client, the client begins choking on hislunch.
Hes coughing forcefully. The nurse should
a.Stand him up and perform the abdominal thrust maneuver from behind.b.Lay him down, straddle him, and perform the abdominal
thrustmaneuver.c.Leave him to get assistanc e d.Stay with him but not intervene at this time.33. Nurse Ron is taking a health
history of an 84 year old client. Whichinformation will be most useful to the nurse for planning care?a.General health for the last 10
years.b.Current health promotion activities.c .Fam ily histo ry of diseases. d . M a r i t a l s t a t u s . 34. When performing oral care on
a comatose client, Nurse Krina should:a.Apply lemon glycerin to the clients lips at least every 2 hours.b.Brush the teeth with client lying
supine.c.Place the client in a side lying position, with the head of the bedlowered.d.Clean the clients mouth with hydrogen
peroxide.35. A 77-year-old male client is admitted with a diagnosis of dehydration andchange in mental status. Hes being hydrated with L.V. fluids.
When the nursetakes his vital signs, she notes he has a fever of 103F (39.4C) a coughproducing yellow sputum and pleuritic chest pain. The nurse
suspects this clientmay have which of the following conditions?a.Adult respiratory distress syndrome (ARDS)b.Myocard ial infarc tion
(MI )c . P n e u m o n i a d . T u b e r c u l o s i s 36. Nurse Oliver is working in a out patient clinic. He has been alerted that thereis an outbreak of
tuberculosis (TB). Which of the following clients entering theclinic today most likely to have TB?a.A 16-year-old female high school
studentb.A 33-year-old day-care worker c.A 43-yesr-old homeless man with a history of alcoholism d .A 54 - year- old
bus in es sman 37. Virgie with a positive Mantoux test result will be sent for a chest X-ray. Thenurse is aware that which of the following reasons this is
done?a.To co nfirm the diagno sis
b.To determine if a repeat skin test is neededc.To determine the extent of lesionsd.To determine if this is a primary or
secondary infection38. Kennedy with acute asthma showing inspiratory and expiratory wheezes anda decreased forced expiratory volume should be
treated with which of thefollowing classes of medication right away?a.Beta-adrenergic blockers b . B r o n c h o d i l a t o r s c . I n h a l e d
s t e r o i d s d . O r a l s t e r o i d s 39. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to twopacks of cigarettes per day has a
chronic cough producing thick sputum,peripheral edema and cyanotic nail beds. Based on this information, he mostlikely has which of the following
conditions?a.Adult respiratory distress syndrome (ARDS) b . A s t h m a c .Chro nic o bs truc tive
bro nch itis d . E m p h y s e m a Situation: Francis, age 46 is admitted to the hospital with diagnosis of ChronicLymphocytic Leukemia.40. The
treatment for patients with leukemia is bone marrow transplantation.Which statement about bone marrow transplantation is not correct?a.The patient
is under local anesthesia during the procedureb.The aspirated bone marrow is mixed with heparin.c.The aspiration site is the
posterior or anterior iliac crest.d.The recipient receives cyclophosphamide (Cytoxan) for 4 consecutivedays before the procedure.41.
After several days of admission, Francis becomes disoriented and complainsof frequent headaches. The nurse in-charge first action would be:a . C a l l
t h e p h y s i c i a n b.Document the patients status in his charts. c.Prep are oxygen treatm en t d . R a i s e t h e s i d e r a i l s 42.
During routine care, Francis asks the nurse, How can I be anemic if thisdisease causes increased my white blood cell production? The nurse inchargebest response would be that the increased number of white blood cells (WBC) is:
a.Cro wd red blo od cells b.Are not responsible for the anemia.c.Uses nutrients from other cellsd.Have an abnormally
short life span of cells.43. Diagnostic assessment of Francis would probably not reveal:a.Predominance of
lymhoblastsb . L e u k o c y t o s i s c.Abnormal blast cells in the bone marrowd.Elevated th rom boc yte counts 44. Robert, a 57-

year-old client with acute arterial occlusion of the left legundergoes an emergency embolectomy. Six hours later, the nurse isnt able toobtain pulses in his
left foot using Doppler ultrasound. The nurse immediatelynotifies the physician, and asks her to prepare the client for surgery. As the nurseenters the
clients room to prepare him, he states that he wont have any moresurgery. Which of the following is the best initial response by the nurse?a.Explain
the risks of not having the surgeryb.Notifying the physician immediatelyc.Notifying the nursing supervisor d.Recording
the clients refusal in the nurses notes45. During the endorsement, which of the following clients should the on-dutynurse assess first?a.The
58-year-old client who was admitted 2 days ago with heart failure,blood pressure of 126/76 mm Hg, and a respiratory rate of 22
breaths/minute.b.The 89-year-old client with end-stage right-sided heart failure, bloodpressure of 78/50 mm Hg, and a do not resuscitate
order c.The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving L.V. heparind.The 75-year-old client
who was admitted 1 hour ago with new-onsetatrial fibrillation and is receiving L.V. dilitiazem (Cardizem)46. Honey, a 23-year old client complains
of substernal chest pain and statesthat her heart feels like its racing out of the chest. She reports no history of cardiac disorders. The nurse attaches her
to a cardiac monitor and notes sinustachycardia with a rate of 136beats/minutes. Breath sounds are clear and therespiratory rate is 26 breaths/minutes.
Which of the following drugs should thenurse question the client about using?a . B a r b i t u r a t e s
b . O p i o i d s c . C o c a i n e d . B e n z o d i a z e p i n e s 47. A 51-year-old female client tells the nurse in-charge that she has found apainless
lump in her right breast during her monthly self-examination. Whichassessment finding would strongly suggest that this client's lump is cancerous?
a.Eversion of the right nipple and mobile massb.Nonmobile mass with irregular edgesc.Mobile mass that is soft and easily
delineatedd.Nonpalpable right axillary lymph nodes 48. A 35-year-old client with vaginal cancer asks the nurse, "What is the usualtreatment
for this type of cancer?" Which treatment should the nurse name?
a . S u r g e r y b . C h e m o t h e r a p y c . R a d i a t i o n d . I m m u n o t h e r a p y 49. Cristina undergoes a biopsy of a suspicious lesion. The
biopsy reportclassifies the lesion according to the TNM staging system as follows: TIS, N0,M0. What does this classification mean?a.No evidence of
primary tumor, no abnormal regional lymph nodes, andno evidence of distant metastasisb.Carcinoma in situ, no abnormal regional lymph
nodes, and noevidence of distant metastasisc.Can't assess tumor or regional lymph nodes and no evidence of metastasisd.Carcinoma
in situ, no demonstrable metastasis of the regional lymphnodes, and ascending degrees of distant metastasis50. Lydia undergoes a laryngectomy
to treat laryngeal cancer. When teachingthe client how to care for the neck stoma, the nurse should include whichinstruction?a."Keep the sto ma
uncovered."b."Keep the stom a dry." c."Have a family member perform stoma care initially until you get usedto the
procedure."d ."Keep the stom a moist."
51. A 37-year-old client with uterine cancer asks the nurse, "Which is the mostcommon type of cancer in women?" The nurse replies that it's breast
cancer.Which type of cancer causes the most deaths in women?a . B r e a s t c a n c e r b . L u n g c a n c e r c . B r a i n c a n c e r d.Co lo n
and rec tal cancer 52. Antonio with lung cancer develops Horner's syndrome when the tumor invades the ribs and affects the sympathetic nerve
ganglia. When assessing for signs and symptoms of this syndrome, the nurse should note:a.miosis, partial eyelid ptosis, and anhidrosis on
the affected side of theface.b.chest pain, dyspnea, cough, weight loss, and fever.c.arm and shoulder pain and atrophy of
arm and hand muscles, both onthe affected side.d.hoarsen ess an d dysphagia. 53. Vic asks the nurse what PSA is. The nurse should reply
that it stands for:a.prostate-specific antigen, which is used to screen for prostate cancer.b.protein serum antigen, which is used to
determine protein levels.c.pneumococcal strep antigen, which is a bacteria that causes pneumonia.d.Papanicolaou-specific
antigen, which is used to screen for cervicalcancer.54. What is the most important postoperative instruction that nurse Kate mustgive a client who
has just returned from the operating room after receiving asubarachnoid block?a."Avoid drinking liquids until the gag reflex
returns."b."Avoid eating milk products for 24 hours."c."Notify a nurse if you experience blood in your urine." d."Remain
supine for the time specified by the physician."55. A male client suspected of having colorectal cancer will require whichdiagnostic study to confirm

the diagnosis?a . S t o o l H e m a t e s t b.Carcinoembryonic antigen (CEA)c . S i g m o i d o s c o p y d.Abdominal computed

tomography (CT) scan
56. During a breast examination, which finding most strongly suggests that theLuz has breast cancer?a. Slight asymmetry of the breasts.b. A fixed
nodular mass with dimpling of the overlying skinc. Bloody discharge from the nippled. Multiple firm, round, freely movable masses that change with
themenstrual cycle57. A female client with cancer is being evaluated for possible metastasis. Whichof the following is one of the most common metastasis
sites for cancer cells?a . L i v e r b . C o l o n c . R e p r o d u c t i v e t r a c t d.White bloo d cells (WBCs) 58. Nurse Mandy is preparing
a client for magnetic resonance imaging (MRI) toconfirm or rule out a spinal cord lesion. During the MRI scan, which of thefollowing would pose a threat
to the client?a.Th e client lies still.b.The clien t asks questio ns. c.The client hears thumping sounds.d.The client wears a
watch and wedding band.59. Nurse Cecile is teaching a female client about preventing osteoporosis.Which of the following teaching points is
correct?a.Obtaining an X-ray of the bones every 3 years is recommended todetect bone loss.b.To avoid fractures, the client should avoid
strenuous exercise.c.The recommended daily allowance of calcium may be found in a widevariety of foods.d.Obtaining the recommended
daily allowance of calcium requires takinga calcium supplement.60. Before Jacob undergoes arthroscopy, the nurse reviews the assessmentfindings
for contraindications for this procedure. Which finding is acontraindication?a. Joint painb. Joint deformityc. Joint flexion of less than 50%d. Joint
stiffness
61. Mr. Rodriguez is admitted with severe pain in the knees. Which form of arthritis is characterized by urate deposits and joint pain, usually in the feet
andlegs, and occurs primarily in men over age 30?a . S e p t i c a r t h r i t i s b.Traumatic arthritisc .I ntermitten t arth ritis d . G o u t y
a r t h r i t i s 62. A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old client withstroke in evolution. The infusion contains 25,000 units of
heparin in 500 ml of saline solution. How many milliliters per hour should be given?a. 15 ml/hour b. 30 ml/hour c. 45 ml/hour d. 50 ml/hour 63. A 76year-old male client had a thromboembolic right stroke; his left arm isswollen. Which of the following conditions may cause swelling after a stroke?
a.Elbow contracture secondary to spasticityb.Loss of muscle contraction decreasing venous return c.Deep vein thrombosis
(DVT) due to immobility of the ipsilateral sided.Hypoalbuminemia due to protein escaping from an inflamedglomerulus64. Heberdens
nodes are a common sign of osteoarthritis. Which of the followingstatement is correct about this deformity?a.I t appears on ly in men b.It
appears on the distal interphalangeal jointc.It appears on the proximal interphalangeal joint d.It appears on the dorsolateral
aspect of the interphalangeal joint.65. Which of the following statements explains the main difference betweenrheumatoid arthritis and
osteoarthritis?a.Osteoarthritis is gender-specific, rheumatoid arthritis isntb.Osteoarthritis is a localized disease rheumatoid arthritis is
systemicc.Osteoarthritis is a systemic disease, rheumatoid arthritis is localizedd.Osteoarthritis has dislocations and subluxations,
rheumatoid arthritisdoesnt66. Mrs. Cruz uses a cane for assistance in walking. Which of the followingstatements is true about a cane or other assistive
devices?
a.A walker is a better choice than a cane.b.The cane should be used on the affected sidec.The cane should be used on the
unaffected sided.A client with osteoarthritis should be encouraged to ambulate withoutthe cane67. A male client with type 1 diabetes is
scheduled to receive 30 U of 70/30insulin. There is no 70/30 insulin available. As a substitution, the nurse may givethe client:a. 9 U regular insulin and
21 U neutral protamine Hagedorn (NPH).b. 21 U regular insulin and 9 U NPH.c. 10 U regular insulin and 20 U NPH.d. 20 U regular insulin and 10 U
NPH.68. Nurse Len should expect to administer which medication to a client withgout?a . a s p i r i n b . f u r o s e m i d e
( L a s i x ) c . c o l c h i c i n e s d.calcium gluconate (Kalcinate)69. Mr. Domingo with a history of hypertension is diagnosed with
primaryhyperaldosteronism. This diagnosis indicates that the client's hypertension iscaused by excessive hormone secretion from which of the following
glands?a . A d r e n a l c o r t e x b . P a n c r e a s c . A d r e n a l m e d u l l a d . P a r a t h y r o i d 70. For a diabetic male client with a foot ulcer, the

doctor orders bed rest, a wet-to-dry dressing change every shift, and blood glucose monitoring before mealsand bedtime. Why are wet-to-dry dressings
used for this client?a.They contain exudate and provide a moist wound environment.b.They protect the wound from mechanical trauma
and promote healing.c.They debride the wound and promote healing by secondary intention.d.They prevent the entrance of
microorganisms and minimize wounddiscomfort.71. Nurse Zeny is caring for a client in acute addisonian crisis. Which laboratorydata would the
nurse expect to find?a . H y p e r k a l e m i a
b.Reduced blood urea nitrogen (BUN)c . H y p e r n a t r e m i a d . H y p e r g l y c e m i a 72. A client is admitted for treatment of the syndrome
of inappropriate antidiuretichormone (SIADH). Which nursing intervention is appropriate?a.Infusing I.V. fluids rapidly as
orderedb.Encouraging increased oral intake c . R e s t r i c t i n g f l u i d s d.Administering glucose-containing I.V. fluids as ordered73. A
female client tells nurse Nikki that she has been working hard for the last 3months to control her type 2 diabetes mellitus with diet and exercise.
Todetermine the effectiveness of the client's efforts, the nurse should check:a.urine gluco se lev el.b.fas tin g bloo d gluco se
lev el.c .s erum fruc to samine lev el. d.glycosylated hemoglobin level.74. Nurse Trinity administered neutral protamine Hagedorn
(NPH) insulin to adiabetic client at 7 a.m. At what time would the nurse expect the client to be mostat risk for a hypoglycemic reaction?a . 1 0 : 0 0
a m b . N o o n c . 4 : 0 0 p m d . 1 0 : 0 0 p m 75. The adrenal cortex is responsible for producing which substances?
a.Glucocorticoids and androgensb.Catecholamines and epinephrinec.Mineralocorticoids and
catecholaminesd.Norepinephrine and epinephrine76. On the third day after a partial thyroidectomy, Proserfina exhibits muscletwitching
and hyperirritability of the nervous system. When questioned, the clientreports numbness and tingling of the mouth and fingertips. Suspecting a lifethreatening electrolyte disturbance, the nurse notifies the surgeon immediately.Which electrolyte disturbance most commonly follows thyroid surgery?
a.Hypocalcemiab.Hyponatremiac.Hyperkalemia
d . H y p e r m a g n e s e m i a 77. Which laboratory test value is elevated in clients who smoke and can't beused as a general indicator of cancer?a.Ac id
pho sph atas e levelb.Serum c alc ito nin levelc. Alkalin e phosphatase lev el d.Carcinoembryonic antigen level78. Francis
with anemia has been admitted to the medical-surgical unit. Whichassessment findings are characteristic of iron-deficiency anemia?a.Nights sweats,
weight loss, and diarrheab.Dyspnea, tachycardia, and pallor c .Nausea, vom itin g, and ano rexiad .Itch in g, rash , and
j aund ic e79. In teaching a female client who is HIV-positive about pregnancy, the nursewould know more teaching is necessary when the client
says:a.The baby can get the virus from my placenta."b. "I'm planning on starting on birth control pills." c."Not everyone who
has the virus gives birth to a baby who has thevirus."d."I'll need to have a C-section if I become pregnant and have a baby."80. When
preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction?
a."Put on disposable gloves before bathing."b."Sterilize all plates and utensils in boiling water."c."Avoid sharing such
articles as toothbrushes and razors."d."Avoid eating foods from serving dishes shared by other familymembers."81. Nurse Marie is
caring for a 32-year-old client admitted with perniciousanemia. Which set of findings should the nurse expect when assessing theclient?a.Pallor,
bradycardia, and reduced pulse pressureb.Pallor, tachycardia, and a sore tonguec.Sore tongue, dyspnea, and weight
gaind.Angina, double vision, and anorexia
82. After receiving a dose of penicillin, a client develops dyspnea andhypotension. Nurse Celestina suspects the client is experiencing anaphylacticshock.
What should the nurse do first?a.Page an anesthesiologist immediately and prepare to intubate theclient.b.Administer epinephrine, as
prescribed, and prepare to intubate theclient if necessary.c.Administer the antidote for penicillin, as prescribed, and continue tomonitor
the client's vital signs.d.Insert an indwelling urinary catheter and begin to infuse I.V. fluids asordered.83. Mr. Marquez with rheumatoid
arthritis is about to begin aspirin therapy toreduce inflammation. When teaching the client about aspirin, the nurse discussesadverse reactions to

prolonged aspirin therapy. These include:a . w e i g h t g a i n . b . f i n e m o t o r t r e m o r s . c.respiratory acidos is .d .bilateral h earin g

loss . 84. A 23-year-old client is diagnosed with human immunodeficiency virus (HIV).After recovering from the initial shock of the diagnosis, the client
expresses adesire to learn as much as possible about HIV and acquired immunodeficiencysyndrome (AIDS). When teaching the client about the
immune system, the nursestates that adaptive immunity is provided by which type of white blood cell?
a . N e u t r o p h i l b . B a s o p h i l c . M o n o c y t e d . L y m p h o c y t e 85. In an individual with Sjgren's syndrome, nursing care should
focus on:a.moisture rep lac ement.b. elec trolyte balanc e.c .n utrition al supplem en tation .d .arrhythm ia
m an agem en t. 86. During chemotherapy for lymphocytic leukemia, Mathew develops abdominalpain, fever, and "horse barn" smelling diarrhea. It
would be most important for thenurse to advise the physician to order:a.enzyme-linked immunosuppressant assay (ELISA) test.b.electrolyte
panel and hemogram.
c.
stool for
Clostridium difficile
test.d.flat plate X-ray of the abdomen.87. A male client seeks medical evaluation for fatigue, night sweats, and a 20-lbweight loss in 6 weeks. To
confirm that the client has been infected with thehuman immunodeficiency virus (HIV), the nurse expects the physician to order:a.E-rosette
immunofluorescence.b.quantification of T-lymphocytes.c.enzyme-linked immunosorbent assay (ELISA). d .Wes tern blot
tes t with ELI SA . 88. A complete blood count is commonly performed before a Joe goes intosurgery. What does this test seek to identify?
a.Potential hepatic dysfunction indicated by decreased blood ureanitrogen (BUN) and creatinine levelsb.Low levels of urine constituents
normally excreted in the urinec.Abnormally low hematocrit (HCT) and hemoglobin (Hb) levelsd.Electrolyte imbalance that could affect
the blood's ability to coagulateproperly89. While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse
should take note of what assessment parameters?a.Platelet count, prothrombin time, and partial thromboplastin timeb.Platelet count, blood
glucose levels, and white blood cell (WBC) countc.Thrombin time, calcium levels, and potassium levelsd.Fibrinogen level, WBC,
and platelet count90. When taking a dietary history from a newly admitted female client, Nurse Lenshould remember that which of the following
foods is a common allergen?a . B r e a d b . C a r r o t s c . O r a n g e d . S t r a w b e r r i e s 91. Nurse John is caring for clients in the
outpatient clinic. Which of the followingphone calls should the nurse return first?a.A client with hepatitis A who states, My arms and legs are
itching.b.A client with cast on the right leg who states, I have a funny feeling inmy right leg.c.A client with osteomyelitis of the spine
who states, I am so nauseousthat I cant eat.
d.A client with rheumatoid arthritis who states, I am having troublesleeping.92. Nurse Sarah is caring for clients on the surgical floor and has
just receivedreport from the previous shift. Which of the following clients should the nurse seefirst?a.A 35-year-old admitted three hours ago with
a gunshot wound; 1.5 cmarea of dark drainage noted on the dressing.b.A 43-year-old who had a mastectomy two days ago; 23 ml
of serosanguinous fluid noted in the Jackson-Pratt drain.c.A 59-year-old with a collapsed lung due to an accident; no drainagenoted in the
previous eight hours.d.A 62-year-old who had an abdominal-perineal resection three daysago; client complaints of chills.93. Nurse Eve is caring
for a client who had a thyroidectomy 12 hours ago for treatment of Graves disease. The nurse would be most concerned if which of thefollowing was
observed?a.Blood pressure 138/82, respirations 16, oral temperature 99 degreesFahrenheit.b.The client supports his head and neck when
turning his head to theright.c.The client spontaneously flexes his wrist when the blood pressure isobtained.d.The client is drowsy and
complains of sore throat.94. Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. To assist with pain
relief, the nurse should take which of thefollowing actions?a.Encourage the client to change positions frequently in bed.b.Administer
Demerol 50 mg IM q 4 hours and PRN.c.Apply warmth to the abdomen with a heating pad. d.Use comfort measures and

pillows to position the client.95. Nurse Tina prepares a client for peritoneal dialysis. Which of the followingactions should the nurse take first?
a.Assess for a bruit and a thrill.b.Warm the dialysate solution.c.Position the client on the left side. d.In sert a Fo ley
c atheter
96. Nurse Jannah teaches an elderly client with right-sided weakness how to usecane. Which of the following behaviors, if demonstrated by the client to
the nurse,indicates that the teaching was effective?a.The client holds the cane with his right hand, moves the can forwardfollowed by the right
leg, and then moves the left leg.b.The client holds the cane with his right hand, moves the cane forwardfollowed by his left leg, and then moves
the right leg.c.The client holds the cane with his left hand, moves the cane forwardfollowed by the right leg, and then moves the left leg.d.The
client holds the cane with his left hand, moves the cane forwardfollowed by his left leg, and then moves the right leg.97. An elderly client is
admitted to the nursing home setting. The client isoccasionally confused and her gait is often unsteady. Which of the followingactions, if taken by the
nurse, is most appropriate?a.Ask the womans family to provide personal items such as photos or mementos.b.Select a room with a bed by
the door so the woman can look down thehall.c.Suggest the woman eat her meals in the room with her roommate.d.Encourage the
woman to ambulate in the halls twice a day.98. Nurse Evangeline teaches an elderly client how to use a standard aluminumwalker. Which of the
following behaviors, if demonstrated by the client, indicatesthat the nurses teaching was effective?a.The client slowly pushes the walker forward 12
inches, then takessmall steps forward while leaning on the walker.b.The client lifts the walker, moves it forward 10 inches, and then
takesseveral small steps forward.c.The client supports his weight on the walker while advancing it forward,then takes small steps while
balancing on the walker.
d.
The client slides the walker 18 inches forward, then takes small stepswhile holding onto the walker for balance.99. Nurse Deric is supervising a group of
elderly clients in a residential homesetting. The nurse knows that the elderly are at greater risk of developingsensory deprivation for what reason?
a.Increased sensitivity to the side effects of medications.b.Decreased visual, auditory, and gustatory abilities.c.Isolation from
their families and familiar surroundings.d.Decrease musculoskeletal function and mobility.
100. A male client with emphysema becomes restless and confused. What stepshould nurse Jasmine take next?a.Encourage the client to
perform pursed lip breathing.b.Check the clients temperature.c.Assess the clients potassium level.d.Increase the clients
oxygen flow rate.

TEST IV - Care of Clients with Physiologic and Psychosocial Alterations

1.Randy has undergone kidney transplant, what assessment would promptNurse Katrina to suspect organ rejection?a . S u d d e n w e i g h t
lossb . P o l y u r i a
c.
Hypertensiond . S h o c k 2.The immediate objective of nursing care for an overweight, mildlyhypertensive male client with ureteral colic
and hematuria is to decrease:a . P a i n b . W e i g h t c . H e m a t u r i a d . H y p e r t e n s i o n 3.Matilda, with hyperthyroidism is to
receive Lugols iodine solution before asubtotal thyroidectomy is performed. The nurse is aware that thismedication is given to:a.Decrease the
total basal metabolic rate.b.Maintain the function of the parathyroid glands.c.Block the formation of thyroxine by the
thyroid gland.d.Decrease the size and vascularity of the thyroid gland. 4.Ricardo, was diagnosed with type I diabetes. The nurse
is aware thatacute hypoglycemia also can develop in the client who is diagnosed with:a . L i v e r d i s e a s e b . H y p e r t e n s i o n

c.
Type 2 diabetesd . H y p e r t h y r o i d i s m 5.Tracy is receiving combination chemotherapy for treatment of metastaticcarcinoma. Nurse Ruby
should monitor the client for the systemic sideeffect of:a . A s c i t e s b . N y s t a g m u s c . L e u k o p e n i a d . P o l y c y t h e m i a
6.Norma, with recent colostomy expresses concern about the inability tocontrol the passage of gas. Nurse Oliver should suggest that the
clientplan to:a.Eliminate foods high in cellulose.b.Decrease fluid intake at meal times.c.Avoid foods that in the past caused
flatus.d.Adhere to a bland diet prior to social events. 7.Nurse Ron begins to teach a male client how to perform
colostomyirrigations. The nurse would evaluate that the instructions wereunderstood when the client states, I should:a.Lie on my left side while
instilling the irrigating solution.b.Keep the irrigating container less than 18 inches above the stoma.c.Instill a minimum of 1200 ml of
irrigating solution to stimulateevacuation of the bowel.d.Insert the irrigating catheter deeper into the stoma if crampingoccurs during the
procedure.8.Patrick is in the oliguric phase of acute tubular necrosis and isexperiencing fluid and electrolyte imbalances. The client is
somewhatconfused and complains of nausea and muscle weakness. As part of theprescribed therapy to correct this electrolyte imbalance, the nurse
wouldexpect to:a.Adm in ister Kayexalateb.Restric t foo ds high in pro tein c.Increase oral intake of cheese and
milk.d.Administer large amounts of normal saline via I.V. 9.Mario has burn injury. After Forty48 hours, the physician orders for
Mario2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is10 gtt/ml. The nurse should set the flow to provide:a. 18 gtt/minb. 28
gtt/minc. 32 gtt/mind. 36 gtt/min10.Terence suffered form burn injury. Using the rule of nines, which has thelargest percent of burns?a . F a c e a n d
n e c k b.Right upp er arm and pen is
c.Right thigh and penisd . U p p e r t r u n k
11.
Herbert, a 45 year old construction engineer is brought to the hospitalunconscious after falling from a 2-story building. When assessing theclient, the
nurse would be most concerned if the assessment revealed:a. Reactive pupilsb. A depressed fontanelc. Bleeding from earsd. An elevated temperature
12.
Nurse Sherry is teaching male client regarding his permanent artificialpacemaker. Which information given by the nurse shows her knowledgedeficit
about the artificial cardiac pacemaker?a. take the pulse rate once a day, in the morning upon awakeningb. May be allowed to use electrical appliancesc.
Have regular follow up cared. May engage in contact sports13.The nurse is ware that the most relevant knowledge about oxygenadministration to a male
client with COPD isa.Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.b.Hypoxia stimulates the central
chemoreceptors in the medulla thatmakes the client breath.c.Oxygen is administered best using a non-rebreathing maskd.Blood
gases are monitored using a pulse oximeter. 14.Tonny has undergoes a left thoracotomy and a partial pneumonectomy.Chest tubes are
inserted, and one-bottle water-seal drainage is institutedin the operating room. In the postanesthesia care unit Tonny is placed inFowler's position on
either his right side or on his back. The nurse isaware that this position:a.Reduce incisional pain . b.Facilitate ventilation of the left
lung.c.Equalize pressure in the pleural space. d.Inc rease venous return 15.Kristine is scheduled for a bronchoscopy. When teaching
Kristine what toexpect afterward, the nurse's highest priority of information would be:
a.Food and fluids will be withheld for at least 2 hours.b.Warm saline gargles will be done q 2h.c.Coughing and deepbreathing exercises will be done q2h.d.Only ice chips and cold liquids will be allowed initially. 16.Nurse Tristan is caring for a
male client in acute renal failure. The nurseshould expect hypertonic glucose, insulin infusions, and sodiumbicarbonate to be used to
treat:a . h y p e r n a t r e m i a . b . h y p o k a l e m i a . c . h y p e r k a l e m i a . d . h y p e r c a l c e m i a . 17.Ms. X has just been diagnosed with
condylomata acuminata (genitalwarts). What information is appropriate to tell this client?a.This condition puts her at a higher risk for cervical

cancer;therefore, she should have a Papanicolaou (Pap) smear annually.b.The most common treatment is metronidazole (Flagyl), whichshould
eradicate the problem within 7 to 10 days.c.The potential for transmission to her sexual partner will be eliminated if condoms are used
every time they have sexualintercourse.d.The human papillomavirus (HPV), which causes condylomataacuminata, can't be transmitted during
oral sex.18.Maritess was recently diagnosed with a genitourinary problem and isbeing examined in the emergency department. When palpating the
her kidneys, the nurse should keep which anatomical fact in mind?a.The left kidney usually is slightly higher than the right one.b.The kidneys
are situated just above the adrenal glands.c.The average kidney is approximately 5 cm (2") long and 2 to 3 cm(" to 1-1/8")
wide.d.The kidneys lie between the 10th and 12th thoracic vertebrae.19.Jestoni with chronic renal failure (CRF) is admitted to the urology unit.
Thenurse is aware that the diagnostic test are consistent with CRF if the resultis:a.Increased pH with decreased hydrogen ions.b.Increased
serum levels of potassium, magnesium, and calcium.c.Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/dl.
d.Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP)excretion 75%.
20.
Katrina has an abnormal result on a Papanicolaou test. After admittingthat she read her chart while the nurse was out of the room, Katrina askswhat
dysplasia
means. Which definition should the nurse provide?a.Presence of completely undifferentiated tumor cells that don'tresemble cells of the tissues of
their origin.b.Increase in the number of normal cells in a normal arrangement ina tissue or an organ.c.Replacement of one type of fully
differentiated cell by another intissues where the second type normally isn't found.d.Alteration in the size, shape, and organization of
differentiated cells.
21.
During a routine checkup, Nurse Mariane assesses a male client withacquired immunodeficiency syndrome(AIDS)for signs and symptoms of cancer.
What is the most common AIDS-related cancer?a.Squamous cell c arc in oma b . M u l t i p l e m y e l o m a c . L e u k e m i a d . K a p o s i ' s
s a r c o m a 22.Ricardo is scheduled for a prostatectomy, and the anesthesiologist plansto use a spinal (subarachnoid) block during surgery. In the
operatingroom, the nurse positions the client according to the anesthesiologist'sinstructions. Why does the client require special positioning for this type
of anesthesia?a.To p rev en t con fusio n b . T o p r e v e n t s e i z u r e s c.To prevent cerebrospinal fluid (CSF) leakaged.To prevent
cardiac arrhythmias23.A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing
action should be to:a.A uscultate bowel so unds.b.Palpate the abdom en .c.Change the c lien t' s position .d .In sert a rectal
tube. 24.Wilfredo with a recent history of rectal bleeding is being prepared for acolonoscopy. How should the nurse Patricia position the client for this
testinitially?
a.Lying on the right side with legs straightb.Lying on the left side with knees bent c.Pron e with th e to rs o elev ated d.Bent
over with hands touching the floor 25.A male client with inflammatory bowel disease undergoes an ileostomy.On the first day after surgery,
Nurse Oliver notes that the client's stomaappears dusky. How should the nurse interpret this finding?a.Blood supply to the stoma has been
interrupted.b.This is a normal finding 1 day after surgery.c.The ostomy bag should be adjusted.d.An intestinal obstruction
has occurred.26.Anthony suffers burns on the legs, which nursing intervention helpsprevent contractures?a.App lyin g knee
sp lin ts b.Elev ating the foo t of the bed c.Hyperextending the client's palmsd.Performing shoulder range-of-motion
exercises27.Nurse Ron is assessing a client admitted with second- and third-degreeburns on the face, arms, and chest. Which finding indicates a
potentialproblem?
a.
Partial pressure of arterial oxygen (PaO

2
) value of 80 mm Hg.b.Urin e outp ut of 20 ml/hour.c.White pulm on ary secretio ns . d.Rectal temperature of 100.6 F (38
C).
28.
Mr. Mendoza who has suffered a cerebrovascular accident(CVA)is tooweak to move on his own. To help the client avoid pressure ulcers, NurseCelia
should:a.Turn him frequen tly. b.Perform passive range-of-motion (ROM) exercises. c.Reduc e th e client's fluid
intake. d.Encourage the client to use a footboard.
29.Nurse Maria plans to administer dexamethasone cream to a female clientwho has dermatitis over the anterior chest. How should the nurse applythis
topical agent?a.With a circular motion, to enhance absorption.b.With an upward motion, to increase blood supply to the
affectedareac.In long, even, outward, and downward strokes in the direction of hair growthd.In long, even, outward, and upward strokes
in the direction oppositehair growth30.Nurse Kate is aware that one of the following classes of medicationprotect the ischemic myocardium by
blocking catecholamines andsympathetic nerve stimulation is:a.Beta -adren ergic bloc kersb.Calc ium chann el
bloc ker c . N a r c o t i c s d . N i t r a t e s 31.A male client has jugular distention. On what position should the nurseplace the head of the bed to
obtain the most accurate reading of jugular vein distention?a . H i g h F o w l e r s b . R a i s e d 1 0 d e g r e e s c . R a i s e d 3 0
d e g r e e s d . S u p i n e p o s i t i o n 32.The nurse is aware that one of the following classes of medicationsmaximizes cardiac performance in clients
with heart failure by increasingventricular contractility?a.Beta-adren ergic bloc kersb.Calcium chann el
bloc ker c . D i u r e t i c s d . I n o t r o p i c a g e n t s 33.A male client has a reduced serum high-density lipoprotein (HDL) leveland an elevated
low-density lipoprotein (LDL) level. Which of the followingdietary modifications is not appropriate for this client?a.F iber in take of 25 to 30 g
d aily
b.Less than 30% of calories form fatc.Cholesterol intake of less than 300 mg dailyd.Less than 10% of calories from
saturated fat34. A 37-year-old male client was admitted to the coronary care unit (CCU) 2days ago with an acute myocardial infarction. Which of the
following actionswould breach the client confidentiality?a.The CCU nurse gives a verbal report to the nurse on the telemetryunit before
transferring the client to that unitb.The CCU nurse notifies the on-call physician about a change in theclients conditionc.The emergency
department nurse calls up the latestelectrocardiogram results to check the clients progress.d.At the clients request, the CCU nurse
updates the clients wife onhis condition35. A male client arriving in the emergency department is receivingcardiopulmonary resuscitation from
paramedics who are giving ventilationsthrough an endotracheal (ET) tube that they placed in the clients home. During apause in compressions, the
cardiac monitor shows narrow QRS complexes anda heart rate of beats/minute with a palpable pulse. Which of the following actionsshould the nurse
take first?a.Start an L.V. line and administer amiodarone (Cardarone), 300 mgL.V. over 10 minutes.b.Check endotracheal tube
placement.c.Obtain an arterial blood gas (ABG) sample.d.Administer atropine, 1 mg L.V. 36. After cardiac surgery, a clients blood
pressure measures 126/80 mm Hg.Nurse Katrina determines that mean arterial pressure (MAP) is which of thefollowing?a . 4 6 m m
H g b . 8 0 m m H g c . 9 5 m m H g d . 9 0 m m H g 37. A female client arrives at the emergency department with chest and
stomachpain and a report of black tarry stool for several months. Which of the followingorder should the nurse Oliver anticipate?a.Cardiac monitor,
oxygen, creatine kinase and lactate dehydrogenase levelsb.Prothrombin time, partial thromboplastin time, fibrinogen and fibrin
splitproduct values.

c.Electrocardiogram, complete blood count, testing for occult blood,comprehensive serum metabolic panel.d.Electroencephalogram,
alkaline phosphatase and aspartate aminotransferaselevels, basic serum metabolic panel38. Macario had coronary artery bypass graft (CABG)
surgery 3 days ago. Whichof the following conditions is suspected by the nurse when a decrease in plateletcount from 230,000 ul to 5,000 ul is noted?
a . P a n c y t o p e n i a b.Idiopathic thrombocytopemic purpura (ITP)c.Disseminated intravascular coagulation
(DIC)d.Heparin-associated thrombosis and thrombocytopenia (HATT)39. Which of the following drugs would be ordered by the physician to
improvethe platelet count in a male client with idiopathic thrombocytopenic purpura(ITP)?a.Ac etyls alicylic ac id
(A SA )b . C o r t i c o s t e r o i d s c . M e t h o t r e z a t e d . V i t a m i n K 40. A female client is scheduled to receive a heart valve replacement with
aporcine valve. Which of the following types of transplant is this?
a . A l l o g e n e i c b . A u t o l o g o u s c . S y n g e n e i c d . X e n o g e n e i c 41. Marco falls off his bicycle and injuries his ankle. Which of the
followingactions shows the initial response to the injury in the extrinsic pathway?a . R e l e a s e o f C a l c i u m b.Release of tissue
thromboplastinc.Conversion of factors XII to factor XIIad.Conversion of factor VIII to factor VIIIa 42. Instructions for a client
with systemic lupus erythematosus (SLE) wouldinclude information about which of the following blood dyscrasias?a.Dres slers
s yn dro me b . P o l y c y t h e m i a c.Essential thro mbocytop en ia
d .V on Willebran ds disease 43. The nurse is aware that the following symptoms is most commonly an earlyindication of stage 1 Hodgkins
disease?a . P e r i c a r d i t i s b . N i g h t s w e a t c . S p l e n o m e g a l y d.Persistent hyp otherm ia 44. Francis with leukemia has
neutropenia. Which of the following functions mustfrequently assessed?a . B l o o d p r e s s u r e b . B o w e l s o u n d s c . H e a r t
s o u n d s d . B r e a t h s o u n d s 45. The nurse knows that neurologic complications of multiple myeloma (MM)usually involve which of the
following body system?a . B r a i n b . M u s c l e s p a s m c . R e n a l d y s f u n c t i o n d.Myo card ial irritability 46. Nurse Patricia is
aware that the average length of time from humanimmunodeficiency virus (HIV) infection to the development of acquiredimmunodeficiency syndrome
(AIDS)?a . L e s s t h a n 5 y e a r s b . 5 t o 7 y e a r s c . 1 0 y e a r s d . M o r e t h a n 1 0 y e a r s 47. An 18-year-old male client admitted
with heat stroke begins to show signs of disseminated intravascular coagulation (DIC). Which of the following laboratoryfindings is most consistent with
DIC?a . L o w p l a t e l e t c o u n t b.Elev ated fibrino gen lev els c.Low levels of fibrin degradation productsd .Red uc ed
p rothrombin time
48. Mario comes to the clinic complaining of fever, drenching night sweats, andunexplained weight loss over the past 3 months. Physical examination
reveals asingle enlarged supraclavicular lymph node. Which of the following is the mostprobable diagnosis?a . I n f l u e n z a b . S i c k l e c e l l
a n e m i a c . L e u k e m i a d . H o d g k i n s d i s e a s e 49. A male client with a gunshot wound requires an emergency bloodtransfusion. His blood
type is AB negative. Which blood type would be the safestfor him to receive?a . A B R h - p o s i t i v e b . A R h - p o s i t i v e c . A R h negatived.O Rh-positive
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.
50. Stacy is discharged from the hospital following her chemotherapy treatments.Which statement of Stacys mother indicated that she understands
when she willcontact the physician?a.I should contact the physician if Stacy has difficulty in sleeping.b.I will call my doctor if Stacy has
persistent vomiting and diarrhea.c.My physician should be called if Stacy is irritable and unhappy.d.Should Stacy have continued
hair loss, I need to call the doctor.51. Stacys mother states to the nurse that it is hard to see Stacy with no hair.The best response for the nurse
is:a.Stacy looks very nice wearing a hat.b.You should not worry about her hair, just be glad that she is alive.c.Yes it is upsetting.
But try to cover up your feelings when you are with her or else she may be upset.d.This is only temporary; Stacy will re-grow new hair in
3-6 months, butmay be different in texture.52. Stacy has beginning stomatitis. To promote oral hygiene and comfort, thenurse in-charge
should:a.Provide frequent mouthwash with normal saline.

b.Apply viscous Lidocaine to oral ulcers as needed.c.Use lemon glycerine swabs every 2 hours.d.Rinse mouth with
Hydrogen Peroxide.53. During the administration of chemotherapy agents, Nurse Oliver observedthat the IV site is red and swollen, when the IV is
touched Stacy shouts in pain.The first nursing action to take is:a.No tify the physician b.Flush the IV line with saline
solutionc.Immediately discontinue the infusiond.Apply an ice pack to the site, followed by warm compress.54. The term blue
bloater refers to a male client which of the followingconditions?a.Adult respiratory distress syndrome (ARDS) b . A s t h m a c .Chro nic
o bstruc tive bro nchitis d . E m p h y s e m a 55. The term pink puffer refers to the female client with which of the followingconditions?
a.Adult respiratory distress syndrome (ARDS)b . A s t h m a c.Chron ic obstructiv e bronch itis d . E m p h y s e m a 56. Jose
is in danger of respiratory arrest following the administration of anarcotic analgesic. An arterial blood gas value is obtained. Nurse Oliver wouldexpect the
paco2 to be which of the following values?a . 1 5 m m H g b . 3 0 m m H g c . 4 0 m m H g d . 8 0 m m H g 57. Timothys
arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG resultrepresents
which of the following conditions?a . M e t a b o l i c a c i d o s i s b.Metabo lic alkalosis c . R e s p i r a t o r y a c i d o s i s
d .Res pirator y alkalosis 58. Norma has started a new drug for hypertension. Thirty minutes after shetakes the drug, she develops chest tightness
and becomes short of breath andtachypneic. She has a decreased level of consciousness. These signs indicatewhich of the following conditions?
a . A s t h m a a t t a c k b . P u l m o n a r y e m b o l i s m c . R e s p i r a t o r y f a i l u r e d.Rheumatoid arthritis
Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver :
59. Which laboratory test indicates liver cirrhosis?a.Decreased red blood cell countb.Decreased serum acid phosphate
levelc.Elev ated white bloo d cell count d.Elevated serum aminotransferase60.The biopsy of Mr. Gonzales confirms the diagnosis of
cirrhosis. Mr. Gonzalesis at increased risk for excessive bleeding primarily because of:a.I mpaired clo tting mech an is m b . V a r i x
f o r m a t i o n c . I n a d e q u a t e n u t r i t i o n d.Trauma of invasive procedure61. Mr. Gonzales develops hepatic encephalopathy. Which
clinical manifestationis most common with this condition?a.I ncreased urine outp ut b.Altered level of consciousnessc .D ecreased
ten do n reflex d . H y p o t e n s i o n 62. When Mr. Gonzales regained consciousness, the physician orders 50 ml of Lactose p.o. every 2 hours. Mr.
Gozales develops diarrhea. The nurse bestaction would be:a.Ill see if your physician is in the hospital.b.Maybe your reacting to the
drug; I will withhold the next dose.
c.Ill lower the dosage as ordered so the drug causes only 2 to 4 stoolsa day.d.Frequently, bowel movements are needed to reduce
sodium level.63. Which of the following groups of symptoms indicates a ruptured abdominalaortic aneurysm?a.Lower back pain, increased blood
pressure, decreased re blood cell(RBC) count, increased white blood (WBC) count.b.Severe lower back pain, decreased blood pressure,
decreasedRBC count, increased WBC count.c.Severe lower back pain, decreased blood pressure, decreasedRBC count, decreased RBC count,
decreased WBC count.d.Intermitted lower back pain, decreased blood pressure, decreasedRBC count, increased WBC count.64. After
undergoing a cardiac catheterization, Tracy has a large puddle of bloodunder his buttocks. Which of the following steps should the nurse take first?
a . C a l l f o r h e l p . b . O b t a i n v i t a l s i g n s c.Ask the c lien t to lift up d.Apply gloves and assess the groin site65. Which of
the following treatment is a suitable surgical intervention for a clientwith unstable angina?a.Cardiac
c atheterization b . E c h o c a r d i o g r a m c . N i t r o g l y c e r i n d.Percutaneous transluminal coronary angioplasty (PTCA)66. The nurse
is aware that the following terms used to describe reduced cardiacoutput and perfusion impairment due to ineffective pumping of the heart
is:a . A n a p h y l a c t i c s h o c k b . C a r d i o g e n i c s h o c k c . D i s t r i b u t i v e s h o c k d.Myo card ial infarctio n (MI) 67. A client with
hypertension ask the nurse which factors can cause bloodpressure to drop to normal levels?a.Kidneys excretion to sodium only.b.Kidneys
retention of sodium and water c.Kidneys excretion of sodium and water

d.Kidneys retention of sodium and excretion of water 68. Nurse Rose is aware that the statement that best explains
whyfurosemide(Lasix)is administered to treat hypertension is:a.It dilates peripheral blood vessels.b.It decreases sympathetic
cardioacceleration.c.It inhibits the angiotensin-coverting enzymes d.It inhibits reabsorption of sodium and water in the loop of
Henle.69. Nurse Nikki knows that laboratory results supports the diagnosis of systemiclupus erythematosus (SLE) is:a.Elavated serum
complement levelb.Thrombocytosis, elevated sedimentation ratec.Pancytopenia, elevated antinuclear antibody (ANA)
titer d.Leukocysis, elevated blood urea nitrogen (BUN) and creatinine levels70. Arnold, a 19-year-old client with a mild concussion is
discharged from theemergency department. Before discharge, he complains of a headache. Whenoffered acetaminophen, his mother tells the nurse the
headache is severe andshe would like her son to have something stronger. Which of the followingresponses by the nurse is appropriate?a.Your son
had a mild concussion, acetaminophen is strong enough.b.Aspirin is avoided because of the danger of Reyes syndrome inchildren or
young adults.c.Narcotics are avoided after a head injury because they may hide aworsening condition.d.Stronger medications may lead to
vomiting, which increases theintracarnial pressure (ICP).71. When evaluating an arterial blood gas from a male client with a subduralhematoma, the
nurse notes the Paco2 is 30 mm Hg. Which of the followingresponses best describes the result?a.Appropriate; lowering carbon dioxide (CO2)
reduces intracranialpressure (ICP)b.Emergent; the client is poorly oxygenated c . N o r m a l d.Significant; the client has
alveolar hypoventilation72. When prioritizing care, which of the following clients should the nurse Oliviaassess first?
a.A 17-year-old clients 24-hours postappendectomyb.A 33-year-old client with a recent diagnosis of Guillain-Barre syndromec.A
50-year-old client 3 days postmyocardial infarctiond.A 50-year-old client with diverticulitis 73. JP has been diagnosed with gout
and wants to know why colchicine is usedin the treatment of gout. Which of the following actions of colchicines explainswhy its effective for gout?
a . R e p l a c e s e s t r o g e n b.Decreases in fectio nc.Dec reases in flammation d.Decreases bone demineralization74. Norma asks
for information about osteoarthritis. Which of the followingstatements about osteoarthritis is correct?a.Osteoarthritis is rarely
debilitatingb.Osteoarthritis is a rare form of arthritisc.Osteoarthritis is the most common form of arthritisd.Osteoarthritis
afflicts people over 6075. Ruby is receiving thyroid replacement therapy develops the flu and forgets totake her thyroid replacement medicine. The
nurse understands that skipping thismedication will put the client at risk for developing which of the following life-threatening complications?
a . E x o p h t h a l m o s b . T h y r o i d s t o r m c . M y x e d e m a c o m a d . T i b i a l m y x e d e m a 76. Nurse Sugar is assessing a client with
Cushing's syndrome. Whichobservation should the nurse report to the physician immediately?a.Pittin g edem a o f the legs b.An irregular
apical puls e c . D r y m u c o u s m e m b r a n e s d . F r e q u e n t u r i n a t i o n 77. Cyrill with severe head trauma sustained in a car accident is
admitted to theintensive care unit. Thirty-six hours later, the client's urine output suddenly risesabove 200 ml/hour, leading the nurse to suspect diabetes
insipidus. Whichlaboratory findings support the nurse's suspicion of diabetes insipidus?
a.Above-normal urine and serum osmolality levelsb.Below-normal urine and serum osmolality levels c.Above-normal urine
osmolality level, below-normal serum osmolalityleveld.Below-normal urine osmolality level, above-normal serum osmolalitylevel78.
Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome(HHNS) is stabilized and prepared for discharge. When preparing the client
for discharge and home management, which of the following statements indicatesthat the client understands her condition and how to control it?a."I
can avoid getting sick by not becoming dehydrated and by payingattention to my need to urinate, drink, or eat more than usual."b."If I
experience trembling, weakness, and headache, I should drink aglass of soda that contains sugar."c."I will have to monitor my blood glucose
level closely and notify thephysician if it's constantly elevated."d."If I begin to feel especially hungry and thirsty, I'll eat a snack high
incarbohydrates."79. A 66-year-old client has been complaining of sleeping more, increasedurination, anorexia, weakness, irritability, depression, and
bone pain thatinterferes with her going outdoors. Based on these assessment findings, thenurse would suspect which of the following disorders?

a.
Diabetes mellitusb . D i a b e t e s i n s i p i d u s c . H y p o p a r a t h y r o i d i s m d.H yp erp arathyro id is m 80. Nurse Lourdes is teaching a client
recovering from addisonian crisis aboutthe need to take fludrocortisone acetate and hydrocortisone at home. Whichstatement by the client indicates an
understanding of the instructions?a."I'll take my hydrocortisone in the late afternoon, before dinner."b."I'll take all of my hydrocortisone in
the morning, right after I wakeup."c. "I'll take two-thirds of the dose when I wake up and one-third in thelate afternoon."d."I'll take the
entire dose at bedtime."81..Which of the following laboratory test results would suggest to the nurse Lenthat a client has a corticotropin-secreting
pituitary adenoma?a.High corticotropin and low cortisol levels
b.Low corticotropin and high cortisol levelsc.High corticotropin and high cortisol levelsd.Low corticotropin and low
cortisol levels82. A male client is scheduled for a transsphenoidal hypophysectomy to removea pituitary tumor. Preoperatively, the nurse should
assess for potentialcomplications by doing which of the following?a.Testing for ketones in the urineb.Testing urine specific
gravityc.Checking temperature every 4 hoursd.Performing capillary glucose testing every 4 hours 83. Capillary glucose
monitoring is being performed every 4 hours for a clientdiagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin
according to glucose results. At 2 p.m., the client has a capillaryglucose level of 250 mg/dl for which he receives 8 U of regular insulin. NurseMariner
should expect the dose's:a.onset to be at 2 p.m. and its peak to be at 3 p.m.b.onset to be at 2:15 p.m. and its peak to be at 3
p.m.c.onset to be at 2:30 p.m. and its peak to be at 4 p.m.d.onset to be at 4 p.m. and its peak to be at 6 p.m. 84. The physician
orders laboratory tests to confirm hyperthyroidism in a femaleclient with classic signs and symptoms of this disorder. Which test result wouldconfirm the
diagnosis?a.No increase in the thyroid-stimulating hormone (TSH) level after 30minutes during the TSH stimulation testb.A dec reas ed
TSH levelc.An increase in the TSH level after 30 minutes during the TSH stimulationtestd.Below-normal levels of serum
triiodothyronine (T3) and serum thyroxine(T4) as detected by radioimmunoassay85. Rico with diabetes mellitus must learn how to self-administer
insulin. Thephysician has prescribed 10 U of U-100 regular insulin and 35 U of U-100isophane insulin suspension (NPH) to be taken before breakfast.
When teachingthe client how to select and rotate insulin injection sites, the nurse should providewhich instruction?a."Inject insulin into healthy
tissue with large blood vessels and nerves."b."Rotate injection sites within the same anatomic region, not amongdifferent regions."
c."Administer insulin into areas of scar tissue or hypotrophy whenever possible."d."Administer insulin into sites above muscles that you
plan to exerciseheavily later that day."86. Nurse Sarah expects to note an elevated serum glucose level in a client withhyperosmolar hyperglycemic
nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?a.Elevated serum acetone levelb.Serum keto ne
bod iesc . S e r u m a l k a l o s i s d.Below-normal serum potassium level87. For a client with Graves' disease, which nursing intervention
promotescomfort?a.Restricting intake of oral fluidsb.Placing extra blankets on the client's bedc.Limiting intake of highcarbohydrate foodsd.Maintaining room temperature in the low-normal range 88. Patrick is treated in the emergency department for a
Colles' fracturesustained during a fall. What is a Colles' fracture?a.Frac ture of the distal radius b.F rac ture of th e
o lec rano nc.Fracture o f the hum erus d.Fracture of the carpal scaphoid89. Cleo is diagnosed with osteoporosis. Which electrolytes are
involved in thedevelopment of this disorder?a . C a l c i u m a n d s o d i u m b.Calcium an d pho spho ro usc.Ph osp horous and
po tass iumd .Potassium an d so dium 90. Johnny a firefighter was involved in extinguishing a house fire and is beingtreated to smoke
inhalation. He develops severe hypoxia 48 hours after theincident, requiring intubation and mechanical ventilation. He most likely hasdeveloped which
of the following conditions?a.Adult respiratory distress syndrome (ARDS)b . A t e l e c t a s i s c . B r o n c h i t i s
d . P n e u m o n i a 91. A 67-year-old client develops acute shortness of breath and progressivehypoxia requiring right femur. The hypoxia was
probably caused by which of thefollowing conditions?a . A s t h m a a t t a c k b . A t e l e c t a s i s c . B r o n c h i t i s d . F a t e m b o l i s m 92. A

client with shortness of breath has decreased to absent breath sounds onthe right side, from the apex to the base. Which of the following conditions
wouldbest explain this?a . A c u t e a s t h m a b . C h r o n i c b r o n c h i t i s c . P n e u m o n i a d.Sp on taneous pneumo th orax 93. A 62year-old male client was in a motor vehicle accident as an unrestraineddriver. Hes now in the emergency department complaining of difficulty
of breathing and chest pain. On auscultation of his lung field, no breath sounds arepresent in the upper lobe. This client may have which of the following
conditions?a . B r o n c h i t i s b.Pneumoniac . P n e u m o t h o r a x d.Tuberculosis (TB)94. If a client requires a pneumonectomy, what fills the area
of the thoraciccavity?a.The space remains filled with air onlyb.The surgeon fills the space with a gelc.Serous fluids fills the
space and consolidates the regiond.The tissue from the other lung grows over to the other side95. Hemoptysis may be present in the
client with a pulmonary embolism becauseof which of the following reasons?a.Alveolar damage in the infracted areab.Involvement of major
blood vessels in the occluded areac .Loss of lun g p arenc hym a
d . L o s s o f l u n g t i s s u e 96. Aldo with a massive pulmonary embolism will have an arterial blood gasanalysis performed to determine the extent of
hypoxia. The acid-base disorder that may be present is?a . M e t a b o l i c a c i d o s i s b . M e t a b o l i c a l k a l o s i s c . R e s p i r a t o r y
a c i d o s i s d.Resp irato ry alkalosis 97. After a motor vehicle accident, Armand an 22-year-old client is admitted witha pneumothorax. The
surgeon inserts a chest tube and attaches it to a chestdrainage system. Bubbling soon appears in the water seal chamber. Which of thefollowing is the
most likely cause of the bubbling?a . A i r l e a k b . A d e q u a t e s u c t i o n c . I n a d e q u a t e s u c t i o n d . K i n k e d c h e s t t u b e 98. Nurse
Michelle calculates the IV flow rate for a postoperative client. Theclient receives 3,000 ml of Ringers lactate solution IV to run over 24 hours. TheIV
infusion set has a drop factor of 10 drops per milliliter. The nurse shouldregulate the clients IV to deliver how many drops per minute?
a . 1 8 b . 2 1 c . 3 5 d . 4 0 99. Mickey, a 6-year-old child with a congenital heart disorder is admitted withcongestive heart
failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. Thebottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amountshould the
nurse administer to the child?a . 1 . 2 m l b . 2 . 4 m l c . 3 . 5 m l d . 4 . 2 m l 100. Nurse Alexandra teaches a client about
elastic stockings. Which of thefollowing statements, if made by the client, indicates to the nurse that theteaching was successful?
a.I will wear the stockings until the physician tells me to remove them.b.I should wear the stockings even when I am
sleep.c.Every four hours I should remove the stockings for a half hour.d.I should put on the stockings before getting out of bed in
the morning.
TEST V - Care of Clients with Physiologic and Psychosocial Alterations
1.Mr. Marquez reports of losing his job, not being able to sleep at night, andfeeling upset with his wife. Nurse John responds to the client, You
maywant to talk about your employment situation in group today. The Nurse isusing which therapeutic technique?
a . O b s e r v a t i o n s b . R e s t a t i n g c . E x p l o r i n g d . F o c u s i n g 2.Tony refuses his evening dose of Haloperidol (Haldol),
then becomesextremely agitated in the dayroom while other clients are watchingtelevision. He begins cursing and throwing furniture. Nurse Oliver
firstaction is to:a.Check the clients medical record for an order for an as-needed I.M.dose of medication for agitation.b.Place the client in
full leather restraints.c.Call the attending physician and report the behavior.d.Remove all other clients from the
dayroom.3.Tina who is manic, but not yet on medication, comes to the drug treatmentcenter. The nurse would not let this client join the
group session because:a.The client is disrup tiv e.b.The c lien t is harm ful to self.c .The c lien t is harm ful to o th ers. d.The
client needs to be on medication first.4.Dervid, an adolescent boy was admitted for substance abuse andhallucinations. The clients
mother asks Nurse Armando to talk with hishusband when he arrives at the hospital. The mother says that she isafraid of what the father might say to the
boy. The most appropriatenursing intervention would be to:a.Inform the mother that she and the father can work through thisproblem
themselves.b.Refer the mother to the hospital social worker.c.Agree to talk with the mother and the father

together.d.Suggest that the father and son work things out. 5.What is Nurse John likely to note in a male client being admitted
for alcohol withdrawal?
a.Perc ep tual d iso rders. b . I m p e n d i n g c o m a . c.Rec en t alc oho l in take.d.Depress io n with mutism . 6.Aira has taken
amitriptyline HCL (Elavil) for 3 days, but now complainsthat it doesnt help and refuses to take it. What should the nurse say or do?
a . W i t h h o l d t h e d r u g . b.Record the clients response.c.Encourage the client to tell the doctor.d.Suggest that it takes
awhile before seeing the results.7.Dervid, an adolescent has a history of truancy from school, running awayfrom home and barrowing
other peoples things without their permission.The adolescent denies stealing, rationalizing instead that as long as noone was using the items, it was all
right to borrow them. It is important for the nurse to understand the psychodynamically, this behavior may belargely attributed to a developmental
defect related to the:a . I d b . E g o c . S u p e r e g o d . O e d i p a l c o m p l e x 8.In preparing a female client for
electroconvulsive therapy (ECT), NurseMichelle knows that succinylcoline (Anectine) will be administered for which therapeutic effect?a.Sh ortactin g anesthesia b.Decreased oral and respiratory secretions.c.Skeletal muscle paralysis. d . A n a l g e s i a . 9.Nurse Gina
is aware that the dietary implications for a client in manicphase of bipolar disorder is:a.Serve the client a bowl of soup, buttered French
bread, and appleslices.b.Increase calories, decrease fat, and decrease protein.c.Give the client pieces of cut-up steak, carrots,
and an apple.d.Increase calories, carbohydrates, and protein. 10.What parental behavior toward a child during an admission
procedureshould cause Nurse Ron to suspect child abuse?
a . F l a t a f f e c t b . E x p r e s s i n g g u i l t c.Acting overly solicitous toward the child.d . I g n o r i n g t h e c h i l d . 11.Nurse Lynnette
notices that a female client with obsessive-compulsivedisorder washes her hands for long periods each day. How should thenurse respond to this
compulsive behavior?a.By designating times during which the client can focus on thebehavior.b.By urging the client to reduce the
frequency of the behavior asrapidly as possible.c.By calling attention to or attempting to prevent the behavior. d.By discouraging
the client from verbalizing anxieties.12.After seeking help at an outpatient mental health clinic, Ruby who wasraped while walking her dog is
diagnosed with posttraumatic stressdisorder (PTSD). Three months later, Ruby returns to the clinic,complaining of fear, loss of control, and helpless
feelings. Which nursingintervention is most appropriate for Ruby?a.Recommending a high-protein, low-fat diet.b.Giving sleep
medication, as prescribed, to restore a normal sleep-wake cycle.c.A llowing the client time to heal. d.Exploring the meaning of the
traumatic event with the client.13.Meryl, age 19, is highly dependent on her parents and fears leaving hometo go away to college. Shortly before the
semester starts, she complainsthat her legs are paralyzed and is rushed to the emergency department.When physical examination rules out a physical
cause for her paralysis,the physician admits her to the psychiatric unit where she is diagnosedwith conversion disorder. Meryl asks the nurse, "Why has
this happenedto me?" What is the nurse's best response?a."You've developed this paralysis so you can stay with your parents.You must deal
with this conflict if you want to walk again."b."It must be awful not to be able to move your legs. You may feelbetter if you realize the problem is
psychological, not physical."c."Your problem is real but there is no physical basis for it. We'll workon what is going on in your life to find out why
it's happened."d."It isn't uncommon for someone with your personality to develop aconversion disorder during times of stress."
14.Nurse Krina knows that the following drugs have been known to beeffective in treating obsessive-compulsive disorder (OCD):a.benztropine
(Cogentin) and diphenhydramine (Benadryl).b.chlordiazepoxide (Librium) and diazepam (Valium)c.fluvoxamine (Luvox) and
clomipramine (Anafranil)d.divalproex (Depakote) and lithium (Lithobid) 15.Alfred was newly diagnosed with anxiety disorder. The
physicianprescribed buspirone (BuSpar). The nurse is aware that the teachinginstructions for newly prescribed buspirone should include which of
thefollowing?a.A warning about the drugs delayed therapeutic effect, which is from14 to 30 days.b.A warning about the incidence of
neuroleptic malignant syndrome(NMS).c.A reminder of the need to schedule blood work in 1 week to checkblood levels of the drug.d.A

warning that immediate sedation can occur with a resultant dropin pulse.16.Richard with agoraphobia has been symptom-free for 4 months.
Classicsigns and symptoms of phobias include:a.Insomnia and an inability to concentrate.b.Sev ere an xiety and
fear.c .D ep ression and weight lo ss. d.Withdrawal and failure to distinguish reality from fantasy.17.Which medications have been
found to help reduce or eliminate panicattacks?a . A n t i d e p r e s s a n t s b . A n t i c h o l i n e r g i c s c . A n t i p s y c h o t i c s d . M o o d
s t a b i l i z e r s 18.A client seeks care because she feels depressed and has gained weight.To treat her atypical depression, the physician prescribes
tranylcyprominesulfate (Parnate), 10 mg by mouth twice per day. When this drug is usedto treat atypical depression, what is its onset of action?a . 1 t o
2 daysb.3 to 5 daysc.6 to 8 days
d.10 to 14 days
19.
A 65 years old client is in the first stage of Alzheimer's disease. NursePatricia should plan to focus this client's care on:a.Offering nourishing finger
foods to help maintain the client'snutritional status.b.Providing emotional support and individual counseling.c.Monitoring the client to
prevent minor illnesses from turning intomajor problems.d.Suggesting new activities for the client and family to do together.20.The nurse
is assessing a client who has just been admitted to theemergency department. Which signs would suggest an overdose of anantianxiety agent?
a.Combativeness, sweating, and confusionb.Agitation, hyperactivity, and grandiose ideationc.Emotional lability, euphoria,
and impaired memoryd.Suspiciousness, dilated pupils, and increased blood pressure21.The nurse is caring for a client diagnosed with
antisocial personalitydisorder. The client has a history of fighting, cruelty to animals, andstealing. Which of the following traits would the nurse be most
likely touncover during assessment?a.H isto ry of gainful employment b.Frequent expression of guilt regarding antisocial
behavior c.Demonstrated ability to maintain close, stable relationshipsd.A low tolerance for frustration22.Nurse Amy is providing care
for a male client undergoing opiatewithdrawal. Opiate withdrawal causes severe physical discomfort and canbe life-threatening. To minimize these
effects, opiate users are commonlydetoxified
with:a . B a r b i t u r a t e s b . A m p h e t a m i n e s c . M e t h a d o n e d . B e n z o d i a z e p i n e s 23.Nurse Cristina is caring for a client who
experiences false sensoryperceptions with no basis in reality. These perceptions are known as:a . D e l u s i o n s b . H a l l u c i n a t i o n s
c.Loose associationsd . N e o l o g i s m s
24.
Nurse Marco is developing a plan of care for a client withanorexianervosa. Which action should the nurse include in the plan?a.Restricts visits with
the family and friends until the client begins toeat.b.Provide privacy during meals.c.Set up a strict eating plan for the
client.d.Encourage the client to exercise, which will reduce her anxiety.25.Tim is admitted with a diagnosis of delusions of grandeur. The nurse
isaware that this diagnosis reflects a belief that one is:a.Highly impo rtan t o r famous. b . B e i n g p e r s e c u t e d c.Connected to events
unrelated to oneself d.Responsible for the evil in the world.26.Nurse Jen is caring for a male client with manic depression. The plan
of care for a client in a manic state would include:a.Offering a high-calorie meals and strongly encouraging the client tofinish all
food.b.Insisting that the client remain active through the day so that hellsleep at night.c.Allowing the client to exhibit hyperactive,
demanding, manipulativebehavior without setting limits.d.Listening attentively with a neutral attitude and avoiding
power struggles.27.Ramon is admitted for detoxification after a cocaine overdose. The clienttells the nurse that he frequently uses cocaine but that he
can control hisuse if he chooses. Which coping mechanism is he using?a . W i t h d r a w a l b . L o g i c a l
t h i n k i n g c . R e p r e s s i o n d . D e n i a l 28.Richard is admitted with a diagnosis of schizotypal personality disorder.Which signs would this
client exhibit during social situations?a.Aggressiv e behavior b . P a r a n o i d t h o u g h t s

c.Emotional affectd.Independence needs

29.
Nurse Mickey is caring for a client diagnosed withbulimia.The most appropriate initial goal for a client diagnosed with bulimia is to:a.Avoid
shopping for large amounts of food.b.Co ntrol eatin g imp ulses. c.Identify anxiety-causing situationsd.Eat on ly th ree
meals per d ay. 30.Rudolf is admitted for an overdose of amphetamines. When assessing theclient, the nurse should expect to see:a.Tens io n an d
irritability b . S l o w p u l s e c . H y p o t e n s i o n d . C o n s t i p a t i o n 31.Nicolas is experiencing hallucinations tells the nurse, The voices
aretelling me Im no good. The client asks if the nurse hears the voices. Themost appropriate response by the nurse would be:a.It is the voice of your
conscience, which only you can control.b.No, I do not hear your voices, but I believe you can hear them.c.The voices are coming
from within you and only you can hear them.d.Oh, the voices are a symptom of your illness; dont pay anyattention to them.32.The
nurse is aware that the side effect of electroconvulsive therapy that aclient may experience:a . L o s s o f a p p e t i t e b.Po stural
h ypoten sion c.Confusion for a time after treatmentd.Complete loss of memory for a time 33.A dying male client gradually moves
toward resolution of feelingsregarding impending death. Basing care on the theory of Kubler-Ross,Nurse Trish plans to use nonverbal interventions
when assessmentreveals that the client is in the:a . A n g e r s t a g e b . D e n i a l s t a g e c . B a r g a i n i n g s t a g e
d . A c c e p t a n c e s t a g e 34.The outcome that is unrelated to a crisis state is:a.Learning more constructive coping
skillsb.Decompensation to a lower level of functioning.c.Adaptation and a return to a prior level of functioning. d.A higher
level of anxiety continuing for more than 3 months.35.Miranda a psychiatric client is to be discharged with orders for haloperidol(haldol) therapy.
When developing a teaching plan for discharge, thenurse should include cautioning the client against:a . D r i v i n g a t n i g h t b . S t a y i n g i n t h e
s u n c.I nges ting wines and cheeses d.Taking medications containing aspirin36.Jen a nursing student is anxious about the upcoming
board examinationbut is able to study intently and does not become distracted by aroommates talking and loud music. The students ability to
ignoredistractions and to focus on studying demonstrates:a . M i l d - l e v e l a n x i e t y b.Pan ic-level anx iety c . S e v e r e - l e v e l
a n x i e t y d .Mod erate-level anx iety 37.When assessing a premorbid personality characteristics of a client with amajor depression, it would be
unusual for the nurse to find that this clientdemonstrated:a . R i g i d i t y b . S t u b b o r n n e s s c . D i v e r s e i n t e r e s t d .Over
metic ulous ness 38.Nurse Krina recognizes that the suicidal risk for depressed client isgreatest:a.As their depression begins to
improveb.When their depression is most severec.Before nay type of treatment is startedd.As they lose interest in the
environment
39.Nurse Kate would expect that a client with vascular dementis wouldexperience:a.Loss of remote memory related to anoxiab.Loss of
abstract thinking related to emotional statec.Inability to concentrate related to decreased stimuli d.Disturbance in recalling
recent events related to cerebral hypoxia.40.Josefina is to be discharged on a regimen of lithium carbonate. In theteaching plan for discharge the
nurse should include:a.Advising the client to watch the diet carefullyb.Suggesting that the client take the pills with
milkc.Reminding the client that a CBC must be done once a month. d.Encouraging the client to have blood levels checked as
ordered.41.The psychiatrist orders lithium carbonate 600 mg p.o t.i.d for a femaleclient. Nurse Katrina would be aware that the teaching about the
sideeffects of this drug were understood when the client state, I will call mydoctor immediately if I notice any:a.Sensitivity to bright light or
sunb.Fine hand tremors or slurred speechc.Sexual dysfunction or breast enlargementd.Inability to urinate or difficulty
when urinating42.Nurse Mylene recognizes that the most important factor necessary for theestablishment of trust in a critical care area
is:a . P r i v a c y b . R e s p e c t c . E m p a t h y d . P r e s e n c e 43.When establishing an initial nurse-client relationship, Nurse Hazel
shouldexplore with the client the:a.Clients perception of the presenting problem.b.Occurrence of fantasies the client may
experience.c.Details of any ritualistic acts carried out by the client d.Clients feelings when external; controls are

instituted.44.Tranylcypromine sulfate (Parnate) is prescribed for a depressed client whohas not responded to the tricyclic antidepressants. After
teaching the clientabout the medication, Nurse Marian evaluates that learning has occurredwhen the client states, I will avoid:
a.Citrus fruit, tuna, and yellow vegetables.b.Chocolate milk, aged cheese, and yogurtc.Green leafy vegetables, chicken,
and milk.d.Whole grains, red meats, and carbonated soda. 45.Nurse John is a aware that most crisis situations should resolve in
about:a . 1 t o 2 w e e k s b . 4 t o 6 w e e k s c . 4 t o 6 m o n t h s d . 6 t o 1 2 m o n t h s 46. Nurse Judy knows that statistics show
that in adolescent suicidebehavior:a.Females use more dramatic methods than malesb.Males account for more attempts than do
femalesc.Females talk more about suicide before attempting it d.Males are more likely to use lethal methods than are females
47.
Dervid with paranoidschizophreniarepeatedly uses profanity during anactivity therapy session. Which response by the nurse would be mostappropriate?
a."Your behavior won't be tolerated. Go to your room immediately."b."You're just doing this to get back at me for making you come
totherapy."c."Your cursing is interrupting the activity. Take time out in your roomfor 10 minutes."d."I'm disappointed in you. You can't
control yourself even for a fewminutes."48.Nurse Maureen knows that the nonantipsychotic medication used to treatsome clients with
schizoaffective disorder is:a.p hen elzin e (Nardil)b.c hlordiazepoxide (Librium )c .lith ium carbon ate
(Lith an e)d.im ip ram in e (Tofranil) 49.Which information is most important for the nurse Trinity to include in ateaching plan for a male
schizophrenic client taking clozapine (Clozaril)?a.Monthly blood tests will be necessary.b.Report a sore throat or fever to the physician
immediately.
c.Blood pressure must be monitored for hypertension.d.Stop the medication when symptoms subside. 50.Ricky with chronic
schizophrenia takes neuroleptic medication is admittedto the psychiatric unit. Nursing assessment reveals rigidity, fever,hypertension, and diaphoresis.
These findings suggest which life-threatening reaction:a.Tardive dyskin esia. b . D y s t o n i a . c.Neuroleptic malignant
syndrome.d . A k a t h i s i a . 51.Which nursing intervention would be most appropriate if a male clientdevelop orthostatic hypotension while taking
amitriptyline (Elavil)?a.Consulting with the physician about substituting a different type of antidepressant.b.Advising the client to sit up for
1 minute before getting out of bed.c.Instructing the client to double the dosage until the problem resolves.d.Informing the client
that this adverse reaction should disappear within 1 week.52.Mr. Cruz visits the physician's office to seek treatment for depression,feelings of
hopelessness, poor appetite, insomnia, fatigue, low self-esteem, poor concentration, and difficulty making decisions. The clientstates that these
symptoms began at least 2 years ago. Based on thisreport, the nurse Tyfany suspects:a.Cyclothymic d iso rd er.b.A typic al affec tive
d iso rd er. c . M a j o r d e p r e s s i o n . d.Dysthym ic diso rder.
53.
After taking an overdose of phenobarbital (Barbita), Mario is admitted to the emergency department. Dr. Trinidad prescribes activated
charcoal(Charcocaps) to be administered by mouth immediately. Beforeadministering the dose, the nurse verifies the dosage ordered. What is theusual
minimum dose of activated charcoal?a.5 g mix ed in 250 ml of water b.15 g mix ed in 500 m l of water c .30 g m ixed in 250
m l of water d .6 0 g mixed in 500 ml o f water
54.What herbal medication for depression, widely used in Europe, is nowbeing prescribed in the United States?a . G i n k g o
b i l o b a b . E c h i n a c e a c . S t . J o h n ' s w o r t d . E p h e d r a 55.Cely with manic episodes is taking lithium. Which electrolyte level
shouldthe nurse check before administering this medication?a . C a l c i u m b . S o d i u m c . C h l o r i d e d . P o t a s s i u m 56.Nurse
Josefina is caring for a client who has been diagnosed withdelirium. Which statement about delirium is true?a.It's characterized by an acute
onset and lasts about 1 month.b.It's characterized by a slowly evolving onset and lasts about 1week.c.It's characterized by a slowly

evolving onset and lasts about 1month.d.It's characterized by an acute onset and lasts hours to a number of days.57.Edward, a 66 year
old client with slight memory impairment and poor concentration is diagnosed with primary degenerative dementia of theAlzheimer's type. Early signs
of this dementia include subtle personalitychanges and withdrawal from social interactions. To assess for progression to the middle stage of Alzheimer's
disease, the nurse shouldobserve the client for:a.Occasional irritable outbursts.b.I mpaired communicatio n. c . L a c k o f
s p o n t a n e i t y . d.Inability to perform self-care activities.58.Isabel with a diagnosis of depression is started on imipramine (Tofranil),75 mg
by mouth at bedtime. The nurse should tell the client that:a.This medication may be habit forming and will be discontinued assoon as the client
feels better.b.This medication has no serious adverse effects.
c.The client should avoid eating such foods as aged cheeses, yogurt,and chicken livers while taking the medication.d.This medication may
initially cause tiredness, which should becomeless bothersome over time.59.Kathleen is admitted to the psychiatric clinic for treatment of
anorexianervosa. To promote the client's physical health, the nurse should plan to:a.Severely restrict the client's physical
activities.b.Weigh the client daily, after the evening meal. c.Monitor vital signs, serum electrolyte levels, and acid-base
balance.d.Instruct the client to keep an accurate record of food and fluidintake.60.Celia with a history of polysubstance abuse is admitted to the
facility. Shecomplains of nausea and vomiting 24 hours after admission. The nurseassesses the client and notes piloerection, pupillary dilation,
andlacrimation. The nurse suspects that the client is going through which of the following withdrawals?a . A l c o h o l w i t h d r a w a l b.Can nibis
with drawal c . C o c a i n e w i t h d r a w a l d . O p i o i d w i t h d r a w a l 61.Mr. Garcia, an attorney who throws books and furniture around the
officeafter losing a case is referred to the psychiatric nurse in the law firm'semployee assistance program. Nurse Beatriz knows that the client'sbehavior
most likely represents the use of which defense mechanism?a . R e g r e s s i o n b . P r o j e c t i o n c . R e a c t i o n f o r m a t i o n d.In tellectualizatio n 62.Nurse Anne is caring for a client who has been treated long term withantipsychotic medication. During the
assessment, Nurse Anne checks theclient for tardive dyskinesia. If tardive dyskinesia is present, Nurse Annewould most likely observe:a.Abnormal
movements and involuntary movements of the mouth,tongue, and face.b.Abnormal breathing through the nostrils accompanied by a
thrill.c.Severe headache, flushing, tremors, and ataxia.d.Severe hypertension, migraine headache,
63.Dennis has a lithium level of 2.4 mEq/L. The nurse immediately wouldassess the client for which of the following signs or symptoms?
a . W e a k n e s s b . D i a r r h e a c . B l u r r e d v i s i o n d . F e c a l i n c o n t i n e n c e 64.Nurse Jannah is monitoring a male client who has
been placed inrestraintsbecause of violent behavior. Nurse determines that it will be safe toremove the restraints when:a.The client verbalizes the
reasons for the violent behavior.b.The client apologizes and tells the nurse that it will never happenagain.c.No acts of aggression have
been observed within 1 hour after therelease of two of the extremity restraints.d.The administered medication has taken effect. 65.Nurse
Irish is aware that Ritalin is the drug of choice for a child withADHD. The side effects of the following may be noted by the nurse:a.Increased
attention span and concentrationb.I ncrease in app etitec.Sleep in ess and lethargyd .Brad yc ard ia an d d iarrh ea 66.Kitty,
a 9 year old child has very limited vocabulary and interaction skills.She has an I.Q. of 45. She is diagnosed to have Mental retardation of
thisclassification:a . P r o f o u n d b . M i l d c . M o d e r a t e d . S e v e r e 67.The therapeutic approach in the care of Armand an autistic
child includethe following EXCEPT:a.Engage in diversionary activities when acting -outb.Provide an atmosphere of
acceptancec.Provide safety m easures d.Rearrange the environment to activate the child68.Jeremy is brought to the emergency
room by friends who state that hetook something an hour ago. He is actively hallucinating, agitated, with
irritated nasal septum.a . H e r o i n b . C o c a i n e c . L S D d . M a r i j u a n a 69.Nurse Pauline is aware that Dementia unlike
delirium is characterized by:a . S l u r r e d s p e e c h b . I n s i d i o u s o n s e t c.Clouding of con scious nessd .Senso ry perc eptual
ch an ge 70.A 35 year old female has intense fear of riding an elevator. She claims As if I will die inside. The client is suffering from:a.

Agoraphobiab . S o c i a l p h o b i a c . C l a u s t r o p h o b i a d . X e n o p h o b i a 71.Nurse Myrna develops a counter-transference reaction. This

is evidencedby:a.Revealing personal information to the clientb.Focusing on the feelings of the client. c.Confronting the client
about discrepancies in verbal or non-verbalbehavior d.The client feels angry towards the nurse who resembles his mother.72.Tristan is on
Lithium has suffered from diarrhea and vomiting. Whatshould the nurse in-charge do first:a. Recognize this as a drug interactionb. Give
the c lien t Co gentin c. Reassure the client that these are common side effects of lithiumtherapyd. Hold the next dose and obtain an
order for a stat serum lithiumlevel73.Nurse Sarah ensures a therapeutic environment for all the client. Which of the following best describes a
therapeutic milieu?a. A therapy that rewards adaptive behavior b. A cognitive approach to change behavior c. A living,
learning or working environment.
d. A permissive and congenial environment74.Anthony is very hostile toward one of the staff for no apparent reason. Heis manifesting:a .
S p l i t t i n g b . T r a n s f e r e n c e c . C o u n t e r t r a n s f e r e n c e d . R e s i s t a n c e 75.Marielle, 17 years old was sexually attacked while on
her way home fromschool. She is brought to the hospital by her mother. Rape is an exampleof which type of crisis:a . S i t u a t i o n a l b .
Adventitiousc. Developmentald . I n t e r n a l
76.
Nurse Greta is aware that the following is classified as an Axis I disorder by the
Diagnosis and Statistical Manual of Mental Disorders,
TextRevision (DSM-IV-TR) is:a . O b e s i t y b.Borderline personality disorder c . M a j o r
d e p r e s s i o n d . H y p e r t e n s i o n 77.Katrina, a newly admitted is extremely hostile toward a staff member shehas just met, without apparent
reason. According to Freudian theory, thenurse should suspect that the client is experiencing which of the followingphenomena?
a.In tellectualizatio n b . T r a n s f e r e n c e c . T r i a n g u l a t i o n d . S p l i t t i n g 78.An 83year-old male client is in extended care facility is
anxious most of thetime and frequently complains of a number of vague symptoms thatinterfere with his ability to eat. These symptoms indicate which of
thefollowing disorders?a.Co nversio n disorder b . H y p o c h o n d r i a s i s c . S e v e r e a n x i e t y
d . S u b l i m a t i o n 79. Charina, a college student who frequently visited the health center during thepast year with multiple vague complaints of GI
symptoms before courseexaminations. Although physical causes have been eliminated, the studentcontinues to express her belief that she has a serious
illness. These symptomsare typically of which of the following disorders?a.Conv ersion
d iso rd er b . D e p e r s o n a l i z a t i o n c . H y p o c h o n d r i a s i s d.So matization diso rder 80. Nurse Daisy is aware that the following
pharmacologic agents are sedative-hypnotic medication is used to induce sleep for a client experiencing a sleepdisorder is:a.Triazolam
(Halc io n)b.Parox etin e (Paxil)\ c . F l u o x e t i n e ( P r o z a c ) d.Risp eridon e (Risp erdal) 81. Aldo, with a somatoform pain disorder
may obtain secondary gain. Which of the following statement refers to a secondary gain?a.It brings some stability to the familyb.It decreases
the preoccupation with the physical illnessc.It enables the client to avoid some unpleasant activityd.It promotes emotional
support or attention for the client82. Dervid is diagnosed with panic disorder with agoraphobia is talking with thenurse in-charge about the
progress made in treatment. Which of the followingstatements indicates a positive client response?a.I went to the mall with my friends last
Saturdayb.Im hyperventilating only when I have a panic attackc.Today I decided that I can stop taking my
medicationd.Last night I decided to eat more than a bowl of cereal 83. The effectiveness of monoamine oxidase (MAO) inhibitor drug
therapy in aclient with posttraumatic stress disorder can be demonstrated by which of thefollowing client self reports?a.Im sleeping better and
dont have nightmaresb.Im not losing my temper as muchc.Ive lost my craving for alcohol

d .I v e los t my pho bia for water 84. Mark, with a diagnosis of generalized anxiety disorder wants to stop takinghis lorazepam (Ativan). Which
of the following important facts should nurse Bettydiscuss with the client about discontinuing the medication?a.Stopping the drug may cause
depressionb.Stopping the drug increases cognitive abilitiesc.Stopping the drug decreases sleeping difficultiesd.Stopping
the drug can cause withdrawal symptoms85. Jennifer, an adolescent who is depressed and reported by his parents ashaving difficulty in school
is brought to the community mental health center to beevaluated. Which of the following other health problems would the nursesuspect?a . A n x i e t y
d i s o r d e r b.Behavio ral diffic ultiesc.Co gn itive impairment d . L a b i l e m o o d s 86. Ricardo, an outpatient in psychiatric facility is
diagnosed with dysthymicdisorder. Which of the following statement about dysthymic disorder is true?a.It involves a mood range from moderate
depression to hypomaniab.It involves a single manic depressionc.Its a form of depression that occurs in the fall and
winter d.Its a mood disorder similar to major depression but of mild tomoderate severity87. The nurse is aware that the following ways in
vascular dementia differentfrom Alzheimers disease is:a.Vascular dementia has more abrupt onsetb.The duration of vascular
dementia is usually brief c.Personality change is common in vascular dementia d.The inability to perform motor activities
occurs in vascular dementia88. Loretta, a newly admitted client was diagnosed with delirium and has historyof hypertension and anxiety. She had
been taking digoxin, furosemide (Lasix),and diazepam (Valium) for anxiety. This clients impairment may be related towhich of the following conditions?
a . I n f e c t i o n b.Metabolic acidosis
c . D r u g i n t o x i c a t i o n d.Hep atic enc ephalop athy 89. Nurse Ron enters a clients room, the client says, Theyre crawling on mysheets! Get
them off my bed! Which of the following assessment is the mostaccurate?a.The client is experiencing aphasiab.The client is
experiencing dysarthriac.The client is experiencing a flight of ideasd.The client is experiencing visual hallucination 90.
Which of the following descriptions of a clients experience and behavior canbe assessed as an illusion?a.The client tries to hit the nurse when vital
signs must be takenb.The client says, I keep hearing a voice telling me to run awayc.The client becomes anxious whenever the
nurse leaves thebedsided.The client looks at the shadow on a wall and tells the nurse shesees frightening faces on the wall.91. During
conversation of Nurse John with a client, he observes that the clientshift from one topic to the next on a regular basis. Which of the following
termsdescribes this disorder?a . F l i g h t o f i d e a s b . C o n c r e t e t h i n k i n g c . I d e a s o f r e f e r e n c e d . L o o s e a s s o c i a t i o n 92.
Francis tells the nurse that her coworkers are sabotaging the computer.When the nurse asks questions, the client becomes argumentative. Thisbehavior
shows personality traits associated with which of the followingpersonality disorder?
a . A n t i s o c i a l b . H i s t r i o n i c c . P a r a n o i d d . S c h i z o t y p a l 93. Which of the following interventions is important for a Cely
experiencing withparanoid personality disorder taking olanzapine (Zyprexa)?a.Explain effects of serotonin syndromeb.Teach the client to
watch for extrapyramidal adverse reaction
c.Explain that the drug is less affective if the client smokes d.Discuss the need to report paradoxical effects such as euphoria94.
Nurse Alexandra notices other clients on the unit avoiding a client diagnosedwith antisocial personality disorder. When discussing appropriate behavior
ingroup therapy, which of the following comments is expected about this client byhis peers?a . L a c k o f h o n e s t y b.Belief in
s upers titio nc.Sho w of temp er tan trum sd.Con stan t need fo r attention 95. Tommy, with dependent personality disorder is
working to increase his self-esteem. Which of the following statements by the Tommy shows teaching wassuccessful?a.Im not going to look just at
the negative things about myselfb.Im most concerned about my level of competence and progressc.Im not as envious of the things
other people have as I used to bed.I find I cant stop myself from taking over things other should bedoing96. Norma, a 42-year-old client
with a diagnosis of chronic undifferentiatedschizophrenia lives in a rooming house that has a weekly nursing clinic. Shescratches while she tells the nurse
she feels creatures eating away at her skin.Which of the following interventions should be done first?a.Talk about his hallucinations and
fearsb.Refer him for anticholinergic adverse reactionsc.Assess for possible physical problems such as rash d.Call his

physician to get his medication increased to control hispsychosis97. Ivy, who is on the psychiatric unit is copying and imitating the movements
of her primary nurse. During recovery, she says, I thought the nurse was mymirror. I felt connected only when I saw my nurse. This behavior is known
bywhich of the following terms?a . M o d e l i n g b . E c h o p r a x i a c . E g o - s y n t o n i c i t y d . R i t u a l i s m
98. Jun approaches the nurse and tells that he hears a voice telling him that hesevil and deserves to die. Which of the following terms describes the
clientsperception?a . D e l u s i o n b.Diso rganized sp eec h c . H a l l u c i n a t i o n d . I d e a o f r e f e r e n c e 99. Mike is admitted to a
psychiatric unit with a diagnosis of undifferentiatedschizophrenia. Which of the following defense mechanisms is probably used bymike?
a . P r o j e c t i o n b . R a t i o n a l i z a t i o n c . R e g r e s s i o n d . R e p r e s s i o n 100. Rocky has started taking haloperidol (Haldol). Which of
the followinginstructions is most appropriate for Ricky before taking haloperidol?a.Should report feelings of restlessness or agitation at
onceb.Use a sunscreen outdoors on a year-round basisc.Be aware youll feel increased energy taking this drugd.This drug
will indirectly control essential hypertension

Tips from NLE Topnotchers

Posted on Saturday, January 09, 2010 No Comments

Blogger's note: Found these tips from Carl Balita Review Center's website and it's worth reading especially for those students who
will take up NLE this year.
Tips from CBRCs recent topnotchers:
Shayne Caseria, RN (#10 December 2007NLE)
Ive been where you are right now, about to take the boards. In fact, Ive actually been there twice. The first time, I was so nervous that I
found myself converting my anxiety into physical symptoms. In contrast, my second try at the boards was quite different. I wasnt even
nervous or a little bit anxious and frankly, I was quite excited to take the exam already because I know that I can soar high and reach the
top. Never ever let any doubt creep into your mind. Doubt is a buzz killer, in other words kontra. Dont sabotage yourself by doubting
or fearing that you will fail (because if you do, it might as well be so). Remember that, whatever you resist, persists. Believe in yourself
that you can do it: that you can reach the top. If the top means that youll become a topnotcher, so be it! Visualize and see it in your
mind that youve reached your goal. Imagine how it would feel. Make this a spirit-lifter everyday and whenever youd feel sad, scared
or doubtful. This would truly do wonders, especially during these times that the exam date is creeping near everyday. Good luck
colleagues!!!
Carla Barbon, RN (#8 June 2008 NLE)
While studying:
1. Set realistic goals and reach them. Prioritize concepts and procedures. Concept map helps to simplify ideas and increase retention.
2. Reward yourself. I suggest chocolate, yung expensive na.
3. A happy brain retains and understands more than an anxious one. So smile, keep it light.
Before the boards:
1. Tell God why you want to pass and ask for His guidance. Pray for a good gut feel and divine intervention when faced with eliminating
answers or guessing.
2. Rest and relax at least a day before.
During the boards:
1. Be early and bring everything that you need. Hindi kajolog-san ang magbaon ng food.
2. Avoid erasures. Mahirap nab aka ma-void ang answer sheet mo.
3. Be confident! Nakagraduate ka nga, nagreview ka pa.
Kayang kaya mo yan! Madaming taong namemental block sa sobrang kaba. God Bless!
Zyena Joyce Untalasco, RN (#8 June 2008 NLE)

1. Have the mindset. If youre going to dream, then dream big. Dont just dream of passing the board exam, dream of topping it.
Visualize yourself achieving that dream.
2. Prove yourself worthy. Show what it takes to top the exam. Listen during lectures and study. (note: Only if you have the time and the
drive.) Focus during the review. Then rest when you get home. Ayus na yun.
3. No stress. Psych tells us that mild anxiety is normal and is indeed helpful. So keep your anxiety on that level. Therefore, spend the last
day before the exam on relaxation. Just enjoy and have fun na. I recommend videoke. Kumanta ka hanggang sa mailabas mo lahat ng
nerbiyos. Kumanta ka hanggang sa mapaos. Tutal, hindi naman oral exam and boards.
John Patrick Dimarucot, RN (#2 November 2008 NLE)
Topping the board exam was not something that Id expected. It actually came as a complete shock to me. When I first received the news
that I got the 2nd top spot in the Nursing Board Exams, my initial reactions were of complete shock and disbelief. I could not believe the
news, not because I didnt prepare for the exams, but because I could not wrap myself around the idea that all my months of hard work
have actually paid off and that I am exactly where I wanted to be right form the very beginning.
When I finally got the news, the shock and disbelief abated, only an intense feeling of joy remained, a feeling that I still have with me
now, months later. It is a great sense of achievement that I think everyone who is willing to work hard should experience. Hence, this
article. It is an enumeration of things that I did in my preparation for the board exams. Here it goes:
1. Aim to be a board topnotcher. My journey towards taking the 2nd place in the November 2008 NLE started with a dream that I made
in 3rd year college- to be a board topnotcher. Set a goal for yourself and work hard towards its achievement. Aim to be a board
topnotcher and start from there.
2. Start reviewing early. Ive always thought that nursing is a combination of all health-related courses rolled into one. It has a little bit
of everything in it, from the pathophysiology and medical management of medicine to the drug actions and interactions of pharmacy. So
after 4 years in nursing school, you are left with heaps of notes and tons of books to read in your preparation for the board exam. It may
seem impossible at first but, it can be done. How? By starting early. I started to review for the board exams a full 4 months before the
examination date. I would usually allot 2-3 hours of my time each night to read. You have a lot of ground to cover and it may be difficult
to be able to cover it completely but you have to cover as much ground as possible if you want to top the boards.
3. Make a timetable. When reviewing for a major exam, I always find myself unable to read all that I am supposed to read and I usually
miss out on the more important concepts or the concepts that I do not yet fully understand. Fortunately, I found a solution to this
predicament in Carl Balitas Ultimate Learning Guide. In the book is the Ultimate Success Planner where you can note down what
subject you would want to review for the day and how much time you want to apportion for it. I would usually coordinate my review
with the schedule of the subjects in the review center, then on weekends, I would study subjects that I find hard (i.e. Community Health
Nursing and Pediatric Nursing).
4. Read! Read! Read! Need I say more?
5. Answer! Answer! Answer! Practice makes perfect. This habit taught me a lot of competencies that I was able to apply when I took the
board exams, a few of which are time management, critical thinking, and test taking strategies.
6. Relax. I can never stress enough the importance of relaxation and keeping your anxiety to a mild level. To emphasize my point, I
would like to state a few things that weve learned in psychiatric Thinursing: Mild anxiety enhances learning. Higher levels of anxiety
lead to diffusion of focus, and therefore impede learning.
7. Pray. This is the most important part. I never would have made it here without His help. This is not something that just happened. My

being part of the roster of the topnotchers was something that I prayed really hard for and worked just as hard for. When I took the
board exams, I took it with God. I asked His wisdom so I can understand all the concepts. I asked for His patience and strength when
the review was taking its toll on me and I felt too tired to study. Every step that I took in my preparation for the board exams, I took it
with God. You should do the same.
Rationale:
Normal urine output for an adult is approximately 1 ml/minute(60 ml/hour). Therefore, this client's output is normal. Beyond continuedevaluation, no
nursing action is warranted.
9.
Answer:
(B) My ankle feels warm.
Rationale:
Ice application decreases pain and swelling. Continued or increasedpain, redness, and increased warmth are signs of inflammation that shouldn'toccur
after ice application
10.
Answer:
(B) Hyperkalemia
Rationale:
A loop diuretic removes water and, along with it, sodium andpotassium. This may result in hypokalemia, hypovolemia, andhyponatremia.
11.
Answer
:(A) Have condescending trust and confidence in their subordinates
Rationale
: Benevolent-authoritative managers pretentiously show their trust and confidence to their followers.
12.
Answer:
(A) Provides continuous, coordinated and comprehensivenursing services.
Rationale:
Functional nursing is focused on tasks and activities and noton the care of the patients.
13.
Answer:
(B) Standard written order
Rationale:
This is a standard written order. Prescribers write a singleorder for medications given only once. A stat order is written for medications given
immediately for an urgent client problem. A standingorder, also known as a protocol, establishes guidelines for treating aparticular disease or set of
symptoms in special care areas such as thecoronary care unit. Facilities also may institute medication protocols thatspecifically designate drugs that a
nurse may not give.
14.

Answer
: (D) Liquid or semi-liquid stools
Rationale
: Passage of liquid or semi-liquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clientswith fecal
impaction don't pass hard, brown, formed stools because thefeces can't move past the impaction. These clients typically report the urgeto defecate
(although they can't pass stool) and a decreased appetite.
15.
Answer
: (C) Pulling the helix up and back
Rationale:
To perform an otoscopic examination on an adult, the nursegrasps the helix of the ear and pulls it up and back to straighten the ear canal. For a child, the
nurse grasps the helix and pulls it down tostraighten the ear canal. Pulling the lobule in any direction wouldn'tstraighten the ear canal for visualization.
16.
Answer:
(A) Protect the irritated skin from sunlight.
Rationale:
Normal urine output for an adult is approximately 1 ml/minute(60 ml/hour). Therefore, this client's output is normal. Beyond continuedevaluation, no
nursing action is warranted.
9.
Answer:
(B) My ankle feels warm.
Rationale:
Ice application decreases pain and swelling. Continued or increasedpain, redness, and increased warmth are signs of inflammation that shouldn'toccur
after ice application
10.
Answer:
(B) Hyperkalemia
Rationale:
A loop diuretic removes water and, along with it, sodium andpotassium. This may result in hypokalemia, hypovolemia, andhyponatremia.
11.
Answer
:(A) Have condescending trust and confidence in their subordinates
Rationale
: Benevolent-authoritative managers pretentiously show their trust and confidence to their followers.
12.
Answer:
(A) Provides continuous, coordinated and comprehensivenursing services.

Rationale:
Functional nursing is focused on tasks and activities and noton the care of the patients.
13.
Answer:
(B) Standard written order
Rationale:
This is a standard written order. Prescribers write a singleorder for medications given only once. A stat order is written for medications given
immediately for an urgent client problem. A standingorder, also known as a protocol, establishes guidelines for treating aparticular disease or set of
symptoms in special care areas such as thecoronary care unit. Facilities also may institute medication protocols thatspecifically designate drugs that a
nurse may not give.
14.
Answer
: (D) Liquid or semi-liquid stools
Rationale
: Passage of liquid or semi-liquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clientswith fecal
impaction don't pass hard, brown, formed stools because thefeces can't move past the impaction. These clients typically report the urgeto defecate
(although they can't pass stool) and a decreased appetite.
15.
Answer
: (C) Pulling the helix up and back
Rationale:
To perform an otoscopic examination on an adult, the nursegrasps the helix of the ear and pulls it up and back to straighten the ear canal. For a child, the
nurse grasps the helix and pulls it down tostraighten the ear canal. Pulling the lobule in any direction wouldn'tstraighten the ear canal for visualization.
16.
Answer:
(A) Protect the irritated skin from sunlight.
Rationale:
Irradiated skin is very sensitive and must be protected withclothing or sunblock. The priority approach is the avoidance of strongsunlight.
17.
Answer:
(C) Assist the client in removing dentures and nail polish.
Rationale:
Dentures, hairpins, and combs must be removed. Nail polishmust be removed so that cyanosis can be easily monitored by observingthe nail beds.
18.
Answer:
(D) Sudden onset of continuous epigastric and back pain.
Rationale:

The autodigestion of tissue by the pancreatic enzymes resultsin pain from inflammation, edema, and possible hemorrhage. Continuous,unrelieved
epigastric or back pain reflects the inflammatory process in thepancreas.
19.
Answer:
(B) Provide high-protein, high-carbohydrate diet.
Rationale:
A positive nitrogen balance is important for meeting metabolicneeds, tissue repair, and resistance to infection. Caloric goals may be ashigh as 5000
calories per day.
20.
Answer:
(A) Blood pressure and pulse rate.
Rationale
: The baseline must be established to recognize the signs of ananaphylactic or hemolytic reaction to the transfusion.
21.
Answer:
(D) Immobilize the leg before moving the client.
Rationale:
If the nurse suspects a fracture, splinting the area beforemoving the client is imperative. The nurse should call for emergency helpif the client is not
hospitalized and call for a physician for the hospitalizedclient.
22.
Answer:
(B) Admit the client into a private room.
Rationale:
The client who has a radiation implant is placed in a privateroom and has a limited number of visitors. This reduces the exposure of others to the
radiation.
23.
Answer:
(C) Risk for infection
Rationale:
Agranulocytosis is characterized by a reduced number of leukocytes (leucopenia) and neutrophils (neutropenia) in the blood. Theclient is at high risk for
infection because of the decreased body defensesagainst microorganisms. Deficient knowledge related to the nature of thedisorder may be appropriate
diagnosis but is not the priority.
24.
Answer:
(B) Place the client on the left side in the Trendelenburg position.
Rationale:
Lying on the left side may prevent air from flowing into thepulmonary veins. The Trendelenburg position increases intrathoracicpressure, which
decreases the amount of blood pulled into the vena cavaduring aspiration

25.
Answer:
(A) Autocratic.
Rationale:
The autocratic style of leadership is a task-oriented anddirective.
26.
Answer
: (D) 2.5 cc
Rationale
: 2.5 cc is to be added, because only a 500 cc bag of solution isbeing medicated instead of a 1 liter.
27.
Answer
: (A) 50 cc/ hour
Rationale:
A rate of 50 cc/hr. The child is to receive 400 cc over a periodof 8 hours = 50 cc/hr.
28.
Answer:
(B) Assess the client for presence of pain.
Rationale:
Assessing the client for pain is a very important measure.Postoperative pain is an indication of complication. The nurse should alsoassess the client for
pain to provide for the clients comfort.
29.
Answer:
(A) BP 80/60, Pulse 110 irregular
Rationale
: The classic signs of cardiogenic shock are low blood pressure,rapid and weak irregular pulse, cold, clammy skin, decreased urinaryoutput, and cerebral
hypoxia.
30.
Answer:
(A) Take the proper equipment, place the client in a comfortableposition, and record the appropriate information in the clients chart.
Rationale:
It is a general or comprehensive statement about the correctprocedure, and it includes the basic ideas which are found in the other options
31.
Answer
: (B)Evaluation
Rationale:
Evaluation includes observing the person, asking questions,and comparing the patients behavioral responses with the expectedoutcomes.
32.
Answer:

(C) History of present illness

Rationale:
The history of present illness is the single most importantfactor in assisting the health professional in arriving at a diagnosis or determining the persons
needs.
33.
Answer:
(A) Trochanter roll extending from the crest of the ileum to themid-thigh.
Rationale:
A trochanter roll, properly placed, provides resistance to theexternal rotation of the hip.
34.
Answer
: (C) Stage III
Rationale:
Clinically, adeep crater or without undermining of adjacenttissue is noted.
35.
Answer:
(A) Secondintention healing
Rationale:
When wounds dehisce, they will allowed to heal by secondaryintention
36.
Answer:
(D) Tachycardia
Rationale:
With an extracellular fluid or plasma volume deficit,compensatory mechanisms stimulate the heart, causing an increase inheart rate.
37.
Answer:
(A) 0.75
Rationale:
To determine the number of milliliters the client should receive,the nurse uses the fraction methodin the following equation.75 mg/X ml = 100 mg/1 mlTo solve for X, crossmultiply:75mg x 1ml = X ml x 100 mg75 = 100X75/100 = X0.75 ml (or ml) = X
38.
Answer:
(D) Its ameasure of effect, not a standard measure of weight or quantity.
Rationale:
An insulin unitis ameasure of effect, not a standard measureof weight or quantity. Different drugs measured in units may have norelationshipto oneanother in quality or
quantity.
39.
Answer:

(B) 38.9 C
Rationale:
To convert Fahrenheit degreed to Centigrade, use this formulaC = (F 32) 1.8C = (102 32) 1.8C = 70 1.8C = 38.9
40.
Answer:
(C) Failing eyesight, especially close vision.
Rationale:
Failing eyesight, especially close vision, is oneof the first signsof aging in middle life (ages 46 to 64). More frequent aches and painsbegin in the early late years (ages 65 to 79).
Increase in loss of muscletone occurs in later years (age 80 and older).
41.
Answer:
(A) Checking and taping all connections
Rationale:
Air leaks commonly occur if the system isnt secure. Checkingall connections and taping them will prevent air leaks. The chest drainagesystem is kept lower to promote drainage
not to preventleaks
42.
Answer:
(A) Check the clients identification band.
Rationale:
Checking the clients identification band is the safest way toverify a clients identity because the band is assigned on admission andisnt be removed at any
time. (If it is removed, it must be replaced). Askingthe clients name or having the client repeated his name would beappropriate only for a client whos
alert, oriented, and able to understandwhat is being said, but isnt the safe standard of practice. Names on bedarent always reliable
43.
Answer:
(B) 32 drops/minute
Rationale:
Giving 1,000 ml over 8 hours is the same as giving 125 mlover 1 hour (60 minutes). Find the number of milliliters per minute asfollows:125/60 minutes
= X/1 minute60X = 125 = 2.1 ml/minuteTo find the number of drops per minute:2.1 ml/X gtt = 1 ml/ 15 gttX = 32 gtt/minute, or 32 drops/minute
44.
Answer
: (A) Clamp the catheter
Rationale
: If a central venous catheter becomes disconnected, the nurseshould immediately apply a catheter clamp, if available. If a clamp isntavailable, the nurse
can place a sterile syringe or catheter plug in thecatheter hub. After cleaning the hub with alcohol or povidone-iodinesolution, the nurse must replace the
I.V. extension and restart the infusion.
45.
Answer:
(D) Auscultation, percussion, and palpation.

Rationale:
The correct order of assessment for examining the abdomen isinspection, auscultation, percussion, and palpation. The reason for thisapproach is that the
less intrusive techniques should be performed beforethe more intrusive techniques. Percussion and palpation can alter naturalfindings during
auscultation.
46.
Answer:
(D) Ulnar surface of the hand
Rationale:
The nurse uses the ulnar surface, or ball, of the hand to assestactile fremitus, thrills, and vocal vibrations through the chest wall. Thefingertips and finger
pads best distinguish texture and shape. The dorsalsurface best feels warmth.
47.
Answer
: (C) Formative
Rationale:
Formative (or concurrent) evaluation occurs continuouslythroughout the teaching and learning process. One benefit is that thenurse can adjust teaching
strategies as necessary to enhance learning.Summative, or retrospective, evaluation occurs at the conclusion of theteaching and learning session.
Informative is not a type of evaluation.
48.
Answer:
(B) Once per year
Rationale:
Yearly mammograms should begin at age 40 and continue for as long as the woman is in good health. If health risks, such as familyhistory, genetic
tendency, or past breast cancer, exist, more frequentexaminations may be necessary.
49.
Answer:
(A) Respiratory acidosis
Rationale:
The client has a below-normal (acidic) blood pH value and anabove-normal partial pressure of arterial carbon dioxide (Paco2) value,indicating
respiratory acidosis. In respiratory alkalosis, the pH value isabove normal and in the Paco2 value is below normal. In metabolicacidosis, the pH and
bicarbonate (Hco3) values are below normal. Inmetabolic alkalosis, the pH and Hco3 values are above normal.
50.
Answer:
(B) To provide support for the client and family in coping withterminal illness.
Rationale:
Hospices provide supportive care for terminally ill clients andtheir families. Hospice care doesnt focus on counseling regarding healthcare costs. Most
client referred to hospices have been treated for their disease without success and will receive only palliative care in thehospice.
51.
Answer:

(C) Using normal saline solution to clean the ulcer and applyinga protective dressing as necessary.
Rationale:
Washing the area with normal saline solution and applying aprotective dressing are within the nurses realm of interventions and willprotect the area.
Using a povidone-iodine wash and an antibiotic creamrequire a physicians order. Massaging with an astringent can further damage the skin.
52.
Answer:
(D) Foot
Rationale:
An elastic bandage should be applied form the distal area tothe proximal area. This method promotes venous return. In this case, thenurse should begin
applying the bandage at the clients foot. Beginning atthe ankle, lower thigh, or knee does not promote venous return.
53.
Answer:
(B) Hypokalemia
Rationale:
Insulin administration causes glucose and potassium to moveinto the cells, causing hypokalemia.
54.
Answer:
(A) Throbbing headache or dizziness
Rationale
: Headache and dizziness often occur when nitroglycerin istaken at the beginning of therapy. However, the client usually developstolerance
55.
Answer:
(D) Check the clients level of consciousness
Rationale:
Determining unresponsiveness is the first step assessmentaction to take. When a client is in ventricular tachycardia, there is asignificant decrease in cardiac output. However,
checking theunresponsiveness ensures whether the client is affected by the decreasedcardiac output.
56.
Answer:
(B) On the affected side of the client.
Rationale:
When walking with clients, the nurseshould stand on theaffected side and grasp the security belt in the midspine area of the smallof the back. The nurse should position the free
hand atthe shoulder areaso that the client can be pulled toward the nurse in the event that there isa forward fall. The client is instructed to look up and outward rather than athis or
her feet.
57.
Answer
: (A) Urine output: 45ml/hr
Rationale

: Adequate perfusion must be maintained to all vital organs inorder for the client to remain visible as an organ donor. A urine output of 45 ml per hour indicates adequate renal
perfusion. Low blood pressureand delayed capillary refill time are circulatory system indicators of inadequate perfusion. A serum pH of 7.32 is acidotic, which adverselyaffects all
body tissues.
58.
Answer:
(D ) Obtaining the specimen from the urinary drainage bag.
Rationale
: A urine specimen is not taken from the urinary drainage bag.Urine undergoes chemical changes while sitting in the bag and doesnotnecessarily reflect the current client status.
In addition, itmay becomecontaminated with bacteria from opening the system.
59.
Answer:
(B) Cover the client, place the call light within reach, and answer the phone call.
Rationale:
Because telephone call is an emergency, the nurse may needto answer it. The other appropriate action is to ask another nurse to acceptthe call. However, is not one of the options.
To maintain privacy andsafety, the nurse covers the client and places the call light within theclients reach. Additionally, the clients door should be closed or the roomcurtains
pulled aroundthe bathing area.
60.
Answer:
(C) Use asterile plastic container for obtaining the specimen.
Rationale
: Sputum specimens for culture and sensitivity testing need tobe obtained using sterile techniques because the test is done to determinethe presence of organisms. If the
procedure for obtaining the specimen isnot sterile, then the specimen is not sterile, then the specimen would becontaminated and the results of the test would be invalid.
61.
Answer:
(A) Puts all the four points of the walker flat on the floor, putsweight on the hand pieces, and then walks into it.
Rationale
: When the client uses a walker, the nurse stands adjacent tothe affected side. The client is instructed to put all four points of the walker 2 feet forward flat on the floor before
putting weighton hand pieces. Thiswill ensure client safety and prevent stress cracks in the walker. The clientis then instructed to move the walker forward and walk into it.
62.
Answer:
(C) Draws one line to cross out the incorrect information andthen initials the change.
Rationale:
To correctan error documented in a medical record, the nursedraws one line through the incorrect information and then initials the error.An error is never erased and correction
fluid is never used in the medicalrecord.
63.
Answer:
(C) Secures the clientsafety belts after transferring to thestretcher.
Rationale:

During the transfer of the client after the surgical procedure iscomplete, the nurse should avoid exposure of the client because of therisk for potential heat loss. Hurried
movements and rapid changes in theposition should be avoided because these predisposethe client tohypotension. At the time of the transfer from the surgery table to
thestretcher, the clientisstill affected by the effects of the anesthesia;therefore, the client should not move self. Safety belts can prevent theclient from falling off the stretcher.
64.
Answer:
(B) Gown and gloves
Rationale:
Contact precautions require the use of gloves and a gown if direct client contact is anticipated. Goggles are not necessary unless thenurse anticipates the splashes of blood, body
fluids, secretions, or excretionsmay occur. Shoeprotectors are not necessary.
65.
Answer
: (C) Quad cane
Rationale:
Crutches and awalker can be difficult to maneuver for a clientwith weakness on one side. A caneis better suited for client withweakness of the arm and leg on oneside. However,
the quad cane wouldprovide the most stability because of the structure of the cane andbecause a quad cane has four legs.
66.
Answer:
(D) Leftside-lying with the head ofthe bed elevated 45 degrees.
Rationale
: To facilitate removalof fluid from the chest wall, the client ispositioned sitting at the edge of the bed leaning over the bedside tablewith the feet supported on a stool. If the client is
unable to situp, the clientis positioned lying in bed on the unaffected side with the head of the bedelevated 30 to 45 degrees.
67.
Answer:
(D) Reliability
Rationale:
Reliability is consistency of the research instrument. It refers tothe repeatability of the instrument in extracting the same responses uponits repeated administration.
68.
Answer
: (A) Keepthe identities of the subject secret
Rationale:
Keeping the identities of the research subject secret willensure anonymity because this will hinder providing link between theinformation given to whoever is its source.
69.
Answer:
(A) Descriptive- correlational
Rationale:
Descriptive- correlational study is the most appropriate for thisstudy because it studies the variables that could be the antecedents of theincreased incidenceof nosocomial
infection.
70.

Answer:
(C) Use of laboratory data
Rationale:
Incidence of nosocomial infection is best collected through theuse of biophysiologic measures, particularly in vitro measurements, hencelaboratory data is essential.
71.
Answer:
(B) Quasi-experiment
Rationale:
Quasi-experimentis done when randomization and control of the variables are not possible.
72.
Answer: (
C) Primary source
Rationale:
This refers to aprimary source which is a direct account of theinvestigation done by the investigator. In contrast to this is a secondarysource, which is written by someone other
than the originalresearcher
.
73.
Answer: (
A) Non-maleficence
Rationale:
Non-maleficence means do not cause harm or do any actionthat will cause any harm to the patient/client. To do good is referred asbeneficence.
74.
Answer: (
C) Res ipsaloquitor
Rationale
: Res ipsaloquitor literally means the thing speaks for itself.This means in operational terms that the injury caused is the proof thatthere was a negligent act.
75.
Answer
: (B) The Board caninvestigate violations of the nursing law andcode of ethics
Rationale:
Quasi-judicialpower means that the Board of Nursing has theauthority to investigate violationsof the nursing lawand can issuesummons, subpoena or subpoena duces tecum
as needed.
76.
Answer:
(C) May apply for re-issuance of his/her license based on certainconditions stipulated in RA 9173
Rationale:
RA 9173 sec. 24 states that for equity and justice, a revokedlicense maybe re-issued provided that the following conditions are met: a)the cause for revocation of license has already
been corrected or removed; and, b) at least four years has elapsed sincethe license hasbeen revoked.

77.
Answer:
(B) Reviewrelated literature
Rationale:
After formulating and delimiting the research problem, theresearcher conducts a reviewof related literature to determine the extentof what has been done on the study by
previous researchers.
78.
Answer:
(B) Hawthorne effect
Rationale
: Hawthorne effect is based on the study of Elton Mayo andcompany about the effect ofan intervention done to improve the workingconditions of the workers on their
productivity. Itresulted to an increasedproductivity but not due to the intervention but due to the psychologicaleffects of being observed. They performed differently because they
wereunder observation.
79.
Answer:
(B) Determines the different nationality of patients frequentlyadmitted and decides to get representations samples from each.
Rationale
: Judgmentsampling involves including samples according tothe knowledge of the investigator about the participants in the study.
80.
Answer:
(B)Madeleine Leininger
Rationale
: Madeleine Leininger developed the theory on transculturaltheory based on her observations on the behavior of selected peoplewithin a culture.
81.
Answer: (
A) Random
Rationale
: Random sampling gives equal chance for all the elements inthe population to be picked as part of the sample.
82.
Answer:
(A) Degree of agreement and disagreement
Rationale
: Likert scale is a5-point summated scale used to determine thedegree of agreement or disagreement of the respondents to a statementin a study
83.
Answer:
(B)Sr. CallistaRoy
Rationale:
Sr. Callista Roy developed the Adaptation Model whichinvolvesthe physiologicmode, self-concept mode, role function mode anddependence mode.
84.

Answer
: (A) Span of control
Rationale
:
Span of control refers to the number of workers who reportdirectly to a manager.
85.
Answer:
(B) Autonomy
Rationale:
Informed consentmeans that the patient fully understandsabout the surgery, including the risks involved and the alternativesolutions. In giving consent it is done with full
knowledge and is givenfreely. The action of allowing the patient to decide whether a surgery istobe done or not exemplifies the bioethical principle of autonomy.
86.
Answer:
(C) Avoid wearing canvas shoes.
Rationale:
The clientshould be instructed to avoid wearing canvas shoes.Canvas shoes cause the feet to perspire, which may, in turn, cause skinirritation and breakdown. Both cotton and
cornstarch absorb perspiration.The client should be instructed to cut toenails straight across with nailclippers.
87.
Answer:
(D) Ground beef patties
Rationale
: Meatis an excellent source of complete protein, which thisclient needs to repair the tissue breakdown caused by pressure ulcers.Oranges and broccoli supply vitamin C but not
protein. Ice cream suppliesonly some incomplete protein, making it less helpful in tissue repair.
88.
Answer:
(D) Sims leftlateral
Rationale:
The Sims' leftlateralposition is the most common positionused to administer a cleansing enema because it allows gravity to aid theflowof fluid along the curve ofthe sigmoid
colon. If the clientcan't assumethis position nor has poor sphincter control, the dorsal recumbent or rightlateral position may be used. The supine and prone positions
areinappropriate and uncomfortable for the client.
89.
Answer:
(A) Arrange for typing and cross matching of the clients blood.
Rationale:
The nurse first arranges for typing and cross matching of theclient's blood to ensure compatibility with donor blood. The other options,although appropriate when preparing to
administer a blood transfusion,come later.
90.

Answer:
(A) Independent
Rationale
: Nursing interventions are classified as independent,interdependent, or dependent. Altering the drug schedule to coincide withthe client's daily routine represents an
independentintervention, whereasconsulting with the physician and pharmacist to change a client'smedication because ofadverse reactionsrepresents an
interdependentintervention. Administering an already-prescribed drug on time is adependent intervention. An intradependent nursing intervention doesn'texist.
91.
Answer:
(D) Evaluation
Rationale:
The nursing actions described constitute evaluation of theexpected outcomes. The findings show that the expected outcomes havebeen
achieved.Assessmentconsists of the client's history, physicalexamination, and laboratory studies. Analysis consists of consideringassessment information
to derive the appropriate nursing diagnosis.Implementation is the phase of the nursing process where the nurse putsthe plan of care into action.
92.
Answer
: (B) To observe the lower extremities
Rationale:
Elastic stockings are used to promote venous return. Thenurse needs to remove them once per day to observe the condition of theskin underneath the
stockings. Applying the stockings increases bloodflow to the heart. When the stockings are in place, the leg muscles can stillstretch and relax, and the
veins can fill with blood.
93.
Answer:
(A) Instructing the client to report any itching, swelling, or dyspnea.
Rationale
: Because administration of blood or blood products may causeserious adverse effects such as allergic reactions, the nurse must monitor the client for
these effects. Signs and symptoms of life-threatening allergicreactions include itching, swelling, and dyspnea. Although the nurseshould inform the client
of the duration of the transfusion and shoulddocument its administration, these actions are less critical to the client'simmediate health. The nurse should
assess vital signs at least hourlyduring the transfusion.
94.
Answer
: (B) Decrease the rate of feedings and the concentration of theformula.
Rationale
: Complaints of abdominal discomfort and nausea are commonin clients receiving tube feedings. Decreasing the rate of the feeding andthe concentration
of the formula should decrease the client's discomfort.Feedings are normally given at room temperature to minimize abdominalcramping. To prevent
aspiration during feeding, the head of the client'sbed should be elevated at least 30 degrees. Also, to prevent bacterialgrowth, feeding containers should
be routinely changed every 8 to 12hours.
95.
Answer:

(D) Roll the vial gently between the palms.

Rationale:
Rolling the vial gently between the palms produces heat,which helps dissolve the medication. Doing nothing or inverting the vialwouldn't help dissolve
the medication. Shaking the vial vigorously couldcause the medication to break down, altering its action.
96.
Answer:
(B) Assist the client to the semi-Fowler position if possible.
Rationale:
By assisting the client to the semi-Fowler position, the nursepromotes easier chest expansion, breathing, and oxygen intake. Thenurse should secure the elastic band so that the
face mask fitscomfortably and snugly rather than tightly, which could lead to irritation.The nurse should apply the face mask from the client's nose down to thechin not vice
versa. The nurse should check the connectors betweenthe oxygen equipment and humidifier to ensure that they're airtight;loosened connectors can cause loss of oxygen.
97.
Answer:
(B) 4hours
Rationale:
A unit of packed RBCs may be given over a period ofbetween1and 4hours. It shouldn't infuse for longer than 4hours because the riskof contamination and sepsis increases after
that time. Discard or return tothe blood bank any blood not givenwithin this time, according to facilitypolicy.
98.
Answer
: (B) Immediately before administering the next dose.
Rationale:
Measuring the blood drug concentration helps determinewhether the dosing has achieved the therapeutic goal. For measurementof the trough, or lowest, blood level of a drug,
the nurse draws a bloodsample immediately before administering the next dose. Depending on thedrug's duration of action and half-life, peak blood drug levels typically
aredrawn after administering the next dose.
99.
Answer:
(A) The nurse can implement medication orders quickly.
Rationale:
A floor stock system enables the nurse to implementmedication orders quickly. It doesn't allow for pharmacist input, nor doesitminimize transcription errors orreinforce
accurate calculations.
100.
Answer:
(C) Shifting dullness over the abdomen.
Rationale:
Shifting dullness over the abdomen indicates ascites, anabnormal finding. The other options are normal abdominal findings.
TEST IIAnswers and Rationale Community Health Nursing and Care of theMother and Child
1.

Answer:
(A) Inevitable
Rationale:
An inevitable abortion is termination of pregnancy that cannotbe prevented. Moderate to severe bleeding with mild cramping andcervical dilation would be noted in this type of
abortion.
2.
Answer:
(B) History of syphilis
Rationale:
Maternal infections such as syphilis, toxoplasmosis, andrubella are causes of spontaneous abortion.
3.
Answer
: (C) Monitoring apical pulse
Rationale:
Nursing care for the client with a possible ectopic pregnancy isfocused on preventing or identifying hypovolemic shock and controllingpain. An elevated pulse rate is an indicator
of shock.
4.
Answer
: (B) Increased caloric intake
Rationale:
Glucose crosses the placenta, but insulin does not. High fetaldemands for glucose, combined with the insulin resistance caused byhormonal changes in the last half of pregnancy
can resultin elevation of maternal blood glucose levels. This increases the mothers demand for insulin and is referred to as the diabetogenic effect of pregnancy.
5.
Answer:
(A) Excessive fetal activity.
Rationale
: The most common signs and symptoms ofhydatidiform moleincludes elevated levels of human chorionic gonadotropin, vaginalbleeding, larger than normal uterus for
gestationalage, failure to detectfetal heart activity even with sensitive instruments, excessive nausea andvomiting, and early development of pregnancy-induced
hypertension.Fetal activity would not be noted.
6.
Answer:
(B) Absentpatellar reflexes
Rationale:
Absence of patellar reflexes is an indicator of hypermagnesemia, which requires administration of calcium gluconate.
7.
Answer:
(C) Presenting partin 2 cmbelowthe plane of the ischial spines.
Rationale:
Fetus at station plus two indicates that the presenting part is 2cm belowthe plane ofthe ischial spines.

8.
Answer:
(A) Contractions every 1 minutes lasting 70-80 seconds.
Rationale:
Contractions every 1 minutes lasting 70-80seconds, isindicative of hyperstimulation of the uterus, which could result in injury tothe mother and the fetus if Pitocin is not
discontinued.
9.
Answer:
(C) EKG tracings
Rationale:
A potential side effectof calcium gluconate administration iscardiac arrest. Continuous monitoring of cardiac activity (EKG) throughtadministration ofcalcium gluconate is an
essentialpartof care.
10.
Answer
: (D) Firstlowtransverse caesarean was for breech position.Fetus in this pregnancy is in a vertex presentation.
Rationale
: This type of client has no obstetrical indication for a caesareansection as she did with her first caesarean delivery.
11.
Answer
: (A) Talk to the mother first and then to the toddler.
Rationale:
When dealing with acrying toddler, the best approach is to talkto the mother and ignore the toddler first. This approach helps the toddler get used to the nurse before she
attempts any procedures. It also givesthe toddler an opportunity to see that the mother trusts the nurse.
12.
Answer
: (D) Place the infants arms in soft elbowrestraints.
Rationale
: Soft restraints from the upper arm to the wrist prevent theinfant from touching her lip but allow himto hold a favorite item such as ablanket. Because they could damage the
operative site, such as objectsas pacifiers, suction catheters, and small spoons shouldnt be placed in ababys mouth after cleft repair. A baby in a proneposition may rub her face
on the sheets and traumatize the operative site. The suture lineshould be cleaned gently to prevent infection, which could interfere withhealing and damage the cosmetic
appearance of the repair.
13.
Answer
: (B) Allowthe infant to rest before feeding.
Rationale:
Because feeding requires so much energy, an infant with heartfailure should rest before feeding.
14.
Answer:

(C) Iron-rich formula only.

Rationale:
The infants atage 5months should receive iron-rich formulaand that they shouldnt receive solid food, even baby food until age 6months.
15.
Answer:
(D) 10 months
Rationale
: A 10 month old infant can sit alone and understands objectpermanence, so he would look for the hidden toy. At age 4 to 6months,infants cant sit securely alone. At age 8
months, infants can sit securelyalone but cannot understand the permanence of objects.
16.
Answer:
(D) Public health nursing focuses on preventive, not curative,services.
Rationale
: The catchments areain PHN consists ofa residential
community, many of whom are well individuals who have greater need for preventive rather than curative services.
17.
Answer:
(B) Efficiency
Rationale:
Efficiency is determining whether the goals were attained atthe least possible cost.
18.
Answer:
(D) Rural Health Unit
Rationale:
R.A. 7160 devolved basic health services to local governmentunits (LGUs ). The public health nurse is an employee of the LGU.
19.
Answer
: (A) Mayor
Rationale:
The local executive serves as the chairman of the MunicipalHealth Board.
20.
Answer: (
A) 1
Rationale
: Each rural health midwife is given a population assignment of about 5,000.
21.
Answer:
(B) Health education and community organizing are necessary inproviding community health services.

Rationale:
The community health nurse develops the health capability of people through health education and community organizing activities.
22.
Answer:
(B)Measles
Rationale
: Presidential Proclamation No. 4 is on the Ligtas TigdasProgram.
23.
Answer:
(D) Core group formation
Rationale
: In core group formation, the nurse is able to transfer thetechnology of community organizing to the potential or informal communityleaders through a
training program.
24.
Answer:
(D) To maximize the communitys resources in dealing withhealth problems.
Rationale:
Community organizing is a developmental service, with thegoal of developing the peoples self-reliance in dealing with communityhealth problems. A, B
and C are objectives of contributory objectives tothis goal.
25.
Answer:
(D) Terminal
Rationale
: Tertiary prevention involves rehabilitation, prevention of permanent disability and disability limitation appropriate for convalescents,the disabled,
complicated cases and the terminally ill (those in the terminalstage of a disease).
26.
Answer: (
A) Intrauterine fetaldeath.
Rationale:
Intrauterine fetaldeath, abruptio placentae, septic shock, andamniotic fluid embolism may trigger normal clotting mechanisms; if clottingfactors are depleted, DIC may occur.
Placentaaccreta, dysfunctionallabor, and premature rupture of the membranes aren't associated withDIC.
27.
Answer:
(C) 120to 160 beats/minute
Rationale
: A rate of 120 to 160beats/minute in the fetal heart appropriatefor filling the heart with blood and pumping it out to the system.
28.
Answer:

(A) Change the diaper more often.

Rationale:
Decreasing the amount of time the skin comes contact withwet soiled diapers will help heal the irritation.
29.
Answer:
(D) Endocardialcushion defect
Rationale
: Endocardial cushiondefects are seen most in children withDown syndrome, asplenia, or polysplenia.
30.
Answer
: (B) Decreased urine output
Rationale
: Decreased urine output may occur in clients receiving I.V.magnesium and should be monitored closely to keep urine output atgreater than 30 ml/hour, because magnesium is
excreted through thekidneys and can easily accumulate to toxic levels.
31.
Answer:
(A) Menorrhagia
Rationale:
Menorrhagiais an excessive menstrual period.
32.
Answer:
(C) Blood typing
Rationale
: Blood type would be a critical value to have because the risk of bloodloss is always a potential complication during the labor and deliveryprocess. Approximately 40% of a
womans cardiac output is delivered tothe uterus, therefore, blood loss can occur quite rapidly in the event of uncontrolled bleeding.
33.
Answer:
(D) Physiologic anemia
Rationale:
Hemoglobin values and hematocrit decrease during pregnancyas the increase in plasma volume exceeds the increase in red blood cellproduction.
34.
Answer:
(D) A 2year oldinfant with stridorous breath sounds, sitting up inhis mothers arms and drooling.
Rationale
: The infantwith the airway emergency should be treated first,because of the risk of epiglottitis.
35.
Answer:
(A) Placentaprevia

Rationale:
Placenta previa with painless vaginal bleeding.
36.
Answer
: (D) Early in the morning
Rationale
: Based on the nurses knowledge of microbiology, thespecimen should be collected early in the morning. The rationale for thistiming is that, because the
female worm lays eggs at night around theperineal area, the first bowel movement of the day will yield the bestresults. The specific type of stool specimen
used in the diagnosis of pinworms is called the tape test.
37.
Answer:
(A) Irritability and seizures
Rationale
: Lead poisoning primarily affects the CNS, causing increasedintracranial pressure. This condition results in irritability and changes inlevel of
consciousness, as well as seizure disorders, hyperactivity, andlearning disabilities.
38.
Answer:
(D) I really need to use the diaphragm and jelly most during themiddle of my menstrual cycle.
Rationale:
The woman must understand that, although the fertile periodis approximately mid-cycle, hormonal variations do occur and can result inearly or late
ovulation. To be effective, the diaphragm should be insertedbefore every intercourse.
39.
Answer:
(C) Restlessness
Rationale
: In a child, restlessness is the earliest sign of hypoxia. Latesigns of hypoxia in a child are associated with a change in color, such aspallor or cyanosis.
40.
Answe
r: (B) Walk one step ahead, with the childs hand on the nurseselbow.
Rationale
: This procedure is generally recommended to follow in guidinga person who is blind.
41.
Answer
: (A) Loud, machinery-like murmur.
Rational
e: A loud, machinery-like murmur is a characteristic findingassociated with patent ductus arteriosus.
42.
Answer
: (C) More oxygen, and the newborns metabolic rate increases.

Rationale
: When cold, the infant requires more oxygen and there is anincrease in metabolic rate. Non-shievering thermogenesis is a complexprocess that increases
the metabolic rate and rate of oxygenconsumption, therefore, the newborn increase heat production.
43.
Answer:
(D) Voided
Rationale:
Before administering potassium I.V. to any client, the nursemust first check that the clients kidneys are functioning and that the client
is voiding. If the client is not voiding, the nurse should withhold thepotassium and notify the physician.
44.
Answer:
(c) Laundry detergent
Rationale
: Eczema or dermatitis is an allergic skin reaction caused by anoffending allergen. The topical allergen that is the most common causativefactor is laundry
detergent.
45.
Answer:
(A) 6 inches
Rationale:
This distance allows for easy flow of the formula by gravity, butthe flow will be slow enough not to overload the stomach too rapidly.
46.
Answer:
(A) The older one gets, the more susceptible he becomes to thecomplications of chicken pox.
Rationale
: Chicken pox is usually more severe in adults than in children.Complications, such as pneumonia, are higher in incidence in adults.
47.
Answer:
(D) Consult a physician who may give them rubellaimmunoglobulin.
Rationale
: Rubella vaccine is made up of attenuated German measlesviruses. This is contraindicated in pregnancy. Immune globulin, a specificprophylactic
against German measles, may be given to pregnant women.
48.
Answer
: (A) Contact tracing
Rationale
: Contact tracing is the most practical and reliable method of finding possible sources of person-to-person transmitted infections, suchas sexually
transmitted diseases.
49.

Answer
: (D)Leptospirosis
Rationale
: Leptospirosis is transmitted through contact with the skin or mucous membrane with water or moist soil contaminated with urine of infected animals,
like rats.
50.
Answer
: (B)Cholera
Rationale:
Passage of profuse watery stools is the major symptom of cholera. Both amebic and bacillary dysentery are characterized by thepresence of blood and/or
mucus in the stools. Giardiasis is characterizedby fat malabsorption and, therefore, steatorrhea.
51.
Answer:
(A) Hemophilus influenzae
Rationale:
Hemophilus meningitis is unusual over the age of 5 years. Indeveloping countries, the peak incidence is in children less than 6 monthsof age.
Morbillivirus is the etiology of measles. Streptococcus pneumoniaeand Neisseria meningitidis may cause meningitis, but age distribution isnot specific in
young children.
52.
Answer:
(B) Buccal mucosa
Rationale:
Kopliks spot may be seen on the mucosa of the mouth or thethroat.
53.
Answer
: (A) 3 seconds
Rationale:
Adequate blood supply to the area allows the return of thecolor of the nailbed within 3 seconds.
54.
Answer:
(B) Severe dehydration
Rationale
: The order of priority in the management of severe dehydrationis as follows: intravenous fluid therapy, referral to a facility where IV fluidscan be initiated
within 30 minutes, Oresol or nasogastric tube. When theforegoing measures are not possible or effective, then urgent referral tothe hospital is done.
55.
Answer:
(A) 45 infants
Rationale:

To estimate the number of infants, multiply total population by3%.

56.
Answer
: (A) DPT
Rationale
: DPT is sensitive to freezing. The appropriate storagetemperature of DPT is 2 to 8 C only. OPV and measles vaccine are highlysensitive to heat and
require freezing. MMR is not an immunization in theExpanded Program on Immunization.
57.
Answer:
(C) Proper use of sanitary toilets
Rationale:
The ova of the parasite get out of the human body together with feces. Cutting the cycle at this stage is the most effective way of preventing the spread of
the disease to susceptible hosts.
58.
Answer:
(D) 5 skin lesions, positive slit skin smear
Rationale
: A multibacillary leprosy case is one who has a positive slit skinsmear and at least 5 skin lesions.
59.
Answer:
(C) Thickened painful nerves
Rationale:
The lesion of leprosy is not macular. It is characterized by achange in skin color (either reddish or whitish) and loss of sensation,sweating and hair growth
over the lesion. Inability to close the eyelids(lagophthalmos) and sinking of the nosebridge are late symptoms.
60.
Answer
: (B) Ask where the family resides.
Rationale:
Because malaria is endemic, the first question to determinemalaria risk is where the clients family resides. If the area of residence isnot a known endemic
area, ask if the child had traveled within the past 6months, where she was brought and whether she stayed overnight in thatarea.
61.
Answer
: (A) Inability to drink
Rationale:
A sick child aged 2 months to 5 years must be referredurgently to a hospital if he/she has one or more of the following signs: notable to feed or drink,
vomits everything, convulsions, abnormally sleepy or difficult to awaken.
62.
Answer

: (A) Refer the child urgently to a hospital for confinement.

Rationale:
Baggy pants is a sign of severe marasmus. The bestmanagement is urgent referral to a hospital.
63.
Answer
: (D) Let the child rest for 10 minutes then continue giving Oresolmore slowly.
Rationale
: If the child vomits persistently, that is, he vomits everythingthat he takes in, he has to be referred urgently to a hospital. Otherwise,vomiting is managed
by letting the child rest for 10 minutes and thencontinuing with Oresol administration. Teach the mother to give Oresolmore slowly.
64.
Answer:
(B) Some dehydration
Rationale
: Using the assessment guidelines of IMCI, a child (2 months to5 years old) with diarrhea is classified as having SOME DEHYDRATION if he shows 2 or
more of the following signs: restless or irritable, sunkeneyes, the skin goes back slow after a skin pinch.
65.
Answer
: (C) Normal
Rationale
: In IMCI, a respiratory rate of 50/minute or more is fastbreathing for an infant aged 2 to 12 months.
66.
Answer
: (A) 1 year
Rationale:
The baby will have passive natural immunity by placentaltransfer of antibodies. The mother will have active artificial immunitylasting for about 10 years.
5 doses will give the mother lifetime protection.
67.
Answer:
(B) 4 hours
Rationale:
While the unused portion of other biologicals in EPI may begiven until the end of the day, only BCG is discarded 4 hours after reconstitution. This is why
BCG immunization is scheduled only in themorning.
68.
Answer:
(B) 6 months
Rationale:
After 6 months, the babys nutrient needs, especially thebabys iron requirement, can no longer be provided by mothers milkalone.
69.
Answer:

(C
)
24 weeks
Rationale:
At approximately 23 to 24 weeks gestation, the lungs are developed enough to sometimes maintain extrauterine life. The lungs
arethe most immature system during the gestation period. Medical care for premature labor begins much earlier (aggressively at 21 weeks
gestation)
70.
Answer:
(B) Sudden infant death syndrome (SIDS)
Rationale
: Supine positioning is recommended to reduce the risk of SIDSin in fanc y. The risk o f asp iratio n is s ligh tly inc reased with
the s upine position. Suffocation would be less likely with an infant supine than proneand the position for GER requires the head of the bed
to be elevated.
71.
Answer:
(C)
Decreased temperature
Rationale:
Temperature instability, especially when it results in a lowtemperature in the neonate, may be a sign of infection. The
neonatescolor often changes with an infection process but generally becomes ashen o r mottled. Th e neo nate with an
infectio n will usually sho w a decrease in activity level or lethargy.
72.
Answer:
(D)
Polycythemia probably due to chronic fetal hypoxia
Rationale
: Th e small- fo r-gestatio n neonate is at risk fo r dev eloping polycythemia during the transitional period in an attempt
to decreaseh y p o x i a . T h e n e o n a t e s a r e a l s o a t i n c r e a s e d r i s k f o r d e v e l o p i n g hypoglycemia and hypothermia due to
decreased glycogen stores.
73.
Answer:

(C)
Desquamation of the epidermis
Rationale:
Postdate fetuses lose the vernix caseosa, and the epidermism ay becom e desquamated. Th ese n eon ates are usually very
alert. Lanugo is missing in the postdate neonate.
74.
Answer:
(C)
Respiratory depression
Rationale
: Magnesium sulfate crosses the placenta and adverse neonataleffects are respiratory depression, hypotonia, and bradycardia. The serumblood sugar
isnt affected by magnesium sulfate. The neonate would befloppy, not jittery.
75.
Answer:
(C)
Respiratory rate 40 to 60 breaths/minute
Rationale:
A respirato ry rate 40 to 60 breaths/m in ute is n orm al fo r a neonate during the transitional period. Nasal flaring, respiratory
rate morethan 60 breaths/minute, and audible grunting are signs of respiratory distress.
76.
Answer:
(C)
Keep the cord dry and open to air
Rationale:
Keeping the cord dry and open to air helps reduce infection and hastens drying. Infants arent given tub bath but are sponged off
untilthe co rd falls off. Petroleum jelly p rev en ts the cord from dryin g an d encourages infection. Peroxide could be painful and
isnt recommended.
77.
Answer
: (B) Conjunctival hemorrhage
Rationale

: Conjunctival hemorrhages are commonly seen in neonates secondary to the cranial pressure applied during the birth process.
Bulgingfontanelles are a sign of intracranial pressure. Simian creases are presentin 40% of the neonates with trisomy 21. Cystic hygroma is a
neck massthat can affect the airway.
78.
Answer:
(B) To assess for prolapsed cord
Rationale:
After a client has an amniotomy, the nurse should assure thatthe cord isn't prolapsed and that the baby tolerated the procedure
well.The most effective way to do this is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal
position is determinedby vaginal examination. Artificial rupture of membranes doesn't indicate animminent delivery.
79.
Answer
: (D) The parents interactions with each other.
Rationale:
P a r e n t a l i n t e r a c t i o n w i l l p r o v i d e t h e n u r s e w i t h a g o o d assessment of the stability of the family's home life but it has
no indicationf o r p a r e n t a l b o n d i n g . W i l l i n g n e s s t o t o u c h a n d h o l d t h e n e w b o r n , expressing interest about the
newborn's size, and indicating a desire tosee the newborn are behaviors indicating parental bonding.
80.
Answer:
(B) Instructing the client to use two or more peripads to cushionthe area
Rationale:
Using two or more peripads would do little to reduce the painor promote perineal healing. Cold applications, sitz baths, and
Kegelexercises are important measures when the client has a fourth-degree laceration.
81.
Answer:
(C) What is your expected due date?
Rationale:
When obtaining the history of a client who may be in labor, thenurse's highest priority is to determine her current status, particularly her due
date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should
askabout chronic illnesses, allergies, and support persons.
82.
Answer:
(D) Aspirate the neonates nose and mouth with a bulb syringe.
Rationale:
The nurse's first action should be to clear the neonate's airwaywith a bulb syrin ge. After the airway is clear and th e neo nate' s
co lor improves, the nurse should comfort and calm the neonate. If the problemrecurs or the neonate's color doesn't improve
readily, the nurse shouldnotify the physician. Administering oxygen when the airway isn't clear would be ineffective.
83.
Answer

: (C) Conducting a bedside ultrasound for an amniotic fluid index

Rationale:
I t is n' t with in a nurse's scop e of prac tice to perfo rm an din terp ret a bedside ultras ound un der th es e cond itions
and witho ut specialized training. Observing for pooling of straw-colored fluid, checkingvaginal discharge with nitrazine paper, and
observing for flakes of vernixare ap prop riate assessments for determining wheth er a client has ruptured membranes.
84.
Answer
: (C) Monitor partial pressure of oxygen (Pao2) levels.
Rationale:
Monitoring PaO
2
l e v e l s a n d r e d u c i n g t h e o x y g e n concentration to keep PaO
2
with in normal lim its reduces the risk of r e t i n o p a t h y o f p r e m a t u r i t y i n a p r e m a t u r e i n f a n t r e c e i v i n g
o x y g e n . Covering the infant's eyes and humidifying the oxygen don't reduce therisk of retinopathy of prematurity. Because cooling
increases the risk of acidosis, the infant should be kept warm so that his respiratory distressisn't aggravated.
85.
Answer:
(A) 110 to 130 calories per kg.
Rationale:
Calories per kg is the accepted way of determined appropriatenutritional intake for a newborn. The recommended calorie requirement is110 to
130 calories per kg of newborn body weight. This level will maintaina c o n s i s t e n t b l o o d g l u c o s e l e v e l a n d p r o v i d e e n o u g h
c a l o r i e s f o r continued growth and development.
86.
Answer:
(C) 30 to 32 weeks
Rationale:
Individual twins usually grow at the same rate as singletons until 30 to 32 weeks gestation, then twins dont gain weight as
rapidly assingletons of the same gestational age. The placenta can no longer keeppace with the nutritional requirements of both fetuses
after 32 weeks, sotheres some growth retardation in twins if they remain
in utero
at 38 to 40weeks.
87.
Answer:
(A) conjoined twins
Rationale:
The typ e of plac en ta that dev elops in mo nozygotic twins depends on the time at which cleavage of the ovum occurs. Cleavage
inconjoined twins occurs more than 13 days after fertilization. Cleavage thatoccurs less than 3 day after fertilization results in diamniotic

dicchorionictwins. Cleavage that occurs between days 3 and 8 results in diamniotic monochorionic twins. Cleavage that occurs
between days 8 to 13 result inmonoamniotic monochorionic twins.
88.
Answer:
(D) Ultrasound
Rationale:
Onc e the mother an d the fetus are stabilized, ultrasound evaluation of the placenta should be done to determine the cause of
thebleeding. Amniocentesis is contraindicated in placenta previa. A digital or sp eculum examination sho uldn t be don e as this
m ay lead to severe
bleeding or hemorrhage. External fetal monitoring wont detect a placentaprevia, although it will detect fetal distress, which may result
from bloodloss or placenta separation.
89.
Answer:
(A) Increased tidalvolume
Rationale:
A pregnant client breathes deeper, which increases the tidalvolume of gas moved in and out of the respiratory tract with each
breath.The expiratory volume and residual volume decrease as the pregnancyp ro g re ss es . Th e in s p i r at o r y c ap a c i t y in c r ea s e s
d ur in g p r eg n a n c y. T he i n c r e a s e d o x y g e n c o n s u m p t i o n i n t h e p r e g n a n t c l i e n t i s 1 5 % t o 2 0 % greater than
in the nonpregnantstate.
90.
Answer
: (A) Diet
Rationale
: Clients with gestational diabetes are usually managed by dieta lo n e t o c o n t ro l t he ir gl uc o s e i n t o l er a n c e. O r a l
h yp o g ly c e m ic d ru gs a re contraindicated in pregnancy. Long-acting insulin usually isnt needed for bloodglucose control in the client with
gestationaldiabetes.
91.
Answer
: (D)Seizure
Rationale:
The anticonvulsant mechanism of magnesium is believes todepress seizure foci in the brain and peripheral neuromuscular
blockade.Hypomagnesemia isnt a complication of preeclampsia. Antihypertensived ru g o t h e r th a n m a gn es iu m ar e p re fe rr ed
fo r s u s t a in ed hyp er te n s io n . Magnesium doesnt help prevent hemorrhage in preeclamptic clients.
92.
Answer
: (C) I.V. fluids
Rationale:

A s ic kl e c e ll c ri si s du ri n g p re gn an c y i s usu a l ly m a n a ge d b y exchange transfusion oxygen, and L.V. Fluids. The client

usually needs as tr o n ge r an a l ge si c th an ac et a m i n o p hen t o c o n t r o l t he p a in o f a c ri s i s . Antihypertensive drugs usually arent
necessary. Diuretic wouldnt be usedunless fluid overload resulted.
93.
Answ
er: (A) Calciumgluconate (Kalcinate)
Rationale:
Calcium gluconate is the antidote for magnesium toxicity. Tenmilliliters of 10% calcium gluconate is given L.V. push over 3 to 5 minutes.Hydralazine is given
for sustained elevated blood pressure in preeclampticc l ie n t s. Rho ( D) im m u n e gl o b u li n i s g iv en t o wo m en w i th Rh - n e g at i v e b l o o d
t o p r e v e n t a n t i b o d y f o r m a t i o n f r o m R H - p o s i t i v e c o n c e p t i o n s . Naloxone is used to correct narcotic toxicity.
94.
Answer:
(B) An indurated wheal over 10 mm in diameter appears in 48 to72 hours.
Rationale
: A p o s it iv e PP D r es ul t w o u ld be a n i n d ur a te d wh e a l o v e r 1 0 mm in diameter that appears in 48 to 72 hours. The area must be a raisedwheal,
not a flatcircumcised area to be considered positive.
95.
Answer:
(C) Pyelonephritis
Rational:
The symptoms indicate acute pyelonephritis, a serious conditionin a pregnant client. UTI symptoms include dysuria, urgency, frequency,and
suprapubic tenderness. Asymptomatic bacteriuria doesnt cause symptoms. Bacterial vaginosis causes milky white vaginal
discharge butno systemic symptoms.
96.
Answer:
( B ) R h - p o s i t i v e f e t a l b l o o d c r o s s e s i n t o m a t e r n a l b l o o d , stimulating maternal antibodies.
Rationale:
Rh isoimmunization occurs when Rh-positive fetal blood cellscross into the matern al circulation and s timulate matern al
an tibo dy production. In subsequent pregnancies with Rh-positive fetuses, maternalantibodies may cross back into the fetal circulation
and destroy the fetalblood cells.
97.
Answer:
(C) Supine position
Rationale:
The supine position causes compression of the client's aortaand in ferior vena cav a by th e fetus . Th is , in turn , inh ibits
m atern al circulation, leading to maternal hypotension and, ultimately, fetal hypoxia.The other positions promote comfort and aid

labor progress. For instance,the lateral, or side-lying, position improves maternal and fetal circulation,enhances comfort, increases
maternal relaxation, reduces muscle tension,and eliminates pressure points. The squatting position promotes comfortb y t a k i n g
a d v a n t a g e o f g r a v i t y . T h e s t a n d i n g p o s i t i o n a l s o t a k e s advantage of gravity and aligns the fetus with the pelvic angle.
98.
Answer:
(B) Irritability and poor sucking.
Rationale:
N e o n a t e s o f h e r o i n - a d d i c t e d m o t h e r s a r e p h y s i c a l l y dependent on the drug and experience withdrawal when
the drug is nolon ger supp lied. Sign s of hero in withdrawal include irritability, poo r sucking, and restlessness. Lethargy
isn't associated with neonatal heroinaddiction. A flattened nose, small eyes, and thin lips are seen in infantswith fetal alcohol
syndrome. Heroin use during pregnancy hasn't beenlinked to specific congenital anomalies.
99.
Answer:
(A) 7
th
to 9
th
day postpartum
Rationale:
The no rm al in volution al proc ess return s the uterus to the pelvic cavity in 7 to 9 days. A significant involutional complication
is thefailure of the uterus to return to the pelvic cavity within the prescribed timeperiod. This is known as subinvolution.
100.
Answer:
(B) Uterine atony
Rationale:
Multiple fetuses, extended labor stimulation with oxytocin, andtraumatic delivery commonly are associated with uterine atony, which maylead to
postpartum hemorrhage. Uterine inversion may precede or followdelivery and commonly results from apparent excessive
traction on the
umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after delivery.
TEST IIIAnswers and Rationale Care of Clients with Physiologic andPsychosocial Alterations
1.
Answer:
(C) Loose, bloody
Rationale
: Normal bowel function and soft-formed stool usually do notoccur until around the seventh day following surgery. The stoolconsistency is related to how
much water is being absorbed.
2.

Answer:
(A) On the clients right side
Rationale
: The client has left visual field blindness. The client will see onlyfrom the right side.
3.
Answer
: (C) Check respirations, stabilize spine, and check circulation
Rationale
: Checking the airway would be priority, and a neck injury shouldbe suspected.
4.
Answer:
(D) Decreasing venous return through vasodilation.
Rationale: The significant effect of nitroglycerin is vasodilation anddecreased
venous return, so the heart does not have to work hard.
5.
Answer:
(A) Call for help and note the time.
Rationale
: Having established, by stimulating the client, that the client isunconscious rather than sleep, the nurse should immediately call for help.This may be
done by dialing the operator from the clients phone andgiving the hospital code for cardiac arrest and the clients room number tothe operator, of if the
phone is not available, by pulling the emergency callbutton. Noting the time is important baseline information for cardiac arrestprocedure.
6.
Answer
: (C) Make sure that the client takes food and medications atprescribed intervals.
Rationale
: Food and drug therapy will prevent the accumulation of hydrochloric acid, or will neutralize and buffer the acid that doesaccumulate.
7.
Answer:
(B) Continue treatment as ordered.
Rationale
: The effects of heparin are monitored by the PTT is normally 30to 45 seconds; the therapeutic level is 1.5 to 2 times the normal level.
8.
Answer
: (B) In the operating room.
Rationale:
The stoma drainage bag is applied in the operating room.Drainage from the ileostomy contains secretions that are rich in digestiveenzymes and highly
irritating to the skin. Protection of the skin from theeffects of these enzymes is begun at once. Skin exposed to these
enzymes even for ashort time becomes reddened, painful, andexcoriated.

9.
Answer
: (B) Flat on back.
Rationale
: To avoid the complication of a painful spinal headache that canlast for several days, the client is kept in flat in a supine position for approximately 4 to 12 hours postoperatively.
Headaches are believed tobe causes by the seepage of cerebral spinal fluid from the puncture site.By keeping the client flat, cerebral spinal fluid pressuresare equalized,which
avoids traumato the neurons.
10.
Answer:
(C) The clientisoriented when aroused from sleep, and goesback to sleep immediately.
Rationale:
This finding suggestthat the level of consciousness isdecreasing.
11.
Answer: (A)
Altered mental status and dehydration
Rationale:
Fever, chills, hemortysis, dyspnea, cough, and pleuritic chestpain are the common symptoms of pneumonia, but elderly clients may firstappear with only an altered lentil status
and dehydration due to a bluntedimmune response.
12.
Answer:
(B)
Chills, fever, nightsweats, and hemoptysis
Rationale:
Typical signs and symptoms are chills, fever, night sweats,and hemoptysis. Chest pain may be present from coughing, but isntusual. Clients with TB typically have low-grade
fevers, nothigher than102F (38.9C). Nausea, headache, and photophobia arent usual TBsymptoms.
13.
Answer
:(A)
Acute asthma
Rationale
: Based on the clients history and symptoms, acute asthma isthe most likely diagnosis. Hes unlikely to have bronchial pneumoniawithout a productive cough and fever and hes
too young to havedeveloped (COPD) and emphysema.
14.
Answer:
(B)
Respiratory arrest
Rationale
: Narcoticscan cause respiratory arrest if givenin largequantities. Its unlikely the client will haveasthma attack or a seizure or wake uponhis own.
15.

Answer:
(D)
Decreased vitalcapacity
Rationale
: Reduction in vital capacity is a normal physiologic changesinclude decreased elastic recoil ofthe lungs, fewer functional capillaries inthe alveoli, and an increased in residual
volume
16.
Answer:
(C) Presence of premature ventricular contractions (PVCs) on acardiac monitor.
Rationale:
Lidocaine drips are commonly used to treat clients whosearrhythmias havent been controlled with oral medication and who arehaving PVCs that are
visible on the cardiac monitor. SaO2, bloodpressure, and ICP are important factors but arent as significant as PVCsin the situation.
17.
Answer
: (B) Avoid foods high in vitamin K
Rationale:
The client should avoid consuming large amounts of vitamin Kbecause vitamin K can interfere with anticoagulation. The client may needto report
diarrhea, but isnt effect of taking an anticoagulant. An electricrazor-not a straight razor-should be used to prevent cuts that causebleeding. Aspirin may
increase the risk of bleeding; acetaminophen shouldbe used to pain relief.
18.
Answer
: (C) Clipping the hair in the area
Rationale
: Hair can be a source of infection and should be removed byclipping. Shaving the area can cause skin abrasions and depilatories canirritate the skin.
19.
Answer
: (A) Bone fracture
Rationale
: Bone fracture is a major complication of osteoporosis thatresults when loss of calcium and phosphate increased the fragility of bones. Estrogen
deficiencies result from menopause-not osteoporosis.Calcium and vitamin D supplements may be used to support normal bonemetabolism, But a
negative calcium balance isnt a complication of osteoporosis. Dowagers hump results from bone fractures. It developswhen repeated vertebral fractures
increase spinal curvature.
20.
Answe
r: (C) Changes from previous examinations.
Rationale
: Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can diagnoselumps that are
cancerous, areas of thickness or fullness that signal thepresence of a malignancy, or masses that are fibrocystic as opposed tomalignant.

21.
Answer:
(C) Balance the clients periods of activity and rest.
Rationale:
A client with hyperthyroidism needs to be encouraged tobalance periods of activity and rest. Many clients with hyperthyroidism arehyperactive and
complain of feeling very warm.
22.
Answer
: (B) Increase his activity level.
Rationale
: The client should be encouraged to increase his activity level.Maintaining an ideal weight; following a low-cholesterol, low sodium diet;
and avoiding stress are all important factors in decreasing the risk of atherosclerosis.
23.
Answer
: (A) Laminectomy
Rationale:
The client who has had spinal surgery, such as laminectomy,must be log rolled to keep the spinal column straight when turning.Thoracotomy and
cystectomy may turn themselves or may be assistedinto a comfortable position. Under normal circumstances,hemorrhoidectomy is an outpatient
procedure, and the client may resumenormal activities immediately after surgery.
24.
Answer:
(D) Avoiding straining during bowel movement or bending at thewaist.
Rationale
: The client should avoid straining, lifting heavy objects, andcoughing harshly because these activities increase intraocular pressure.Typically, the client is
instructed to avoid lifting objects weighing more than15 lb (7kg) not 5lb. instruct the client when lying in bed to lie on either the side or back. The client
should avoid bright light by wearingsunglasses.
25.
Answer:
(D) Before age 20.
Rationale:
Testicular cancer commonly occurs in men between ages 20and 30. A male client should be taught how to perform testicular self-examination before age
20, preferably when he enters his teens.
26.
Answer:
(B) Place a saline-soaked sterile dressing on the wound.
Rationale:
The nurse should first place saline-soaked sterile dressings onthe open wound to prevent tissue drying and possible infection. Then thenurse should call
the physician and take the clients vital signs. Thedehiscence needs to be surgically closed, so the nurse should never try toclose it.

27.
Answer:
(A) A progressively deeper breaths followed by shallower breaths with apneic periods.
Rationale:
Cheyne-Strokes respirations are breaths that becomeprogressively deeper fallowed by shallower respirations with apneasperiods. Biots respirations are
rapid, deep breathing with abrupt pausesbetween each breath, and equal depth between each breath. Kussmaulsrespirationa are rapid, deep breathing
without pauses. Tachypnea isshallow breathing with increased respiratory rate.
28.
Answer:
(B) Fine crackles
Rationale
: Fine crackles are caused by fluid in the alveoli and commonlyoccur in clients with heart failure. Tracheal breath sounds are auscultatedover the trachea.
Coarse crackles are caused by secretion accumulationin the airways. Friction rubs occur with pleural inflammation.
29.
Answer:
(B) The airways are so swollen that no air cannot get through
Rationale
: During an acute attack, wheezing may stop and breath soundsbecome inaudible because the airways are so swollen that air cant getthrough. If the
attack is over and swelling has decreased, there would beno more wheezing and less emergent concern. Crackles do not replacewheezes during an acute
asthma attack.
30.
Answer:
(D) Place the client on his side, remove dangerous objects, andprotect his head.
Rationale
: During the active seizure phase, initiate precautions by placingthe client on his side, removing dangerous objects, and protecting hishead from injury. A
bite block should never be inserted during the activeseizure phase. Insertion can break the teeth and lead to aspiration.
31.
Answer
: (B) Kinked or obstructed chest tube
Rationales
: Kinking and blockage of the chest tube is a common cause of a tension pneumothorax. Infection and excessive drainage wont cause atension
pneumothorax. Excessive water wont affect the chest tubedrainage.
32.
Answer
: (D) Stay with him but not intervene at this time.
Rationale:

If the client is coughing, he should be able to dislodge theobject or cause a complete obstruction. If complete obstruction occurs, thenurse should perform
the abdominal thrust maneuver with the clientstanding. If the client is unconscious, she should lay him down. A nurseshould never leave a choking client
alone.
33.
Answer:
(B) Current health promotion activities
Rationale:
Recognizing an individuals positive health measures is veryuseful. General health in the previous 10 years is important, however, thecurrent activities of
an 84 year old client are most significant in planningcare. Family history of disease for a client in later years is of minor significance. Marital status
information may be important for dischargeplanning but is not as significant for addressing the immediate medicalproblem.
34.
Answer
: (C) Place the client in a side lying position, with the head of thebed lowered.
Rationale:
The client should be positioned in a side-lying position with thehead of the bed lowered to prevent aspiration. A small amount of toothpaste should be
used and the mouth swabbed or suctioned toremove pooled secretions. Lemon glycerin can be drying if used for extended periods. Brushing the teeth
with the client lying supine may leadto aspiration. Hydrogen peroxide is caustic to tissues and should not beused.
35.
Answer:
(C) Pneumonia
Rationale
: Fever productive cough and pleuritic chest pain are commonsigns and symptoms of pneumonia. The client with ARDS has dyspneaand hypoxia with worsening hypoxia over
time, if nottreated aggressively.Pleuritic chest pain varies with respiration, unlike the constant chest painduring an MI; so this client most likely isnt having an MI. the client with
TBtypically has acough producing blood-tinged sputum. A sputum cultureshould be obtained to confirm the nurses suspicions.
36.
Answer: (C)
A 43-yesr-old homeless man with a history of alcoholism
Rationale:
Clients who are economically disadvantaged, malnourished,and have reduced immunity, such as a client with a history of alcoholism,are at extremely high risk for developing
TB. A high schoolstudent, day-care worker, and businessman probably have a much lowrisk of contracting TB.
37.
Answer: (C )
To determine the extent of lesions
Rationale
: If the lesions are large enough, the chest X-ray will show their presence in the lungs. Sputum culture confirms the diagnosis. There canbe false-positive and false-negative skin
test results. Achest X-ray cantdetermine if this is a primary or secondary infection.
38.
Answer: (B)

Bronchodilators
Rationale:
Bronchodilators are the first line of treatment for asthmabecause broncho-constriction is the cause of reduced airflow. Beta-adrenergicblockers arent used to treat asthma and
can cause broncho-constriction. Inhaled oral steroids may be given to reduce the inflammationbut arent used for emergency relief.
39.
Answer: (C)
Chronic obstructive bronchitis
Rationale
:
Because of this extensive smoking history and symptoms theclient most likely has chronicobstructive bronchitis. Client with ARDShave acute symptoms of hypoxia and typically
need large amounts of oxygen. Clients with asthma and emphysema tend not to have chroniccough or peripheral edema.
40.
Answer:
(A) The patient is under local anesthesiaduring the procedure
Rationale
: Before the procedure, the patient is administered with drugsthat would help to prevent infection and rejection of the transplanted cellssuch as antibiotics, cytotoxic, and
corticosteroids. During the transplant,the patient is placed under general anesthesia.
41.
Answer
: (D) Raise the side rails
Rationale
: A patient who is disoriented is at risk of falling out of bed. Theinitial action of the nurse should be raising the side rails to ensure patientssafety.
42.
Answer:
(A) Crowd red blood cells
Rationale
: The excessive production of white blood cells crowd out redblood cells production which causes anemia to occur.
43.
Answer
: (B) Leukocytosis
Rationale:
Chronic Lymphocytic leukemia (CLL) is characterized byincreased production of leukocytes and lymphocytes resulting inleukocytosis, and proliferation
of these cells within the bone marrow,spleen and liver.
44.
Answer:
(A) Explain the risks of not having the surgery
Rationale:

The best initial response is to explain the risks of not havingthe surgery. If the client understands the risks but still refuses the
nurseshould notify the physician and the nurse supervisor and then record theclients refusal in the nurses notes.
45.
Answer:
(D) The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem)
Rationale
: The client with atrial fibrillation has the greatest potential to become unstable and is on L.V. medication that requires close
monitoring.After assessing this client, the nurse should assess the client with thrombophlebitis who is receiving a
heparin infusion, and then the 58-year-old client admitted 2 days ago with heart failure (h is s igns and sym ptoms
are reso lving an d don t require immediate attention ). The lowest priority is the 89-year-old with end-stage right-sided heart
failure,who requires time-consuming supportive measures.
46.
Answer:
(C) Cocaine
Rationale:
Because of the clients age and negative medical history, then u r s e s h o u l d q u e s t i o n h e r a b o u t c o c a i n e u s e . C o c a i n e
i n c r e a s e s myocardial oxygen consumption and can cause coronary artery spasm,leading to tachycardia, ventricular fibrillation,
myocardial ischemia, andmyoc ardial in farc tio n. Barbiturate overdose m ay trigger respiratoryd ep ress ion and slo w
puls e. Op io ids c an c ause marked respirato ry depression, while benzodiazepines can cause drowsiness and confusion.
47.
Answer
:
(B)
Nonmobile mass with irregular edges
Rationale:
Breast cancer tumors are fixed, hard, and poorly delineatedwith irregular edges. A mobile mass that is soft and easily delineated ismost
often a fluid-filled benign cyst. Axillary lymph nodes may or may notbe palpable on initial detection of a cancerous mass. Nipple
retraction not eversion may be a sign of cancer
48.
Answer
: (C) Radiation
Rationale:
T h e u s u a l t r e a t m e n t f o r v a g i n a l c a n c e r i s e x t e r n a l o r intravaginal radiation therapy. Less often,
s u r g e r y i s p e r f o r m e d . Chemotherapy typically is prescribed only if vaginal cancer is diagnosed inan early stage, which is rare.
Immunotherapy isn't used to treat vaginalcancer.
49.
Answer:
(B) Carcinoma in situ, no abnormal regional lymph nodes, andno evidence of distant metastasis

Rationale:
TIS, N0, M0 denotes carcinoma in situ, no abnormal regionallymph nodes, and no evidence of distant metastasis. No evidence
of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis is classified as T0, N0, M0. If
the tumor and regionallymph nodes can't be assessed and no evidence of metastasis exists, thelesion is classified as TX, NX, M0. A
progressive increase in tumor size,no demonstrable metastasis of the regional lymph nodes, and ascendingdegrees of distant metastasis
is classified as T1, T2, T3, or T4; N0; andM1, M2, or M3.
50.
Answer:
(D) "Keep the stoma moist."
Rationale:
The nurse should instruct the client to keep the stoma moist,such as by applying a thin layer of petroleum jelly around the
edges,because a dry stoma may become irritated. The nurse should recommendplacing a stoma bib over the stoma to filter and warm air before
it enterst h e s t o m a . T h e c l i e n t s h o u l d b e g i n p e r f o r m i n g s t o m a c a r e w i t h o u t a s s i s t a n c e a s s o o n a s p o s s i b l e
t o g a i n i n d e p e n d e n c e i n s e l f - c a r e activities.
51.
Answer:
(B) Lung cancer
Rationale:
Lung cancer is the most deadly type of cancer in both womenand men. Breast cancer ranks second in women, followed (in
descendingorder) by colon and rectal cancer, pancreatic cancer, ovarian cancer, uterine cancer, lymphoma, leukemia, liver
cancer, brain cancer, stomachcancer, and multiple myeloma.
52.
Answer:
(A) miosis, partial eyelid ptosis, and anhidrosis on the affectedside of the face.
Rationale:
Horner's syndrome, which occurs when a lung tumor invadesthe ribs and affects the sympathetic nerve ganglia, is characterized
bymiosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. Chest pain, dyspnea, cough, weight loss, and fever
are associatedwith pleural tumors. Arm and shoulder pain and atrophy of the arm and hand m uscles o n the affected s id e
s uggest Panco ast' s tumo r, a lun g tumor involving the first thoracic and eighth cervical nerves within the brachial plexus.
Hoarseness in a client with lung cancer suggests that the
tumor has extended to the recurrent laryngeal nerve; dysphagia suggeststhat the lung tumor is compressing the esophagus.
53.
Answer:
(A) prostate-specific antigen, which is used to screen for prostatecancer.
Rationale:
P SA s ta n d s fo r p ro st a te - sp ec if ic an t i ge n , wh ic h i s us ed t o screen for prostate cancer. The other answers are incorrect.
54.
Answer:

(D) "Remain supine for the time specified by the physician."

Rationale:
The nurse should instruct the client to remain supine for thetime specified by the physician. Local anesthetics used in a
subarachnoidblock don't alter the gag reflex. No interactions between local anestheticsand food occur. Local anestheticsdon't cause hematuria.
55.
Answer:
(C) Sigmoidoscopy
Rationale:
U s e d t o v i s u a l i z e t h e l o w e r G I t r a c t , s i g m o i d o s c o p y a n d p ro c t o s c o p y a id i n th e d e te c t io n o f t wo t h i rd s o f a l l c o lo r ec ta l c a n c e rs . S t o o l H e m a t e s t d e t e c t s b l o o d , w h i c h i s a s i g n o f c o l o r e c t a l
c a n c e r ; however, the test doesn't confirm the diagnosis. CEA may be elevated incolorectal cancer but isn't considered a confirming
test. An abdominal CTscan is used to stage the presence ofcolorectal cancer.
56.
Answer
: (B) A fixed nodular mass with dimpling of the overlying skin
Rationale:
A fix ed n o d u l ar m a ss w i th d im p li n g o f th e o v e rl yi n g sk in i s common during late stages of breast cancer. Many women have
slightlya s y m m et ri c a l br ea s ts . B lo o d y n ip p le di sc ha r ge is a s ig n o f in t r ad uc ta l papilloma, a benign condition. Multiple firm, round,
freely movable massesthat change with the menstrual cycle indicate fibrocystic breasts, a benigncondition.
57.
Answer
: (A) Liver
Rationale:
The liver is one of the five most common cancer metastasissites. The others are the lymph nodes, lung, bone, and brain. The
colon,reproductive tract, and WBCs are occasional metastasis sites.
58.
Answer:
(D) The client wears awatch and wedding band.
Rationale:
During an MRI, the client should wear no metal objects, suchas jewelry, because the strong magnetic field can pull on them,
causingi n j ur y t o th e c l ie n t a n d (i f th ey fl y o f f) to o th er s. Th e c li en t m ust li e s ti l ld ur in g t h e MR I bu t c an t a lk to
t h o s e p e rfo rm in g th e te s t b y w ay o f th e microphone inside the scanner tunnel. The client should hear thumpingsounds, which
are caused by the sound waves thumping on the magneticfield.
59.
Answer
: (C) The recommended daily allowance of calcium may be foundin a wide variety of foods.
Rationale:

Premenopausal women require 1,000 mg of calcium per day.Postmenopausal women require 1,500 mg per day. It's often, though
notalways, possible to get the recommended daily requirement in the foodsw e e a t . S u p p l e m e n t s a r e
a v a i l a b l e b u t n o t a l w a y s n e c e s s a r y . Osteoporosis doesn't show up on ordinary X-rays until 30% of the
boneloss has occurred. Bone densitometry can detect bone loss of 3% or less.This test is sometimes recommended routinely for women
over 35 whoare atrisk. Strenuous exercise won't cause fractures.
60.
Answer:
(C) Jointflexion of less than 50%
Rationale:
A r th ro s c o p y is c o n tr a in di c a t ed in c l ie n t s w i th jo i n t fl ex io n o f less than 50% because of technical problems in inserting
the instrumentin to t he jo i n t to se e it c l ea r ly . Ot he r c o n tr a i n d ic at i o n s f o r t hi s p ro c ed ur e include skin and wound
infections. Joint pain may be an indication, not acontraindication, for arthroscopy. Joint deformity and joint stiffness
aren'tcontraindications for this procedure.
61.
Answer:
(D) Gouty arthritis
Rationale:
Gouty arthritis, a metabolic disease, is characterized by uratedeposits and pain in the joints, especially those in the feet and legs.
Uratedeposits don't occur in septic or traumatic arthritis. Septic arthritis resultsfrom bacterial invasion of a joint and leads to
inflammation of the synoviallining. Traumatic arthritis results from blunt trauma to a joint or ligament.I n t e r m i t t e n t a r t h r i t i s
i s a r a r e , b e n i g n c o n d i t i o n m a r k e d b y r e g u l a r , recurrent joint effusions, especially in the knees.
62.
Answer:
(B)
30 ml/hou
Rationale:
An infusion prepared with 25,000 units of heparin in 500 ml of sa l in e so l u ti o n y ie ld s 5 0 un it s o f h ep a ri n p e r m i ll i li t er o f
s o lu t io n . Th e equation is set up as 50 units times X (the unknown quantity) equals 1,500units/hour, X equals 30 ml/hour.
63.
Answer:
(B) Loss of muscle contraction decreasing venous return
Rationale
: In clients with hemiplegia or hemiparesis loss of musclecontraction decreases venous
r e t u r n a n d m a y c a u s e s w e l l i n g o f t h e affected extremity. Contractures, or bony calcifications may occur with astroke,
but dont appear with swelling. DVT may develop in clients with ast ro ke bu t i s m o re l i ke l y to o c c ur i n th e lo we r
ex tr em i ti es . A st ro ke is n t linked to protein loss.
64.
Answer:

(B) It appears on the distal interphalangeal joint

Rationale:
Heberdens nodes appear on the distal interphalageal joint onb o t h m e n a n d w o m e n . B o u c h a r d s n o d e a p p e a r s o n
t h e d o r s o l a t e r a l aspect of the proximal interphalangeal joint
65.
Answer:
(B) Osteoarthritis is a localized disease rheumatoid arthritis issystemic
Rationale:
Osteoarthritis is a localized disease, rheumatoid arthritis is systemic. Osteoarthritis isnt gender-specific, but rheumatoid arthritis
is.Clients have dislocations and subluxations in both disorders.
66.
Answer
: (C) The cane should be used on the unaffected side
Rationale:
A cane should be used on the unaffected side. A client with osteoarthritis should be encouraged to ambulate with a cane, walker,
or other assistive device as needed; their use takes weight and stress off joints.
67.
Answer:
(A) a. 9 U regular insulin and 21 U neutral protamine Hagedorn(NPH).
Rationale:
A 70 /30 in sulin preparatio n is 70% NPH and 30% regular insulin. Therefore, a correct substitution requires mixing 21 U of
NPH and9 U of regular insulin. The other choices are incorrect dosages for the prescribed insulin.
68.
Answer:
(C) colchicines
Rationale:
A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints.
Thephysician prescribes colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin is used to reduce joint
inflammationand pain in clients with osteoarthritis and rheumatoid arthritis, it isn'tindicated for gout because it has no
effect on urate crystal formation.Furosemide, a diuretic, doesn't relieve gout. Calcium gluconate is used toreverse a negative
calcium balance and relieve muscle cramps, not to treat gout.
69.
Answer
: (A) Adrenal cortex
Rationale:
Excessive secretion of aldosterone in the adrenal cortex is responsible for the client's hypertension. This hormone acts on the
renaltubule, where it prom otes reabso rptio n of sodium an d exc retion of potassium and hydrogen ions. The pancreas

mainly secretes hormonesi n v o l v e d i n f u e l m e t a b o l i s m . T h e a d r e n a l m e d u l l a s e c r e t e s t h e catecholamines

epinephrine and norepinephrine. The parathyroidssecrete parathyroid hormone.
70.
Answer
: (C) They debride the wound and promote healing by secondaryintention
Rationale:
Fo r th is clien t, wet-to-dry dressin gs are most ap prop riatebec ause they c lean th e foo t ulcer by d ebriding exudate
and necrotic tissue, thus promoting healing by secondary intention. Moist, transparentdres sings co ntain exud ate an d pro vide
a moist wound enviro nment.Hydrocolloid dressin gs p rev en t the entran ce of mic roo rganism s and
minimize wound discomfort. Dry sterile dressings protect the wound frommechanical trauma and promote healing.
71.
Answer:
(A) Hyperkalemia
Rationale:
I n a d r en a l in s u ff ic i en c y, th e c l ie n t ha s hyp er k al em i a d ue to reduced aldosterone secretion. BUN increases as the
glomerular filtrationr a t e i s r e d u c e d . H y p o n a t r e m i a i s c a u s e d b y r e d u c e d
a l d o s t e r o n e secretion. Reduced cortisol secretion leads to impaired glyconeogenesisa n d a r e d u c t i o n o f
g l y c o g e n i n t h e l i v e r a n d m u s c l e , c a u s i n g hypoglycemia.
72.
Answer:
(C) Restricting fluids
Rationale:
T o r e d u c e w a t e r r e t e n t i o n i n a c l i e n t w i t h t h e S I A D H , t h e nurse should restrict fluids. Administering fluids by any route
would further increase the client's already heightened fluid load.
73.
Answer:
(D) glycosylated hemoglobin level.
Rationale:
Because some of the glucose in the bloodstream attaches tosome of the hemoglobin and stays attached during the 120-day life spano f
r ed b lo o d c el l s, gl yc o sy l a te d hem o g lo bi n le v e ls p ro v i de i n f o rm a ti o n about blood glucose levels during the previous 3
months. Fasting bloodg lu c o s e an d ur in e g luc o se l ev el s o n l y g iv e in fo r m a t io n ab o u t g lu c o s e levels at the point in time
when they were obtained. Serum fructosaminelevels provide information about blood glucose control over the past 2 to 3weeks.
74.
Answer:
(C) 4:00 pm
Rationale:
NPH is an intermediate-acting insulin that peaks 8 to 12 hoursaf t er ad m i n i st r a t io n . B ec au se th e n u rs e ad m i n i s t er ed NP H in s u li n a t
7 a.m., the clientis atgreatest risk for hypoglycemia from 3 p.m. to 7 p.m.

75.
Answer
: (A) Glucocorticoids and androgens
Rationale:
T h e a d r e n a l g l a n d s h a v e t w o d i v i s i o n s , t h e c o r t e x a n d medulla. The cortex produces three types of
hormones: glucocorticoids,mineralocorticoids, and androgens. The medulla produces catecholamines epinephrine and norepinephrine.
76.
Answer:
(A) Hypocalcemia
Rationale:
H yp o c a l c em i a m ay fo l lo w t hy ro id s ur ge ry if t he p ar a th y ro id glands were removed accidentally. Signs and symptoms of
hypocalcemiam a y be del a ye d fo r up to 7 da ys a f te r s ur ge ry . Th yr o i d sur ge ry d o e s n ' td i re c t ly c a us e s er um s o d i um ,
p o ta s s iu m , o r m a gn es iu m ab n o rm a li t ie s . Hyponatremia may occur if the client inadvertently received too much fluid;however, this can happen to any
surgicalclientreceiving I.V. fluid therapy,n o t j u s t o n e r e c o v e r i n g f r o m t h y r o i d s u r g e r y .
H y p e r k a l e m i a a n d
hypermagnesemia usually are associated with reduced renal excretion of potassium and magnesium, not thyroid surgery.
77.
Answer
: (D) Carcinoembryonic antigen level
Rationale:
In clients who smoke, the level of carcinoembryonic antigen isel ev a te d. Th er ef o r e, it c a n ' t be u se d a s a ge n e ra l in d ic a to r o f
c an c er .H o w ev er , i t i s hel p f ul in m o n it o r in g c an c er t re a t m e n t bec au se th e le v e l u s u a l l y f a l l s t o n o r m a l
within 1 month if treatment is successful. Anelevated acid phosphatase level may indicate
p r o s t a t e c a n c e r . A n e le v a t ed a l k a l in e p ho sp ha t a se l ev el m a y re fl ec t bo n e m e t as t a s i s . A n elevated serum calcitonin level
usually signals thyroid cancer.
78.
Answer
: (B) Dyspnea, tachycardia, and pallor
Rationale:
Signs of iron-deficiency anemia include dyspnea, tachycardia,and pallor as well as fatigue, listlessness, irritability, and headache. Nightsweats, weight
loss, and diarrhea may signal acquired immunodeficiencys y n d r o m e ( A I D S ) . N a u s e a , v o m i t i n g , a n d a n o r e x i a
m a y b e s i g n s o f hep a ti t is B. I tc hi n g , r as h, an d j au n d ic e m ay re su lt fr o m an al l er g ic o r hemolytic reaction.
79.
Answer:
(D) "I'll need to have a C-section if I become pregnant and havea baby."
Rationale:
Thehuman immunodeficiency virus (HIV)is transmitted fromm o t h e r t o c h i l d v i a t h e t r a n s p l a c e n t a l r o u t e , b u t a
C e s a r e a n s e c t i o n delivery isn't necessary when the mother is HIV-positive. The use of birthcontrol will prevent the conception of

a child who might have HIV. It's truet h a t a m o t h e r w h o ' s H I V p o s i t i v e c a n g i v e b i r t h t o a b a b y w h o ' s

H I V negative.
80.
Answer:
(C) "Avoid sharing such articles as toothbrushes and razors."
Rationale:
T h e h u m a n i m m u n o d e f i c i e n c y v i r u s ( H I V ) , w h i c h c a u s e s AIDS, i s m o s t c o n c e n t r a t e d i n t h e
b l o o d . F o r t h i s r e a s o n , t h e c l i e n t shouldn't share personal articles that may be blood-contaminated, such astoothbrushes and razors, with
other family members. HIV isn't transmittedby bathing or by eating from plates, utensils, or serving dishes used by aperson with AIDS.
81.
Answer:
(B) Pallor, tachycardia, and a sore tongue
Rationale:
P a l lo r, t ac h yc ar di a , an d a so re t o n gu e ar e a l l c h ar a c t e ri st i c f i n d i n g s i n p e r n i c i o u s a n e m i a . O t h e r
c l i n i c a l m a n i f e s t a t i o n s i n c l u d e anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure;palpitations;
angina; weakness; fatigue; and paresthesia of the hands andfeet. Bradycardia, reduced pulse pressure, weight gain, and double
visionaren'tcharacteristic findings in perniciousanemia
82.
Answer:
(B) Administer epinephrin e, as prescribed, and prep are to intubate the client if necessary.
Rationale:
T o r e v e r s e a n a p h y l a c t i c s h o c k , t h e n u r s e f i r s t s h o u l d administer ep in eph rine, a po tent bronc hod ilator
as presc ribed. The physician is likely to order additional medications, such as antihistaminesand corticosteroids; if these
medications don't relieve the respiratorycompromise associated with anaphylaxis, the nurse should prepare tointubate the
client. No antidote for penicillin exists; however, the nurseshould continue to monitor the client's vital signs. A client who
remainshypotensive may need fluid resuscitation and fluid intake and output monitoring; however, administering epinephrine is the
first priority.
83.
Answer:
(D) bilateral hearing loss.
Rationale:
Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of 30 to 40 decibels. Usually, this
adverseeffect resolves within 2 weeks after the therapy is discontinued. Aspirin doesn't lead to weight gain or fine motor
tremors. Large or toxic salicylatedoses may cause respiratory alkalosis, not respiratory acidosis.
84.
Answer:
(D) Lymphocyte
Rationale:

The lymphocyte provides adaptive immunity recognition of a foreign antigen and formation of memory cells against the
antigen.Adaptiv e imm un ity is mediated by B an d T lymp hocytes and c an be acquired actively or passively. The neutrophil
is crucial to phagocytosis.The baso phil p lays an important ro le in the release of in flamm ato rymediato rs . The
mo nocyte functio ns in phagoc ytosis and mo nokin e production.
85.
Answer:
(A) moisture replacement.
Rationale:
Sjogren's syndromeis an auto im mune diso rder leadin g to progressive loss of lubrication of the skin, GI tract, ears, nose, and
vagina.Moisture replacement is the mainstay of therapy. Though malnutrition andelectrolyte imbalance may occur as a result of Sjogren's
syndrome's effecton the GI tract, it isn't the predominant problem. Arrhythmias aren't a problem associated with Sjogren's syndrome.
86.
Answer
: (C) stool for
Clostridium difficile
test.
Rationale:
Immunosuppressed clients for example, clients receivingchemotherapy, are at risk for infection with
C. difficile,
which causes"h orse barn " sm ellin g diarrhea. Succ essful treatment begins with an a c c u r a t e d i a g n o s i s , w h i c h
i n c l u d e s a s t o o l t e s t . T h e E L I S A t e s t i s diagnostic for human immunodeficiency virus (HIV) and isn't indicated inthis case.
An electrolyte panel and hemogram may be useful in the overallevaluation of a client but aren't diagnostic for specific causes of diarrhea.A flat
plate of the abdomen may provide useful information about bowelfunction but isn't indicated in the case of "horse barn" smelling diarrhea
87.
Answer:
(D) Western blot test with ELISA.
Rationale:
HIV infection is detected by analyzing blood for antibodies toHIV, which form approximately 2 to 12 weeks after exposure to HIV
anddenote infection. The Western blot test electrophoresis of antibody proteins is more than 98% accurate in detecting HIV
antibodies whenused in conjunction with the ELISA. It isn't specific when used alone. E-rosette immunofluorescence is used to detect viruses
in general; it doesn'tc o n f i r m H I V i n f e c t i o n . Q u a n t i f i c a t i o n o f T - l y m p h o c y t e s i s a u s e f u l monitoring test but isn't
diagnostic for HIV. The ELISA test detects HIVantibody particles but may yield inaccurate results; a positive ELISA resultmust be confirmed
by the Western blot test.
88.
Answer:
(C) Abnormally low hematocrit (HCT) and hemoglobin (Hb)levels
Rationale:

Low preoperative HCT and Hb levels indicate the client

mayrequire a blood transfusion before surgery. If the HCT and Hb levelsdecrease during surgery because of blood loss, the
potential need for atransfusion increases. Possible renal failure is indicated by elevated
BUNo r c r e a t i n i n e l e v e l s . U r i n e c o n s t i t u e n t s a r e n ' t f o u n d i n t h e b l o o d . Coagulation is determined by the presence
of appropriate clotting factors,not electrolytes.
89.
Answer:
(A) Platelet count, prothrombin time, and partial thromboplastintime
Rationale:
The diagnosis of DIC is based on the results of
laboratorys t u d i e s o f p r o t h r o m b i n t i m e , p l a t e l e t c o u n t , t h r o m b i n t i m e , p a r t i a l thromboplastin time, and fibrinogen level
as well as client history and other assessment factors. Blood glucose levels, WBC count, calcium levels, andpotassium levels aren't used to confirm a
diagnosis of DIC.
90.
Answer:
(D) Strawberries
Rationale:
Common food allergens include berries, peanuts, Brazil nuts,cashews, shellfish, and eggs. Bread, carrots, and oranges rarely
causeallergic reactions.
91.
Answer:
(B) A client with cast on the right leg who states, I have a funnyfeeling in my right leg.
Rationale:
It may indicate neurovascular compromise, requires immediateassessment.
92.
Answer
: (D) A 62-year-old who had an abdominal-perineal resection threedays ago; client complaints of chills.
Rationale
: The client is at risk for peritonitis; should be assessed for further symptoms and infection.
93.
Answer
: (C) The client spontaneously flexes his wrist when the blood pressure is obtained.
Rationale:
Carpal spasms indicate hypocalcemia.
94.
Answer:
(D) Use comfort measures and pillows to position the client.
Rationale:

Using comfort measures and pillows to position the client is anon-pharmacological methods of pain relief.
95.
Answer:
(B) Warm the dialysate solution.
Rationale:
Cold dialysate increases discomfort. The solution should
bew a r m e d t o b o d y t e m p e r a t u r e i n w a r m e r o r h e a t i n g p a d ; d o n t u s e microwave oven.
96.
Answer:
(C) The client holds the cane with his left hand, moves the caneforward followed by the right leg, and then moves the left leg.
Rationale:
The cane acts as a support and aids in weight bearing for theweaker right leg.
97.
Answer:
(A) Ask the womans family to provide personal items such asphotos or mementos.
Rationale:
Photos and mementos provide visual stimulation to reduce sensory deprivation.
98.
Answer:
(B) The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward.
Rationale:
A walker needs to be picked up, placed down on all legs.
99.
Answer:
(C) Isolation from their families and familiar surroundings.
Rationale:
Gradual loss of sight, hearing, and taste interferes with normalfunctioning.
100.
Answer:
(A) Encourage the client to perform pursed lip breathing.
Rationale:
Purse lip breathing prevents the collapse of lung unit and helpsclient control rate and depth of breathing
TEST IVAnswers and Rationale Care of Clients with Physiologic andPsychosocial Alterations
1.
Answer:
(C) Hypertension
Rationale:
Hypertension, along with fever, and tenderness over thegrafted kidney, reflects acute rejection.

2.
Answer:
(A) Pain
Rationale
: Sharp, severe pain (renal colic) radiating toward the genitaliaand thigh is caused by uretheral distention and smooth muscle
spasm;relief form pain is the priority.
3.
Answer:
(D) Decrease the size and vascularity of the thyroid gland.
Rationale:
Lugols solution provides iodine, which aids in decreasing thevascularity of the thyroid gland, which limits the risk of hemorrhage
whensurgery is performed.
4.
Answer:
(A) Liver Disease
Rationale:
T h e c l i e n t w i t h l i v e r d i s e a s e h a s a d e c r e a s e d a b i l i t y t o metabolize carbohydrates because of a decreased ability to form
glycogen(glycogenesis) and to form glucose from glycogen.
5.
Answer:
(C) Leukopenia
Rationale
: Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of myelosuppression.
6.
Answer:
(C) Avoid foods that in the past caused flatus.
Rationale
: Foods that bothered a person preoperatively will continue to doso after a colostomy.
7.
Answer:
(B) Keep the irrigating container less than 18 inches above thestoma.
Rationale:
This height permits the solution to flow slowly with little forceso that excessive peristalsis is not immediately precipitated.
8.
Answer:
(A) Administer Kayexalate
Rationale:
Kayexalate,a potassium exchange resin, permits sodium to beexchanged for potassium in the intestine, reducing the serum
potassiumlevel.

9.
Answer:
(B) 28 gtt/min
Rationale:
This is the correct flow rate; multiply the amount to be infused(2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes
(12 hours x 60 minutes)
10.
Answer:
(D) Upper trunk
Rationale:
The percentage designated for each burned part of the bodyusing the rule of nines: Head and neck 9%; Right upper extremity 9%; Leftupper
extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left lower extremity 18%; Perineum 1%.
11.
Answer:
(C)
Bleeding from ears
Rationale:
The nurse needs to perform a thorough assessment that couldindicate alterations in cerebral function, increased intracranial pressures,fractures and
bleeding. Bleeding from the ears occurs only with basal skullfractures that can easily contribute to increased intracranial pressure andbrain herniation.
12.
Answer:
(D) may engage in contact sports
Rationale:
The client should be advised by the nurse to avoid contactsports. This will prevent trauma to the area of the pacemaker generator.
13.
Answer
: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulusfor breathing.
Rationale:
COPD causes a chronic CO2 retention that renders themedulla insensitive to the CO2 stimulation for breathing. The hypoxic stateof the client then
becomes the stimulus for breathing. Giving the clientoxygen in low concentrations will maintain the clients hypoxic drive.
14.
Answer:
(B) Facilitate ventilation of the left lung.
Rationale:
Since only a partial pneumonectomy is done, there is a needto promote expansion of this remaining Left lung by positioning the clienton the opposite
unoperated side.
15.

Answer:
(A) Food and fluids will be withheld for at least 2 hours.
Rationale:
Prior to bronchoscopy, the doctors sprays the back of thethroat with anesthetic to minimize the gag reflex and thus facilitate theinsertion of the
bronchoscope. Giving the client food and drink after theprocedure without checking on the return of the gag reflex can cause theclient to aspirate. The
gag reflex usually returns after two hours.
16.
Answer:
(C) hyperkalemia.
Rationale:
Hyperkalemia is a common complication of acute renal failure.It's life-threatening if immediate action isn't taken to reverse it. Theadministration of
glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassiuminto the cells and
temporarily reducing serum potassium levels.Hypernatremia, hypokalemia, and hypercalcemia don't usually occur withacute renal failure and aren't
treated with glucose, insulin, or sodiumbicarbonate.
17.
Answer:
(A) This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.
Rationale:
Women with condylomata acuminata are at risk for cancer
of th e cerv ix an d vulv a. Y early Pap sm ears are very impo rtan t fo r early d e t e c t i o n . B e c a u s e c o n d y l o m a t a a c u m i
n a t a i s a v i r u s , t h e r e i s n o permanent cure. Because condylomata acuminata can occur on the vulva,a condom won't protect sexual
partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx.
18.
Answer:
(A) The left kidney usually is slightly higher than the right one.
Rationale:
The left kidney usually is slightly higher than the right one.
Anad ren al glan d lies atop each kidney. The av erage kidn ey measures approximately 11 cm (4-3/8") long, 5 to 5.8 cm (2" to
2") wide, and 2.5cm (1") thick. The kidneys are located retroperitoneally, in the posterior aspect of the abdomen, on either side of
the vertebral column. They liebetween the 12th thoracic and 3rd lumbar vertebrae.
19.
Answer:
(C) Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine6.5 mg/dl.
Rationale:
The normal BUN level ranges 8 to 23 mg/dl; the normal serumcreatinine level ranges from 0.7 to 1.5 mg/dl. The test results in option Care
abnormally elevated, reflecting CRF and the kidneys' decreased
abilityt o r e m o v e n o n p r o t e i n n i t r o g e n w a s t e f r o m t h e b l o o d . C R F c a u s e s decreased pH and increased hydrogen ions
not vice versa. CRF alsoincreases serum levels of potassium, magnesium, and phosphorous, anddecreases serum levels of calcium. A

uric acid analysis of 3.5 mg/dl fallswithin the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls with the normal
range of 60% to 75%.
20.
Answer:
( D ) A l t e r a t i o n i n t h e s i z e , s h a p e , a n d o r g a n i z a t i o n o f differentiated cells
Rationale:
Dysplasia
refers to an alteration in the size, shape, andorganization of differentiated cells. The presence of comp
l e t e l y undifferentiated tumor cells that don't resemble cells of the tissues of their origin is called
anaplasia.
An increase in the number of normal cells in an o r m a l a r r a n g e m e n t i n a t i s s u e o r a n o r g a n i s c a l l e d
hyperplasia.
Replacement of one type of fully differentiated cell by another in tissueswhere the second type normally isn't found is called
metaplasia.
21.
Answer:
(D) Kaposi's sarcoma
Rationale:
Kaposi's sarcoma is the most common cancer associated withAIDS. Squamous cell carcinoma, multiple myeloma, and leukemia mayoccur in
anyone and aren't associated specifically with AIDS.
22.
Answer:
(C) To prevent cerebrospinal fluid (CSF) leakage
Rationale:
The client receiving a subarachnoid block requires specialpositioning to prevent CSF leakage and headache and to ensure
proper anesthetic distribution. Proper positioning doesn't help prevent confusion,seizures, or cardiac arrhythmias.
23.
Answer:
(A) Auscultate bowel sounds.
Rationale:
If abdominal distention is accompanied by nausea, the nursemust first auscultate bowel sounds. If bowel sounds are absent,
the nurseshould suspect gastric or small intestine dilation and these findings mustbe reported to the physician. Palpation should
be avoided postoperativelywith abdominal distention. If peristalsis is absent, changing positions andinserting a rectal tube won't relieve the
client's discomfort.
24.
Answer:
(B) Lying on the left side with knees bent

Rationale:
For a colonoscopy, the nurse initially should position the clienton the left side with knees bent. Placing the client on the right side
withlegs straight, prone with the torso elevated, or bent over with handstouching the floor wouldn't allow proper visualization
of the large intestine.
25.
Answer:
(A) Blood supply to the stoma has been interrupted
Rationale:
An ileostomy stoma forms as the ileum is brought through theabdominal wall to the surface skin, creating an artificial opening for
wasteelimination. The stoma should appear cherry red, indicating adequatearterial perfusion. A dusky stoma suggests decreased
perfusion, whichmay result from interruption of the stoma's blood supply and may lead totissue damage or necrosis. A dusky stoma isn't a
normal finding. Adjustingthe ostomy bag wouldn't affect stoma color, which depends on bloodsupply to the area. An intestinal
obstruction also wouldn't change stomacolor.
26.
Answer:
(A) Applying knee splints
Rationale:
Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't
preventcontractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended
time is inappropriatebecause it can cause contractures. Performing shoulder range-of-motionexercises can prevent contractures in the
shoulders, but not in the legs.
27.
Answer:
(B) Urine output of 20 ml/hour.
Rationale:
A urine output of less than 40 ml/hour in a client with burnsindicates a fluid volume deficit. This client's PaO
2
value falls within thenormal range (80 to 100 mm Hg). White pulmonary secretions also
arenormal. The client's rectal temperature isn't significantly elevated andprobably results from the fluid volume deficit.
28.
Answer:
(A) Turn him frequently.
Rationale:
The most important intervention to prevent pressure ulcers
isfrequent position changes, which relieve pressure on the skin andunderlying tissues. If pressure isn't relieved, capillaries
become occluded,reducing circulation and oxygenation of the tissues and resulting in
celldeath and ulcer formation. During passive ROM exercises, the nursemoves each joint through its range of movement,
which improves jointmobility and circulation to the affected area but doesn't prevent

pressureulcers. Adequate hydration is necessary to maintain healthy skin andensure tissue repair. A footboard prevents plantar
flexion and footdrop bymaintaining the foot in a dorsiflexed position.
29.
Answer:
( C ) I n l o n g , e v e n , o u t w a r d , a n d d o w n w a r d s t r o k e s i n t h e direction of hair growth
Rationale:
When applying a topical agent, the nurse should begin at
themidline and use long, even, outward, and downward strokes in thedirection of hair growth. This application pattern
reduces the risk of follicleirritation and skin inflammation.
30.
Answer
:
(A) Beta -adrenergic blockers
Rationale:
Beta-adrenergic blockers work by blocking beta receptors
int h e m y o c a r d i u m , r e d u c i n g t h e r e s p o n s e t o c a t e c h o l a m i n e s a n d sympathetic nerve stimulation. They protect
the myocardium, helping toreduce the risk of another infraction by decreasing myocardial oxygen demand. Calcium channel
blockers reduce the workload of the heart bydecreasing the heart rate. Narcotics reduce myocardial oxygen demand,promote
vasodilation, and decrease anxiety. Nitrates reduce myocardialoxygen consumption bt decreasing left ventricular end diastolic
pressure(preload) and systemic vascular resistance (afterload).
31.
Answer
:
(C)
Raised 30 degrees
Rationale:
Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point
of highest pulsation with the head of the bed inclined between 15 to 30 degrees. Increased pressure cant be seen when the
client is supine or when the head of the bed is raised 10 degrees because the point that marks the pressure level is above the jaw
(therefore, not visible). In highFowlers position, the veins would be barely discernible above the clavicle.
32.
Answer:
(D)
Inotropic agents
Rationale:

Inotropic agents are administered to increase the force of

thehearts contractions, thereby increasing ventricular contractility andultimately increasing cardiac output. Beta-adrenergic
blockers and calciumchannel blockers decrease the heart rate and ultimately decreased the workload of the heart. Diuretics are
administered to decrease the overallvascular volume, also decreasing the workload of the heart.
33.
Answer:
(B)
Less than 30% of calories form fat
Rationale
:
A client with low serum HDL and high serum LDL levels shouldget less than 30% of daily calories from fat. The other modifications
areappropriate for this client.
34.
Answer
:
( C ) T h e e m e r g e n c y d e p a r t m e n t n u r s e c a l l s u p t h e l a t e s t electrocardiogram results to check the clients progress
Rationale:
T h e e m e r g e n c y d e p a r t m e n t n u r s e i s n o l o n g e r d i r e c t l y involved with the clients care and thus has no legal right
to informationabout his present condition. Anyone directly involved in his care (such asthe telemetry nurse and the on-call physician)
has the right to informationabout his condition. Because the client requested that the nurse updatehis wife on his condition, doing so doesnt
breach confidentiality.
35.
Answer
:
(B)
Check endotracheal tube placement.
Rationale:
ET tube placement should be confirmed as soon as the
clientarriv es in the em ergenc y dep artment. On ce the airways is secured, oxygenation and ventilation should be confirmed using
an end-tidal carbondioxide monitor and pulse oximetry. Next, the nurse should make
sureL . V . a c c e s s i s e s t a b l i s h e d . I f t h e c l i e n t e x p e r i e n c e s s y m p t o m a t i c bradycardia, atropine is administered as
ordered 0.5 to 1 mg every 3 to 5minutes to a total of 3 mg. Then the nurse should try to find the cause of the clients arrest by obtaining
an ABG sample. Amiodarone is indicatedfor ventricular tachycardia, ventricular fibrillation and atrial flutter not symptomatic
bradycardia.

36.
Answer
:
(C) 95 mm Hg
Rationale:
Use the following formula to calculate MAPMAP = systolic + 2 (diastolic)3MAP=126 mm Hg + 2 (80 mm Hg)3MAP=286 mm HG3MAP=95 mm Hg
37.
Answer
:
(C) Electrocardiogram, complete blood count, testing for occultblood, comprehensive serum metabolic panel.
Rationale:
An electrocardiogram evaluates the complaints of chest pain,laboratory tests determines anemia, and the stool test for occult
blooddetermines blood in the stool. Cardiac monitoring, oxygen, and creatinekinase and lactate dehydrogenase levels are
appropriate for a cardiacprimary problem. A basic metabolic panel and alkaline phosphatase andaspartate aminotransferase levels assess
liver function. Prothrombin time,partial throm boplastin tim e, fibrin ogen an d fibrin sp lit pro duc ts are
measured to verify bleeding dyscrasias, An electroencephalogram evaluates brain electrical activity.
38.
Answer
:
(D) Heparin-associated thrombosis and thrombocytopenia (HATT)
Rationale:
HATT may occur after CABG surgery due to heparin use during surgery. Although DIC
and ITP cause platelet aggregation andbleeding, neither is common in a client after revascularization surgery. Pancytopenia is
a reduction in all blood cells.
39.
Answer
:
(B) Corticosteroids
Rationale
:
Corticosteroid therapy can decrease antibody production andphagocytosis of the antibody-coated platelets, retaining more
functioningplatelets. Methotrexate can cause thrombocytopenia. Vitamin K is used totreat an excessive anticoagulate state from
warfarin overload, and ASAdecreases platelet aggregation.
40.
Answer
:
(D) Xenogeneic
Rationale:

An xenogeneic transplant is between is between human

andanother species. A syngeneic transplant is between identical twins,allogeneic transplant is between two human
s, and autologous is atransplant from the same individual.
41.
Answer
:
(B)
Rationale:
Tissue thromboplastin is released when damaged tissuecomes in contact with clotting factors. Calcium is released to
assist theconversion of factors X to Xa. Conversion of factors XII to XIIa and VIII toVIIIa are part of the
intrinsic
pathway.
42.
Answer
:
(C) Essential thrombocytopenia
Rationale:
Essential thrombocytopenia is linked to immunologic disorders,such as SLE and human immunodeficiency vitus. The disorder known asvon
Willebrands disease is a type of hemophilia and isnt linked to SLE.Moderate to severe anemia is associated with SLE, not
polycythermia.Dresslers syndrome is pericarditis that occurs after a myocardial infarctionand isnt linked to SLE.
43.
Answer
:
(B) Night sweat
Rationale:
In stage 1, symptoms include a single enlarged lymph
node(usually), unexplained fever, night sweats, malaise, and generalizedpruritis. Although splenomegaly may be present in
some clients,
nightsweats are generally more prevalent. Pericarditis isnt associated withHodgkins disease, nor is hypothermia. Moreove
r, splenomegaly andpericarditis arent symptoms. Persistent hypothermia is associated withHodgkins but isnt an early sign of the disease.
44.
Answer
:
(D) Breath sounds
Rationale:
Pneumonia, both viral and fungal, is a common cause of deathin clients with neutropenia, so frequent assessment of respiratory rate
andbreath sounds is required. Although assessing blood pressure, bowelsounds, and heart sounds is important, it wont help detect
pneumonia.

45.
Answer
:
(B) Muscle spasm
Rationale:
Back pain or paresthesia in the lower extremities may indicateimpending spinal cord compression from a spinal tumor. This should
berecognized and treated promptly as progression of the tumor may result inparaplegia. The other options, which reflect parts of the nervous
system,arent usually affected by MM.
46.
Answer
:
(C)10 years
Rationale:
Epidermiologic studies show the average time from initialcontact with HIV to the development of AIDS is 10 years.
47.
Answer
:
(A) Low platelet count
Rationale:
In DIC, platelets and clotting factors are consumed, resulting
inmicrothrombi and excessive bleeding. As clots form, fibrinogen levelsdecrease and the prothrombin time increases. Fi
brin degeneration products increase as fibrinolysis takes places.
48.
Answer
:
(D) Hodgkins disease
Rationale:
Hodgkins disease typically causes fever night sweats, weightloss, and lymph mode enlargement. Influenza doesnt last for
months.Clients with sickle cell anemia manifest signs and symptoms of
chronicanemia with pallor of the mucous membrane, fatigue, and decreasedtolerance for exercise; they dont show fever, night
sweats, weight loss or l y m p h n o d e e n l a r g e m e n t . L e u k e m i a d o e s n t c a u s e l y m p h n o d e enlargement.
49.
Answer
:
(C) A Rh-negative
Rationale:
Human blood can sometimes contain an inherited D antigen.Persons with the D antigen have Rh-positive blood type; those lacking theantigen
have Rh-negative blood. Its important that a person with Rh- negative blood receives Rh-negative blood. If Rhpositive blood isadministered to an Rh-negative person, the recipient develops anti-

Rhagglutinins, and sub sequent transfusions with Rh-positive blood maycause serious reactions with clumping and hemolysis of red
blood cells.
50.
Answer:
(B) I will call my doctor if Stacy has persistent vomiting and diarrhea.
Rationale:
Persistent (more than 24 hours) vomiting, anorexia, anddiarrhea are signs of toxicity and the patient should stop the
medication
and notify the health care provider. The other manifestations are expectedside effects of chemotherapy.
51.
Answer:
(D) This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be different in texture.
Rationale:
This is the appropriate response. The nurse should help themother how to cope with her own feelings regarding the childs disease soas
not to affect the child negatively. When the hair grows back, it is still of the same color and texture.
52.
Answer:
(B) Apply viscous Lidocaine to oral ulcers as needed.
Rationale:
Stomatitis can cause pain and this can be relieved by applyingtopical anesthetics such as lidocaine before mouth care. When the patientis already
comfortable, the nurse can proceed with providing the patientwith oral rinses of saline solution
mixed with equal part of water or hydrogen peroxide mixed water in 1:3 concentrations to promote oralhygiene. Every 2-4
hours.
53.
Answer
: (C) Immediately discontinue the infusion
Rationale:
Edema or swelling at the IV site is a sign that the needle hasbeen dislodged and the IV solution is leaking into the tissues causing
theedema. The patient feels pain as the nerves are irritated by pressure andthe IV solution. The first action of the nurse would be to
discontinue theinfusion right away to prevent further edema and other complication.
54.
Answer
:
(C) Chronic obstructive bronchitis
Rationale:
Clients with chronic obstructive bronchitis appear bloated; theyhave large barrel chest and peripheral edema, cyanotic nail beds, and attimes,
circumoral cyanosis. Clients with ARDS are acutely short of

breathand frequently need intubation for mechanical ventilation and largeamount of oxygen. Clients with asthma don
t exhibit characteristics of chronic disease, and clients with emphysema appear pink and cachectic.
55.
Answer
:
(D) Emphysema
Rationale:
Because of the large amount of energy it takes to breathe, clients with emphysema are usually cachectic. Theyre pink and
usuallybreathe through pursed lips, hence the term puffer. Clients with ARDSare usually acutely short of breath. Clients with
asthma dont have anyparticular characteristics, and clients with chronic obstructive bronchitisare bloated and cyanotic in appearance.
56.
Answer
:D
80 mm Hg
Rationale:
A client about to go into respiratory arrest will have inefficientventilation and will be retaining carbon dioxide. The value expected
wouldbe around 80 mm Hg. All other values are lower than expected.
57.
Answer
: (C) Respiratory acidosis
Rationale:
B e c a u s e P a c o 2 i s h i g h a t 8 0 m m H g a n d t h e m e t a b o l i c measure, HCO3- is normal, the client has respiratory acidosis.
The pH isless than 7.35, academic, which eliminates metabolic and respiratoryalkalosis as possibilities. If the HCO3- was
below 22 mEq/L the clientwould have metabolic acidosis.
58.
Answer
: (C) Respiratory failure
Rationale:
The client was reacting to the drug with respiratory signs of impending anaphylaxis, which could lead to eventually respiratory
failure.Although the signs are also related to an asthma attack or a
pulmonaryem bo lism , con sider the n ew drug first. Rheum ato id arthritis do es nt manifest these signs.
59.
Answer:
(D) Elevated serum aminotransferase
Rationale:
Hepatic cell death causes release of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST) and
lactatedehydrogenase (LDH) into the circulation. Liver cirrhosis is a chronic andirreversible disease of the liver characterized
by generalized inflammationand fibrosis of the liver tissues.

60.
Answer:
(A) Impaired clotting mechanism
Rationale:
Cirrhosis of the liver results in decreased Vitamin K absorptionand formation of clotting factors resulting in impaired clotting mechanism.
61.
Answer:
(B) Altered level of consciousness
Rationale:
Changes in behavior and level of consciousness are the firstsins of hepatic encephalopathy. Hepatic encephalopathy is caused by liver failure
and develops when the liver is unable to convert protein metabolicproduct ammonia to urea. This results in accumulation of ammonia
andother toxic in the blood that damages the cells.
62.
Answer:
(C) Ill lower the dosage as ordered so the drug causes only 2 to4 stools a day.
Rationale:
Lactulose is given to a patients with hepatic encephalopathy toreduce absorption of ammonia in the intestines by binding with ammoniaand
promoting more frequent bowel movements. If the patient experiencediarrhea, it indicates over dosage and the nurse must reduce the
amounto f m e d i c a t i o n g i v e n t o t h e p a t i e n t . T h e s t o o l w i l l b e m a s h y o r s o f t . Lactulose is also very sweet and may cause
cramping and bloating.
63.
Answer:
( B ) S e v e r e l o w e r b a c k p a i n , d e c r e a s e d b l o o d p r e s s u r e , decreased RBC count, increased WBC count.
Rationale:
Sev ere lo wer bac k p ain in dic ates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity.
Whenruptured occurs, the pain is constant because it cant be alleviated until
the aneurysm is repaired. Blood pressure decreases due to the loss of blood. After the aneurysm ruptures, the vasculature is
interrupted andblood volume is lost, so blood pressure wouldnt increase. For the samereason, the RBC count is decreased not
increased. The WBC countincreases as cell migrate to the site of injury.
64.
Answer:
(D) Apply gloves and assess the groin site
Rationale:
Observing standard precautions is the first priority whendealing with any blood fluid. Assessment of the groin site is
the secondpriority. This establishes where the blood is coming from and determineshow much blood has been lost. The goal in
this situation is to stop thebleeding. The nurse would call for help if it were warranted after the assessment of the
situation. After determining the extent of the bleeding,vital signs assessment is important. The nurse should never move
theclient, in case a clot has formed. Moving can disturb the clot and cause rebleeding.

65.
Answer:
(D) Percutaneous transluminal coronary angioplasty (PTCA)
Rationale:
PTCA can alleviate the blockage and restore blood flow
ando x y g e n a t i o n . A n e c h o c a r d i o g r a m i s a n o n i n v a s i v e d i a g n o s i s t e s t . Nitroglycerin is an oral sublingual medication.
Cardiac catheterization is adiagnostic tool not a treatment.
66.
Answer:
(B) Cardiogenic shock
Rationale:
Cardiogenic shock is shock related to ineffective pumping of the heart. Anaphylactic shock results from an allergic reaction. Distributiveshock
results from changes in the intravascular volume distribution and isusually associated with increased cardiac output. MI isnt a shock
state,though a severe MI can lead to shock.
67.
Answer: (
C) Kidneys excretion of sodium and water
Rationale:
The kidneys respond to rise in blood pressure by excreting sodium and excess water. This response ultimately affects sysmolic
bloodpressure by regulating blood volume. Sodium or water retention wouldonly further increase blood pressure. Sodium
and water travel together across the membrane in the kidneys; one cant travel without the other.
68.
Answer
:
(D) It inhibits reabsorption of sodium and water in the loop of Henle.
Rationale:
Furosemide is a loop diuretic that inhibits sodium and
water reabsorption in the loop Henle, thereby causing a decrease in bloodpressure. Vasodilators cause dilation of
peripheral blood vessels,
directlyr e l a x i n g v a s c u l a r s m o o t h m u s c l e a n d d e c r e a s i n g b l o o d p r e s s u r e . Adrenergic blockers decrease sympath
etic cardioacceleration anddecrease blood pressure. Angiotensin-converting enzyme inhibitors decrease blood pressure
due to their action on angiotensin.
69.
Answer
:
(C) Pancytopenia, elevated antinuclear antibody (ANA) titer
Rationale:

L a b o r a t o r y f i n d i n g s f o r c l i e n t s w i t h S L E u s u a l l y s h o w pancytopenia, elevated ANA titer, and decreased serum com

plementl e v e l s . C l i e n t s m a y h a v e e l e v a t e d B U N a n d c r e a t i n i n e l e v e l s f r o m nephritis, but the increase does
not
indicate SLE.
70.
Answer
: (C) Narcotics are avoided after a head injury because they mayhide a worsening condition.
Rationale:
Narcotics may mask changes in the level of consciousness that indicate increased ICP and shouldnt acetaminophen is strong
enoughignores the mothers question and therefore isnt appropriate. Aspirin is contraindicated in conditions that may have bleeding,
such as trauma, andfor children or young adults with viral illnesses due to the danger of Reyessyndrome. Stronger medications may
not necessarily lead to vomiting
butw i l l s e d a t e t h e c l i e n t , t h e r e b y m a s k i n g c h a n g e s i n h i s l e v e l o f consciousness.
71.
Answer
: (A)
Appropriate; lowering carbon dioxide (CO2) reducesintracranial pressure (ICP)
Rationale:
A n o r m a l P a c o 2 v a l u e i s 3 5 t o 4 5 m m H g C O 2 h a s vasodilating properties; therefore, lowering Paco2 through
hyperventilationw i l l l o w e r I C P c a u s e d b y d i l a t e d c e r e b r a l v e s s e l s . O x y g e n a t i o n i s evaluated through Pao2 and oxygen
saturation. Alveolar hypoventilationwould be reflected in an increased Paco2.
72.
Answer
: (B) A 33-year-old client with a recent diagnosis of Guillain-Barresyndrome
Rationale:
Guillain-Barre syndrome is characterized by ascendingparalysis and potential respiratory failure. The order of client
assessmentshould follow client priorities, with disorder of airways, breathing, and thencirculation. Theres no information to suggest the
postmyocardial infarctionclient has an arrhythmia or other complication. Theres no evidence to suggest hemorrhage or perforation for
the remaining clients as a priority of care.
73.
Answer
: (C) Decreases inflammation
Rationale:
Then action of colchicines is to decrease inflammation byreducing the migration of leukocytes to synovial fluid. Colchicine
doesntreplace estrogen, decrease infection, or decrease bone demineralization.
74.
Answer
: (C) Osteoarthritis is the most common form of arthritis

Rationale:
Osteoarthritis is the most common form of arthritis and can beextremely debilitating. It can afflict people of any age, although most
areelderly.
75.
Answer
: (C) Myxedema coma
Rationale:
Myxedema coma, severe hypothyroidism, is a life-threateningcondition that may develop if thyroid replacement medication isn't
taken.Exophthalmos, protrusion of the eyeballs, is seen with hyperthyroidism.Thyroid storm is life-threatening but is caused by severe
hyperthyroidism.Tibial myxedema, peripheral mucinous edema involving the lower leg, isassociated with hypothyroidism but isn't lifethreatening.
76.
Answer:
(B) An irregular apical pulse
Rationale:
B e c a u s e C u s h i n g ' s s y n d r o m e c a u s e s a l d o s t e r o n e overproduction, which increases urinary potassium loss,
the disorder maylead to hypokalemia. Therefore, the nurse should immediately report signsand symptoms of hypokalemia, such as an irregular
apical pulse, to
thep h y s i c i a n . E d e m a i s a n e x p e c t e d f i n d i n g b e c a u s e a l d o s t e r o n e o v e r p r o d u c t i o n c a u s e s s o d i u m a n d
f l u i d r e t e n t i o n . D r y m u c o u s m e m b r a n e s a n d f r e q u e n t u r i n a t i o n s i g n a l d e h y d r a t i o n , w h i c h i s n ' t associated
with Cushing's syndrome.
77.
Answer:
(D) Below-normal urine osmolality level, above-normal serumosmolality level
Rationale:
In diabetes insipidus, excessive polyuria causes dilute urine,resulting in a belownormal urine osmolality level. At the same time,polyuria depletes the body of water, causing dehydration that leads to
anabove-normal serum osmolality level. For the same reasons, diabetesinsipidus doesn't cause above-normal urine osmolality or
below-normalserum osmolality levels.
78.
Answer:
(A) "I can avoid getting sick by not becoming dehydrated and bypaying attention to my need to urinate, drink, or eat more than usual."
Rationale:
Inadequate fluid intake during hyperglycemic episodes
oftenleads to HHNS. By recognizing the signs of hyperglycemia (polyuria,polydipsia, and polyphagia) and increasing fluid i
ntake, the client mayprevent HHNS. Drinking a glass of nondiet soda would be appropriate for hypoglycemia. A client whose diabetes
is controlled with oral antidiabeticagents usually doesn't need to monitor blood glucose levels. A high-carbohydrate diet would
exacerbate the client's condition, particularly if fluid intake is low.

79.
Answer:
(D) Hyperparathyroidism
Rationale:
Hyperparathyroidism is most common in older women and
ischaracterized by bone pain and weakness from excess parathyroidhormone (PTH). Clients also exhibit hypercaliuriacausing polyuria. Whileclients with diabetes mellitus and diabetes insipidus also have polyuria,they don't have bone pain and increased
sleeping. Hypoparathyroidism ischaracterized by urinary frequency rather than polyuria
80.
Answer:
(C) "I'll take two-thirds of the dose when I wake up and one-thirdin the late afternoon."
Rationale:
Hydrocortisone, a glucocorticoid, should be administeredaccording to a schedule that closely reflects the body's own secretion
of this hormone; therefore, two-thirds of the dose of hydrocortisone shouldbe taken in the morning and one-third in the late afternoon.
This dosageschedule reduces adverse effects.
81.
Answer:
(C) High corticotropin and high cortisol levels
Rationale:
A corticotropin-secreting pituitary tumor would cause highcorticotropin and high cortisol levels. A high corticotropin level with a
lowcortisol level and a low corticotropin level with a low cortisol level would beassociated with hypocortisolism. Low corticotropin and
high cortisol levelswould be seen if there was a primary defect in the adrenal glands.
82.
Answer:
(D) Performing capillary glucose testing every 4 hours
Rationale:
The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance, placing
theclient at risk for hyperglycemia. Urine ketone testing isn't indicated because the client does secrete insulin and,
therefore, isn't at risk for ketosis. Urine specific gravity isn't indicated because although fluidbalance can be
compromised, it usually isn't dangerously imbalanced. Temperature regulation may be affected by excess cortisol and isn't
anaccurate indicator of infection.
83.
Answer:
(C) onset to be at 2:30 p.m. and its peak to be at 4 p.m.
Rationale:
Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave theinsulin
at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m.and the peak from 4 p.m. to 6 p.m.
84.

Answer:
(A) No increase in the thyroid-stimulating hormone (TSH) levelafter 30 minutes during the TSH stimulation test
Rationale:
In the TSH test, failure of the TSH level to rise after
3 0 minutes confirms hyperthyroidism. A decreased TSH level indicates apituitary deficiency of this hormone. Below-normal
levels of T3 and T4, asdetected by radioimmunoassay, signal hypothyroidism. A below-normal T4level also occurs in malnutrition and liver
disease and may result fromadministration of phenytoin and certain other drugs.
85.
Answer:
(B) "Rotate injection sites within the same anatomic region, notamong different regions."
Rationale:
The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different
regionsmay cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to
the next. Insulin should
be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other deviations. Injecting insulin into areas of
hypertrophymay delay absorption. The client shouldn't inject insulin into areas of lipodystrophy (such as hypertrophy or
atrophy); to prevent lipodystrophy,the client should rotate injection sites systematically. Exercise speedsdrug
absorption, so the client shouldn't inject insulin into sites abovemuscles that will be exercised heavily.
86.
Answer:
(D) Below-normal serum potassium level
Rationale:
A client with HHNS has an overall body deficit of
potassiumresulting from diuresis, which occurs secondary to the hyperosmolar,hyperglycemic state caused by the relative
insulin deficiency. An elevatedserum ac eton e level and serum keton e bodies are ch aracteristic of diabetic ketoacidosis.
Metabolic acidosis, not serum alkalosis, may occur in HHNS.
87.
Answer:
(D) Maintaining room temperature in the low-normal range
Rationale:
G r a v e s ' d i s e a s e c a u s e s s i g n s a n d s y m p t o m s o f hypermetabolism, such as heat intolerance,
diaphoresis, excessive thirsta n d a p p e t i t e , a n d w e i g h t l o s s . T o r e d u c e h e a t i n t o l e r a n c e a n d diaphoresis, the
nurse should keep the client's room temperature in thelow-normal range. To replace fluids lost via diaphoresis, the nurse
shouldencourage, not restrict, intake of oral fluids. Placing extra blankets on thebed of a client with heat intolerance would cause
discomfort. To provideneeded energy and calories, the nurse should encourage the client to eathigh-carbohydrate foods.
88.
Answer:
(A) Fracture of the distal radius

Rationale:
Colles' fracture is a fracture of the distal radius, such as
froma fall on an outstretc hed han d. It's most commo n in wom en . Co lles' fracture doesn't refer to a fracture of the
olecranon, humerus, or carpalscaphoid.
89.
Answer:
(B) Calcium and phosphorous
Rationale:
In osteoporosis, bones lose calcium and phosphate salts,becoming porous, brittle, and abnormally vulnerable to fracture.
Sodiumand potassium aren't involved in the development of osteoporosis.
90.
Answer:
(A)
Adult respiratory distress syndrome (ARDS)
Rationale:
Severe hypoxia after smoke inhalation is typically related to ARDS. The other conditions listed arent typically associated with
smokeinhalation and severe hypoxia.
91.
Answer:
(D) Fat embolism
Rationale:
Long bone fractures are correlated with fat emboli,
whichc a u s e s h o r t n e s s o f b r e a t h a n d h y p o x i a . I t s u n l i k e l y t h e c l i e n t h a s
developed asthma or bronchitis without a previous history. He coulddevelop atelectasis but it typically doesnt produce
progressive hypoxia.
92.
Answer:
(D)
Spontaneous pneumothorax
Rationale:
A spontaneous pneumothorax occurs when the clients lungcollapses, causing an acute decreased in the amount of functional lungused
in oxygenation. The sudden collapse was the cause of his chest painand shortness of breath. An asthma attack would show wheezing
breathsounds, and bronchitis would have rhonchi. Pneumonia would havebronchial breath sounds over the area of
consolidation.
93.
Answer:

(C) Pneumothorax
Rationale:
From the trauma the client experienced, its unlikely he
hasbronchitis, pneumonia, or TB; rhonchi with bronchitis, bronchial breathsounds with TB would be heard.
94.
Answer
: (C) Serous fluids fills the space and consolidates the region
Rationale:
Serous fluid fills the space and eventually consolidates, preventing extensive mediastinal shift of the heart and remaining
lung. Air cant be left in the space. Theres no gel that can be placed in the
pleuralspace. The tissue from the other lung cant cross the mediastinum, although a temporary mediastinal shift exits until the
space is filled.
95.
Answer
: (A) Alveolar damage in the infracted area
Rationale:
The infracted area produces alveolar damage that can lead tothe production of bloody sputum, sometimes in massive amounts.
Clotformation usually occurs in the legs. Theres a loss of lung parenchymaand subsequent scar tissue formation.
96.
Answer
: (D) Respiratory alkalosis
Rationale:
A client with massive pulmonary embolism will have a largeregion and blow off large amount of carbon dioxide, which
crosses theunaffected alveolar-capillary membrane more readily than does oxygenand results in respiratory alkalosis.
97.
Answer
: (A) Air leak
Rationale:
Bubbling in the water seal chamber of a chest drainage systemstems from an air leak. In pneumothorax an air leak can occur as air
ispulled from the pleural space. Bubbling doesnt normally occur with either adequate or inadequate suction or any preexisting
bubbling in the water seal chamber.
98.
Answer
: (B) 21
Rationale:
3000 x 10 divided by 24 x 60.
99.
Answer:
(B) 2.4 ml

Rationale:
.05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml.
100.
Answer:
(D) I should put on the stockings before getting out of bed inthe morning.
Rationale:
Promote venous return by applying external pressure on veins.
TEST VAnswers and Rationale Care of Clients with Physiologic andPsychosocial Alterations
1.
Answer
: (D) Focusing
Rationale
: The nurse is using focusing by suggesting that the clientdiscuss a specific issue. The nurse didnt restate the question, makeobservation, or ask further
question (exploring).
2.
Answer
: (D) Remove all other clients from the dayroom.
Rationale
: The nurses first priority is to consider the safety of the clientsin the therapeutic setting. The other actions are appropriate responsesafter ensuring the
safety of other clients.
3.
Answer
: (A) The client is disruptive.
Rationale
: Group activity provides too much stimulation, which the clientwill not be able to handle (harmful to self) and as a result will be disruptiveto others.
4.
Answer
: (C) Agree to talk with the mother and the father together.
Rationale
: By agreeing to talk with both parents, the nurse can provideemotional support and further assess and validate the familys needs.
5.
Answer
: (A) Perceptual disorders.
Rationale
: Frightening visual hallucinations are especially common inclients experiencing alcohol withdrawal.
6.
Answer

: (D) Suggest that it takes awhile before seeing the results.

Rationale
: The client needs a specific response; that it takes 2 to 3 weeks(a delayed effect) until the therapeutic blood level is reached.
7.
Answer
: (C) Superego
Rationale
: This behavior shows a weak sense of moral consciousness.According to Freudian theory, personality disorders stem from a weaksuperego.
8.
Answer
: (C) Skeletal muscle paralysis.
Rationale
: Anectine is a depolarizing muscle relaxant causing paralysis. Itis used to reduce the intensity of muscle contractions during theconvulsive stage,
thereby reducing the risk of bone fractures or dislocation.
9.
Answer
: (D) Increase calories, carbohydrates, and protein.
Rationale
: This client increased protein for tissue building and increasedcalories to replace what is burned up (usually via carbohydrates)
10.
Answer
: (C) Acting overly solicitous toward the child.
Rationale
: This behavior is an example of reaction formation, a copingmechanism.
11.
Answer
: (A) By designating times during which the client can focus on thebehavior.
Rationale
: The nurse should designate times during which the client canfocus on the compulsive behavior or obsessive thoughts. The nurseshould urge the client
to reduce the frequency of the compulsive behavior gradually, not rapidly. She shouldn't call attention to or try to prevent thebehavior. Trying to
prevent the behavior may cause pain and terror in theclient. The nurse should encourage the client to verbalize anxieties to helpdistract attention from
the compulsive behavior.
12.
Answer
: (D) Exploring the meaning of the traumatic event with the client.
Rationale
: The client with PTSD needs encouragement to examine andunderstand the meaning of the traumatic event and consequent losses.Otherwise,
symptoms may worsen and the client may become depressedor engage in self-destructive behavior such as substance abuse. Theclient must explore the

meaning of the event and won't heal without this,no matter how much time passes. Behavioral techniques, such asrelaxation therapy, may help
decrease the client's anxiety and inducesleep. The physician may prescribe antianxiety agents or antidepressantscautiously to avoid dependence; sleep
medication is rarely appropriate. Aspecial diet isn't indicated unless the client also has an eating disorder or a nutritional problem.
13.
Answer
: (C) "Your problem is real but there is no physical basis for it.We'll work on what is going on in your life to find out why it's happened."
Rationale
: The nurse must be honest with the client by telling her that theparalysis has no physiologic cause while also conveying empathy andacknowledging
that her symptoms are real. The client will benefit frompsychiatric treatment, which will help her understand the underlying causeof her symptoms.
After the psychological conflict is resolved, her symptoms will disappear. Saying that it must be awful not to be able tomove her legs wouldn't answer
the client's question; knowing that thecause is psychological wouldn't necessarily make her feel better. Tellingher that she has developed paralysis to
avoid leaving her parents or thather personality caused her disorder wouldn't help her understand andresolve the underlying conflict.
14.
Answer
: (C) fluvoxamine (Luvox) and clomipramine (Anafranil)
Rationale
: The antidepressants fluvoxamine and clomipramine havebeen effective in the treatment of OCD. Librium and Valium may be helpfulin treating
anxiety related to OCD but aren't drugs of choice to treat the
illness. The other medications mentioned aren't effective in the treatmentof OCD.
15.
Answer
: (A) A warning about the drugs delayed therapeutic effect, whichis from 14 to 30 days.
Rationale
: The client should be informed that the drug's therapeutic effectmight not be reached for 14 to 30 days. The client must be instructed tocontinue taking
the drug as directed. Blood level checks aren't necessary.NMS hasn't been reported with this drug, but tachycardia is frequentlyreported.
16.
Answer
: (B) Severe anxiety and fear.
Rationale
: Phobias cause severe anxiety (such as a panic attack) that isout of proportion to the threat of the feared object or situation. Physicalsigns and
symptoms of phobias include profuse sweating, poor motor control, tachycardia, and elevated blood pressure. Insomnia, an inability toconcentrate,
and weight loss are common in depression. Withdrawal andfailure to distinguish reality from fantasy occur in schizophrenia.
17.
Answer
: (A) Antidepressants
Rationale
: Tricyclic and monoamine oxidase (MAO) inhibitor antidepressants have been found to be effective in treating clients withpanic attacks. Why these
drugs help control panic attacks isn't clearlyunderstood. Anticholinergic agents, which are smooth-muscle relaxants,relieve physical symptoms of

anxiety but don't relieve the anxiety itself.Antipsychotic drugs are inappropriate because clients who experiencepanic attacks aren't psychotic. Mood
stabilizers aren't indicated becausepanic attacks are rarely associated with mood changes.
18.
Answer
: (B) 3 to 5 days
Rationale
: Monoamine oxidase inhibitors, such as tranylcypromine, havean onset of action of approximately 3 to 5 days. A full clinical responsemay be delayed
for 3 to 4 weeks. The therapeutic effects may continue for 1 to 2 weeks after discontinuation.
19.
Answer
: (B) Providing emotional support and individual counseling.
Rationale
: Clients in the first stage of Alzheimer's disease are aware thatsomething is happening to them and may become overwhelmed andfrightened.
Therefore, nursing care typically focuses on providingemotional support and individual counseling. The other options areappropriate during the
second stage of Alzheimer's disease, when theclient needs continuous monitoring to prevent minor illnesses fromprogressing into major problems and
when maintaining adequate nutritionmay become a challenge. During this stage, offering nourishing finger foods helps clients to feed themselves and
maintain adequate nutrition
20.
Answer
: (C) Emotional lability, euphoria, and impaired memory
Rationale
: Signs of antianxiety agent overdose include emotional lability,euphoria, and impaired memory. Phencyclidine overdose can causecombativeness,
sweating, and confusion. Amphetamine overdose canresult in agitation, hyperactivity, and grandiose ideation. Hallucinogenoverdose can produce
suspiciousness, dilated pupils, and increased bloodpressure.
21.
Answer
: (D) A low tolerance for frustration
Rationale
: Clients with an antisocial personality disorder exhibit a lowtolerance for frustration, emotional immaturity, and a lack of impulsecontrol. They
commonly have a history of unemployment, miss workrepeatedly, and quit work without other plans for employment. They don'tfeel guilt about their
behavior and commonly perceive themselves asvictims. They also display a lack of responsibility for the outcome of their actions. Because of a lack of
trust in others, clients with antisocialpersonality disorder commonly have difficulty developing stable, closerelationships.
22.
Answer
: (C) Methadone
Rationale

: Methadone is used to detoxify opiate users because it bindswith opioid receptors at many sites in the central nervous system butdoesnt have the same
deterious effects as other opiates, such ascocaine, heroin, and morphine. Barbiturates, amphetamines, andbenzodiazepines are highly addictive and
would require detoxificationtreatment.
23.
Answer
: (B) Hallucinations
Rationale
: Hallucinations are visual, auditory, gustatory, tactile, or olfactory perceptions that have no basis in reality. Delusions are falsebeliefs, rather than
perceptions, that the client accepts as real. Looseassociations are rapid shifts among unrelated ideas. Neologisms arebizarre words that have meaning
only to the client.
24.
Answer
: (C) Set up a strict eating plan for the client.
Rationale
: Establishing a consistent eating plan and monitoring theclients weight are very important in this disorder. The family and friendsshould be included
in the clients care. The client should be monitoredduring meals-not given privacy. Exercise must be limited and supervised.
25.
Answer
: (A) Highly important or famous.
Rationale
: A delusion of grandeur is a false belief that one is highlyimportant or famous. A delusion of persecution is a false belief that one isbeing persecuted. A
delusion of reference is a false belief that one isconnected to events unrelated to oneself or a belief that one is responsiblefor the evil in the world
26.
Answer
: (D) Listening attentively with a neutral attitude and avoidingpower struggles.
Rationale
: The nurse should listen to the clients requests, expresswillingness to seriously consider the request, and respond later. The nurseshould encourage the
client to take short daytime naps because heexpends so much energy. The nurse shouldnt try to restrain the clientwhen he feels the need to move
around as long as his activity isntharmful. High calorie finger foods should be offered to supplement theclients diet, if he cant remain seated long
enough to eat a complete meal.The nurse shouldnt be forced to stay seated at the table to finid=sh ameal. The nurse should set limits in a calm, clear,
and self-confident toneof voice.
27.
Answer
: (D) Denial
Rationale
: Denial is unconscious defense mechanism in which emotionalconflict and anxiety is avoided by refusing to acknowledge feelings,desires, impulses, or
external facts that are consciously intolerable.Withdrawal is a common response to stress, characterized by apathy.Logical thinking is the ability to

think rationally and make responsibledecisions, which would lead the client admitting the problem and seekinghelp. Repression is suppressing past
events from the consciousnessbecause of guilty association.
28.
Answer
: (B) Paranoid thoughts
Rationale
: Clients with schizotypal personality disorder experienceexcessive social anxiety that can lead to paranoid thoughts. Aggressivebehavior is uncommon,
although these clients may experience agitationwith anxiety. Their behavior is emotionally cold with a flattened affect,regardless of the situation. These
clients demonstrate a reduced capacityfor close or dependent relationships.
29.
Answer
: (C) Identify anxiety-causing situations
Rationale
: Bulimic behavior is generally a maladaptive coping response tostress and underlying issues. The client must identify anxiety-causingsituations that
stimulate the bulimic behavior and then learn new ways of coping with the anxiety.
30.
Answer
: (A) Tension and irritability
Rationale
: An amphetamine is a nervous system stimulant that is subjectto abuse because of its ability to produce wakefulness and euphoria. Anoverdose
increases tension and irritability. Options B and C are incorrectbecause amphetamines stimulate norepinephrine, which increase theheart rate and
blood flow. Diarrhea is a common adverse effect so optionD in is incorrect.
31.
Answer
: (B) No, I do not hear your voices, but I believe you can hear them.
Rationale
: The nurse, demonstrating knowledge and understanding,accepts the clients perceptions even though they are hallucinatory.
32.
Answer
: (C) Confusion for a time after treatment
Rationale
: The electrical energy passing through the cerebral cortexduring ECT results in a temporary state of confusion after treatment.
33.
Answer
: (D) Acceptance stage
Rationale
: Communication and intervention during this stage are mainlynonverbal, as when the client gestures to hold the nurses hand.
34.

Answer
: (D) A higher level of anxiety continuing for more than 3 months.
Rationale
: This is not an expected outcome of a crisis because bydefinition a crisis would be resolved in 6 weeks.
35.
Answer
: (B) Staying in the sun
Rationale
: Haldol causes photosensitivity. Severe sunburn can occur onexposure to the sun.
36.
Answer
: (D) Moderate-level anxiety
Rationale
: A moderately anxious person can ignore peripheral events andfocuses on central concerns.
37.
Answer
: (C) Diverse interest
Rationale
: Before onset of depression, these clients usually have very narrow, limited interest.
38.
Answer
: (A) As their depression begins to improve
Rationale
: At this point the client may have enough energy to plan andexecute an attempt.
39.
Answer
: (D) Disturbance in recalling recent events related to cerebral hypoxia.
Rationale
: Cell damage seems to interfere with registering input stimuli,which affects the ability to register and recall recent
events; vascular dementia is related to multiple vascular lesions of the cerebral cortex andsubcortical structure.
40.
Answer
: (D) Encouraging the client to have blood levels checked as ordered.
Rationale
: Blood levels must be checked monthly or bimonthly when theclient is on maintenance therapy because there is only a small
rangebetween therapeutic and toxic levels
1.
Answer
: (B) Fine hand tremors or slurred speech

Rationale
: These are common side effects of lithium carbonate.
42.
Answer
: (D) Presence
Rationale
: The constant presence of a nurse provides emotional supportbecause the client knows that someone is attentive and available in caseof
an emergency.
43.
Answer
: (A) Clients perception of the presenting problem.
Rationale
: The nurse can be most therapeutic by starting where the clientis, because it is the clients concept of the problem that serves as
thestarting point of the relationship.
44.
Answer
: (B) Chocolate milk, aged cheese, and yogurt
Rationale
: These high-tyramine foods, when ingested in the presence of an MAO inhibitor, cause a severe hypertensive response.
45.
Answer
: (B) 4 to 6 weeks
Rationale
: Crisis is self-limiting and lasts from 4 to 6 weeks.
46.
Answer
: (D) Males are more likely to use lethal methods than are females
Rationale
: This finding is supported by research; females account for 90%of suicide attempts but males are three times more successful because
of methods used.
47.
Answer
: (C) "Your cursing is interrupting the activity. Take time out in your room for 10 minutes."
Rationale
: The nurse should set limits on client behavior to ensure acomfortable environment for all clients. The nurse should accept
hostile or quarrelsome client outbursts within limits without becoming personallyoffended, as in option A. Option B is incorrect
because it implies that theclient's actions reflect feelings toward the staff instead of the client's ownmisery. Judgmental remarks, such as
option D, may decrease the client'sself-esteem.
48.

Answer
: (C) lithium carbonate (Lithane)
Rationale
: Lithium carbonate, an antimania drug, is used to treat clientswith cyclical schizoaffective disorder, a psychotic disorder once
classifiedunder schizophrenia that causes affective symptoms, including
maniclikeactivity. Lithium helps control the affective component of this disorder.Phenelzine is a monoamine oxidase inhibitor
prescribed for clients
whod o n ' t r e s p o n d t o o t h e r a n t i d e p r e s s a n t d r u g s s u c h a s i m i p r a m i n e . Chlordiazepoxide, an antianxiety agent, ge
nerally is contraindicated inpsychotic clients. Imipramine, primarily considered an antidepressantagent, is also used to treat
clients with agoraphobia and that undergoingcocaine detoxification.
49.
Answer
: (B) Report a sore throat or fever to the physician immediately.
Rationale
: A sore throat and fever are indications of an infection causedby agranulocytosis, a potentially life-threatening complication of clozapine.Because of the
risk of agranulocytosis, white blood cell (WBC) counts arenecessary weekly, not monthly. If the WBC count drops below 3,000/l,the medication must
be stopped. Hypotension may occur in clients takingthis medication. Warn the client to stand up slowly to avoid dizziness fromorthostatic hypotension.
The medication should be continued, even whensymptoms have been controlled. If the medication must be stopped, itshould be slowly tapered over 1 to
2 weeks and only under thesupervision of a physician.
50.
Answer
: (C) Neuroleptic malignant syndrome.
Rationale
: The client's signs and symptoms suggest neurolepticmalignant syndrome, a life-threatening reaction to neuroleptic medicationthat requires immediate
treatment. Tardive dyskinesia causes involuntarymovements of the tongue, mouth, facial muscles, and arm and legmuscles. Dystonia is characterized by
cramps and rigidity of the tongue,face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness.
51.
Answer
: (B) Advising the client to sit up for 1 minute before getting out of bed.
Rationale
: To minimize the effects of amitriptyline-induced orthostatichypotension, the nurse should advise the client to sit up for 1 minutebefore getting out of
bed. Orthostatic hypotension commonly occurs withtricyclic antidepressant therapy. In these cases, the dosage may bereduced or the physician may
prescribe nortriptyline, another tricyclicantidepressant. Orthostatic hypotension disappears only when the drug isdiscontinued.
52.
Answer
: (D) Dysthymic disorder.
Rationale

: Dysthymic disorder is marked by feelings of depression lastingat least 2 years, accompanied by at least two of the following symptoms:sleep
disturbance, appetite disturbance, low energy or fatigue, low self-esteem, poor concentration, difficulty making decisions, andhopelessness. These
symptoms may be relatively continuous or separated by intervening periods of normal mood that last a few days to afew weeks. Cyclothymic disorder is a
chronic mood disturbance of at least2 years' duration marked by numerous periods of depression andhypomania. Atypical affective disorder is
characterized by manic signs andsymptoms. Major depression is a recurring, persistent sadness or loss of interest or pleasure in almost all activities, with
signs and symptomsrecurring for at least 2 weeks.
53.
Answer
: (C) 30 g mixed in 250 ml of water
Rationale
: The usual adult dosage of activated charcoal is 5 to 10 timesthe estimated weight of the drug or chemical ingested, or a minimum doseof 30 g, mixed in
250 ml of water. Doses less than this will be ineffective;doses greater than this can increase the risk of adverse reactions,although toxicity doesn't occur
with activated charcoal, even at themaximum dose.
54.
Answer
: (C) St. John's wort
Rationale
: St. John's wort has been found to have serotonin-elevatingproperties, similar to prescription antidepressants. Ginkgo biloba isprescribed to enhance
mental acuity. Echinacea has immune-stimulatingproperties. Ephedra is a naturally occurring stimulant that is similar toephedrine.
55.
Answer
: (B) Sodium
Rationale
: Lithium is chemically similar to sodium. If sodium levels arereduced, such as from sweating or diuresis, lithium will be reabsorbed bythe kidneys,
increasing the risk of toxicity. Clients taking lithium shouldn'trestrict their intake of sodium and should drink adequate amounts of fluideach day. The
other electrolytes are important for normal body functionsbut sodium is most important to the absorption of lithium.
56.
Answer
: (D) It's characterized by an acute onset and lasts hours to anumber of days
Rationale
: Delirium has an acute onset and typically can last fromseveral hours to several days.
57.
Answer
: (B) Impaired communication.
Rationale
: Initially, memory impairment may be the only cognitive deficitin a client with Alzheimer's disease. During the early stage of this disease,subtle
personality changes may also be present. However, other thanoccasional irritable outbursts and lack of spontaneity, the client is usuallycooperative and

exhibits socially appropriate behavior. Signs of advancement to the middle stage of Alzheimer's disease includeexacerbated cognitive impairment with
obvious personality changes andimpaired communication, such as inappropriate conversation, actions, andresponses. During the late stage, the client
can't perform self-careactivities and may become mute.
58.
Answer
: (D) This medication may initially cause tiredness, which shouldbecome less bothersome over time.
Rationale
: Sedation is a common early adverse effect of imipramine, atricyclic antidepressant, and usually decreases as tolerance develops.Antidepressants aren't
habit forming and don't cause physical or psychological dependence. However, after a long course of high-dosetherapy, the dosage should be decreased
gradually to avoid mild
withdrawal symptoms. Serious adverse effects, although rare, includemyocardial infarction, heart failure, and tachycardia. Dietary restrictions,such as
avoiding aged cheeses, yogurt, and chicken livers, are necessaryfor a client taking a monoamine oxidase inhibitor, not a tricyclicantidepressant.
59.
Answer
: (C) Monitor vital signs, serum electrolyte levels, and acid-basebalance.
Rationale
: An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias,hypothermia,
malnutrition, infection, or cardiac abnormalities secondary toelectrolyte imbalances. Therefore, monitoring the client's vital signs, serumelectrolyte
level, and acid base balance is crucial. Option A may worsenanxiety. Option B is incorrect because a weight obtained after breakfast ismore accurate
than one obtained after the evening meal. Option D wouldreward the client with attention for not eating and reinforce the controlissues that are central
to the underlying psychological problem; also, theclient may record food and fluid intake inaccurately.
60.
Answer
: (D) Opioid withdrawal
Rationale
: The symptoms listed are specific to opioid withdrawal. Alcoholwithdrawal would show elevated vital signs. There is no real withdrawalfrom cannibis.
Symptoms of cocaine withdrawal include depression,anxiety, and agitation.
61.
Answer
: (A) Regression
Rationale
: An adult who throws temper tantrums, such as this one, isdisplaying regressive behavior, or behavior that is appropriate at ayounger age. In
projection, the client blames someone or something other than the source. In reaction formation, the client acts in opposition to hisfeelings. In
intellectualization, the client overuses rational explanations or abstract thinking to decrease the significance of a feeling or event.
62.
Answer
: (A) Abnormal movements and involuntary movements of themouth, tongue, and face.
Rationale

: Tardive dyskinesia is a severe reaction associated with longterm use of antipsychotic medication. The clinical manifestations includeabnormal
movements (dyskinesia) and involuntary movements of themouth, tongue (fly catcher tongue), and face.
63.
Answer
: (C) Blurred vision
Rationale
: At lithium levels of 2 to 2.5 mEq/L the client will experiencedblurred vision, muscle twitching, severe hypotension, and persistentnausea and
vomiting. With levels between 1.5 and 2 mEq/L the clientexperiencing vomiting, diarrhea, muscle weakness, ataxia, dizziness,slurred speech, and
confusion. At lithium levels of 2.5 to 3 mEq/L or
higher, urinary and fecal incontinence occurs, as well as seizures, cardiacdysrythmias, peripheral vascular collapse, and death.
64.
Answer
: (C) No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints.
Rationale
: The best indicator that the behavior is controlled, if the clientexhibits no signs of aggression after partial release of restraints. OptionsA, B, and D do
not ensure that the client has controlled the behavior.
65.
Answer:
(A) increased attention span and concentration
Rationale
: The medication has a paradoxic effect that decreasehyperactivity and impulsivity among children with ADHD. B, C, D. Sideeffects of Ritalin include
anorexia, insomnia, diarrhea and irritability.
66.
Answer:
(C) Moderate
Rationale
: The child with moderate mental retardation has an I.Q. of 35-50 Profound Mental retardation has an I.Q. of below 20; Mild mentalretardation 50-70
and Severe mental retardation has an I.Q. of 20-35.
67.
Answer:
(D) Rearrange the environment to activate the child
Rationale
: The child with autistic disorder does not want change.Maintaining a consistent environment is therapeutic. A. Angry outburst canbe re-channeling
through safe activities. B. Acceptance enhances atrusting relationship. C. Ensure safety from self-destructive behaviors likehead banging and hair
pulling.
68.
Answer:
(B) cocaine

Rationale
: The manifestations indicate intoxication with cocaine, a CNSstimulant. A. Intoxication with heroine is manifested by euphoria thenimpairment in
judgment, attention and the presence of papillaryconstriction. C. Intoxication with hallucinogen like LSD is manifested bygrandiosity, hallucinations,
synesthesia and increase in vital signs D.Intoxication with Marijuana, a cannabinoid is manifested by sensation of slowed time, conjunctival redness,
social withdrawal, impaired judgmentand hallucinations.
69.
Answer
: (B) insidious onset
Rationale
: Dementia has a gradual onset and progressive deterioration. Itcauses pronounced memory and cognitive disturbances. A,C and D are
allcharacteristics of delirium.
70.
Answer:
(C) Claustrophobia
Rationale
: Claustrophobia is fear of closed space. A. Agoraphobia is fear of open space or being a situation where escape is difficult. B. Socialphobia is fear of
performing in the presence of others in a way that will behumiliating or embarrassing. D. Xenophobia is fear of strangers
71.
Answer:
(A) Revealing personal information to the client
Rationale
: Counter-transference is an emotional reaction of the nurse onthe client based on her unconscious needs and conflicts. B and C. Theseare therapeutic
approaches. D. This is transference reaction where aclient has an emotional reaction towards the nurse based on her past.
72.
Answer:
(D) Hold the next dose and obtain an order for a stat serumlithium level
Rationale
: Diarrhea and vomiting are manifestations of Lithium toxicity.The next dose of lithium should be withheld and test is done to validatethe observation.
A. The manifestations are not due to drug interaction. B.Cogentin is used to manage the extra pyramidal symptom side effects of antipsychotics. C. The
common side effects of Lithium are fine handtremors, nausea, polyuria and polydipsia.
73.
Answer:
(C) A living, learning or working environment.
Rationale
: A therapeutic milieu refers to a broad conceptual approach inwhich all aspects of the environment are channeled to provide atherapeutic environment
for the client. The six environmental elementsinclude structure, safety, norms; limit setting, balance and unitmodification. A. Behavioral approach in
psychiatric care is based on thepremise that behavior can be learned or unlearned through the use of reward and punishment. B. Cognitive approach to

change behavior isdone by correcting distorted perceptions and irrational beliefs to correctmaladaptive behaviors. D. This is not congruent with
therapeutic milieu.
74.
Answer:
(B) Transference
Rationale
: Transference is a positive or negative feeling associated with asignificant person in the clients past that are unconsciously assigned toanother A.
Splitting is a defense mechanism commonly seen in a clientwith personality disorder in which the world is perceived as all good or allbad C. Counterttransference is a phenomenon where the nurse shiftsfeelings assigned to someone in her past to the patient D. Resistance isthe clients refusal to submit
himself to the care of the nurse
75.
Answer:
(B) Adventitious
Rationale
: Adventitious crisis is a crisis involving a traumatic event. It isnot part of everyday life. A. Situational crisis is from an external sourcethat upset ones
psychological equilibrium C and D. Are the same. Theyare transitional or developmental periods in life
76.
Answer
: (C) Major depression
Rationale
: The DSM-IV-TR classifies major depression as an Axis Idisorder. Borderline personality disorder as an Axis II; obesity andhypertension, Axis III.
77.
Answer
: (B) Transference
Rationale
: Transference is the unconscious assignment of negative or positive feelings evoked by a significant person in the clients past toanother person.
Intellectualization is a defense mechanism in which theclient avoids dealing with emotions by focusing on facts. Triangulationrefers to conflicts
involving three family members. Splitting is a defensemechanism commonly seen in clients with personality disorder in whichthe world is perceived as
all good or all bad.
78.
Answer
: (B) Hypochondriasis
Rationale
:
Complains of vague physical symptoms that have no apparentmedical causes are characteristic of clients with hypochondriasis. In manycases, the GI
system is affected. Conversion disorders are characterizedby one or more neurologic symptoms. The clients symptoms dontsuggest severe anxiety. A
client experiencing sublimation channelsmaladaptive feelings or impulses into socially acceptable behavior

79.
Answer
: (C) Hypochondriasis
Rationale
: Hypochodriasis in this case is shown by the clients belief thatshe has a serious illness, although pathologic causes have beeneliminated. The
disturbance usually lasts at lease 6 with identifiable lifestressor such as, in this case, course examinations. Conversion disorder sare characterized by one
or more neurologic symptoms.Depersonalization refers to persistent recurrent episodes of feelingdetached from ones self or body. Somatoform
disorders generally have achronic course with few remissions.
80.
Answer
: (A) Triazolam (Halcion)
Rationale
: Triazolam is one of a group of sedative hypnotic medicationthat can be used for a limited time because of the risk of dependence.Paroxetine is a
scrotonin-specific reutake inhibitor used for treatment of depression panic disorder, and obsessive-compulsive disorder. Fluoxetineis a scrotoninspecific reuptake inhibitor used for depressive disorders andobsessive-compulsive disorders. Risperidome is indicated for psychoticdisorders.
81.
Answer
: (D) It promotes emotional support or attention for the client
Rationale
: Secondary gain refers to the benefits of the illness that allowthe client to receive emotional support or attention. Primary gain enablesthe client to avoid
some unpleasant activity. A dysfunctional family maydisregard the real issue, although some conflict is relieved. Somatoformpain disorder is a
preoccupation with pain in the absence of physicaldisease.
82.
Answer
: (A) I went to the mall with my friends last Saturday
Rationale
: Clients with panic disorder tent to be socially withdrawn. Goingto the mall is a sign of working on avoidance behaviors. Hyperventilating isa key
symptom of panic disorder. Teaching breathing control is a major intervention for clients with panic disorder. The client taking medicationsfor panic
disorder; such as tricylic antidepressants and benzodiazepines,must be weaned off these drugs. Most clients with panic disorder withagoraphobia dont
have nutritional problems.
83.
Answer
: (A) Im sleeping better and dont have nightmares
Rationale
:MAO inhibitors are used to treat sleep problems, nightmares,and intrusive daytime thoughts in individual with posttraumatic stressdisorder. MAO
inhibitors arent used to help control flashbacks or phobiasor to decrease the craving for alcohol.
84.
Answer

: (D) Stopping the drug can cause withdrawal symptoms

Rationale:
Stopping antianxiety drugs such as benzodiazepines cancause the client to have withdrawal symptoms. Stopping a benzodiazepinedoesnt tend to cause
depression, increase cognitive abilities, or decreasesleeping difficulties.
85.
Answer
: (B) Behavioral difficulties
Rationale
: Adolescents tend to demonstrate severe irritability andbehavioral problems rather than simply a depressed mood. Anxietydisorder is more commonly
associated with small children rather than withadolescents. Cognitive impairment is typically associated with delirium or dementia. Labile mood is more
characteristic of a client with cognitiveimpairment or bipolar disorder.
86.
Answer
: (D) Its a mood disorder similar to major depression but of mild tomoderate severity
Rationale
: Dysthymic disorder is a mood disorder similar to major depression but it remains mild to moderate in severity. Cyclothymicdisorder is a mood disorder
characterized by a mood range from moderatedepression to hypomania. Bipolar I disorder is characterized by a singlemanic episode with no past major
depressive episodes. Seasonal-affective disorder is a form of depression occurring in the fall and winter.
87.
Answer
: (A) Vascular dementia has more abrupt onset
Rationale
: Vascular dementia differs from Alzheimers disease in that ithas a more abrupt onset and runs a highly variable course. Personallychange is common in
Alzheimers disease. The duration of delirium isusually brief. The inability to carry out motor activities is common inAlzheimers disease.
88.
Answer
: (C) Drug intoxication
Rationale
: This client was taking several medications that have apropensity for producing delirium; digoxin (a digitalis glycoxide),furosemide (a thiazide
diuretic), and diazepam (a benzodiazepine).Sufficient supporting data dont exist to suspect the other options ascauses.
89.
Answer
: (D) The client is experiencing visual hallucination
Rationale
: The presence of a sensory stimulus correlates with thedefinition of a hallucination, which is a false sensory perception. Aphasiarefers to a
communication problem. Dysarthria is difficulty in speechproduction. Flight of ideas is rapid shifting from one topic to another.
90.

Answer
: (D) The client looks at the shadow on a wall and tells the nurseshe sees frightening faces on the wall.
Rationale
: Minor memory problems are distinguished from dementia bytheir minor severity and their lack of significant interference with theclients social or
occupational lifestyle. Other options would be included inthe history data but dont directly correlate with the clients lifestyle.
91.
Answer
: (D) Loose association
Rationale
: Loose associations are conversations that constantly shift intopic. Concrete thinking implies highly definitive thought processes. Flightof ideas is
characterized by conversation thats disorganized from theonset. Loose associations dont necessarily start in a cogently, thenbecomes loose.
92.
Answer
: (C) Paranoid
Rationale
: Because of their suspiciousness, paranoid personalitiesascribe malevolent activities to others and tent to be defensive, becomingquarrelsome and
argumentative. Clients with antisocial personalitydisorder can also be antagonistic and argumentative but are lesssuspicious than paranoid
personalities. Clients with histrionic personalitydisorder are dramatic, not suspicious and argumentative. Clients withschizoid personality disorder are
usually detached from other and tend tohave eccentric behavior.
93.
Answer
: (C) Explain that the drug is less affective if the client smokes
Rationale
: Olanzapine (Zyprexa) is less effective for clients who smokecigarettes. Serotonin syndrome occurs with clients who take acombination of
antidepressant medications. Olanzapine doesnt causeeuphoria, and extrapyramidal adverse reactions arent a problem.However, the client should be
aware of adverse effects such as tardivedyskinesia.
94.
Answer
: (A) Lack of honesty
Rationale
:
Clients with antisocial personality disorder tent to engage inacts of dishonesty, shown by lying. Clients with schizotypal personalitydisorder tend to be
superstitious. Clients with histrionic personalitydisorders tend to overreact to frustrations and disappointments, havetemper tantrums, and seek
attention.
95.
Answer
: (A) Im not going to look just at the negative things about myself

Rationale
: As the clients makes progress on improving self-esteem, self-blame and negative self evaluation will decrease. Clients with dependentpersonality
disorder tend to feel fragile and inadequate and would beextremely unlikely to discuss their level of competence and progress.These clients focus on self
and arent envious or jealous. Individuals withdependent personality disorders dont take over situations because theysee themselves as inept and
inadequate.
96.
Answer
: (C) Assess for possible physical problems such as rash
Rationale
: Clients with schizophrenia generally have poor visceralrecognition because they live so fully in their fantasy world. They need tohave as in-depth
assessment of physical complaints that may spill over into their delusional symptoms. Talking with the client wont provide asassessment of his itching,
and itching isnt as adverse reaction of antipsychotic drugs, calling the physician to get the clients medicationincreased doesnt address his physical
complaints.
97.
Answer
: (B) Echopraxia
Rationale
: Echopraxia is the copying of anothers behaviors and is theresult of the loss of ego boundaries. Modeling is the conscious copying of someones
behaviors. Ego-syntonicity refers to behaviors that correspondwith the individuals sense of self. Ritualism behaviors are repetitive andcompulsive.
98.
Answer
: (C) Hallucination
Rationale
: Hallucinations are sensory experiences that aremisrepresentations of reality or have no basis in reality. Delusions arebeliefs not based in reality.
Disorganized speech is characterized by jumping from one topic to the next or using unrelated words. An idea of reference is a belief that an unrelated
situation holds special meaning for the client.
99.
Answer
: (C) Regression
Rationale
: Regression, a return to earlier behavior to reduce anxiety, isthe basic defense mechanism in schizophrenia. Projection is a defensemechanism in which
one blames others and attempts to justify actions; itsused primarily by people with paranoid schizophrenia and delusionaldisorder. Rationalization is a
defense mechanism used to justify onesaction. Repression is the basic defense mechanism in the neuroses; its
an involuntary exclusion of painful thoughts, feelings, or experiences fromawareness.100.
Answer
: (A) Should report feelings of restlessness or agitation at once
Rationale

: Agitation and restlessness are adverse effect of haloperidol and can be treated with antocholinergic drugs. Haloperidol isnt likely
tocause photosensitivity or control essential hypertension. Although theclient may experience increased concentration and
activity, these effectsare due to a decreased in symptoms, not the drug itself.

FOUNDATION OF NURSING
1.Which element in the circular chain of infection can be eliminated bypreserving skin integrity?
a . H o s t b . R e s e r v o i r c . M o d e o f t r a n s m i s s i o n d . P o r t a l o f e n t r y 2.Which of the following will probably
result in a break in sterile technique for respiratory isolation?a.Opening the patients window to the outside
environmentb.Turning on the patients room ventilator c.Opening the door of the patients room leading into the
hospitalcorridor d.Failing to wear gloves when administering a bed bath 3.Which of the following patients is at greater risk
for contracting aninfection?a . A p a t i e n t w i t h l e u k o p e n i a b.A patient receiving broad-spectrum antibiotics c.A postoperative
patient who has undergone orthopedic surgeryd.A newly diagnosed diabetic patient
4.
Effectivehand washingrequires the use of:a.Soap or detergent to promote emulsificationb . H o t w a t e r t o d e s t r o y b a c t e r i a c.A
disinfectant to increase surface tension d . A l l o f t h e a b o v e
5.
After routine patient contact,hand washingshould last at least:a . 3 0 s e c o n d s b . 1
m i n u t e c . 2 m i n u t e d . 3 m i n u t e s 6.Which of the following procedures always requires surgical asepsis?a.Vaginal
instillation of conjugated estrogen
b.
Urinary catheterization
c.
Nasogastric tube insertion
d.
Colostomy irrigation7.Sterile technique is used whenever:a . S t r i c t i s o l a t i o n i s r e q u i r e d b.Terminal disinfection is
performedc.Invasive procedures are performedd.Protective isolation is necessary8.Which of the following constitutes
a break in sterile technique whilepreparing a sterile field for a dressing change?a.Using sterile forceps, rather than sterile gloves, to handle a
sterileitem

b.Touching the outside wrapper of sterilized material without sterileglovesc.Placing a sterile object on the edge of the sterile
fieldd.Pouring out a small amount of solution (15 to 30 ml) before pouringthe solution into a sterile container 9.A natural body defense that
plays an active role in preventing infection is:a . Y a w n i n g b . B o d y h a i r c . H i c c u p p i n g d . R a p i d e y e m o v e m e n t s
10.
All of the following statement are true aboutdonning sterile glovesexcept:a.The first glove should be picked up by grasping the inside of
thecuff.b.The second glove should be picked up by inserting the glovedfingers under the cuff outside the glove.c.The gloves should
be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wristd.The inside of the glove is considered
sterile11.When removing a contaminated gown, the nurse should be careful thatthe first thing she touches is the:a.Waist tie and neck tie at the
back of the gownb.Waist tie in front of the gown c . C u f f s o f t h e g o w n d . I n s i d e o f t h e g o w n 12.Which of the following
nursing interventions is considered the mosteffective form or universal precautions?a.Cap all used needles before removing them from their
syringesb.Discard all used uncapped needles and syringes in an impenetrable protective container c.Wear gloves when
administering IM injectionsd.Follow enteric precautions 13.All of the following measures are recommended to prevent pressure
ulcersexcept:a.Massaging the reddened are with lotionb.Using a water or air mattress c.Adhering to a schedule for
positioning and turningd.Providing meticulous skin care14.Which of the following blood tests should be performed before a
bloodtransfusion?a.Prothrombin and coagulation timeb.Blood typing and cross-matchingc.Bleeding and clotting time
d.
Complete blood count (CBC)and electrolyte levels.15.The primary purpose of a platelet count is to evaluate the:a.Potential for clot
formationb.Potential for bleeding
c.Presence of an antigen-antibody responsed.Presence of cardiac enzymes 16.Which of the following white blood cell (WBC) counts
clearly indicatesleukocytosis?a . 4 , 5 0 0 / m m b . 7 , 0 0 0 / m m c . 1 0 , 0 0 0 / m m d . 2 5 , 0 0 0 / m m
17.
After 5 days of diuretic therapy with 20mg of furosemide(Lasix) daily, apatient begins to exhibit fatigue, muscle cramping and muscle weakness.These
symptoms probably indicate that the patient is
experiencing:a . H y p o k a l e m i a b . H y p e r k a l e m i a c . A n o r e x i a d . D y s p h a g i a 18.Which of the following statements about
chest X-ray is false?a.No contradictions exist for this testb.Before the procedure, the patient should remove all jewelry,metallic
objects, and buttons above the waistc.A signed consent is not required d.Eating, drinking, and medications are allowed before this
test19.The most appropriate time for the nurse to obtain a sputum specimen for culture is:a . E a r l y i n t h e m o r n i n g b.After the patient eats
a light breakfastc . A f t e r a e r o s o l t h e r a p y d.After chest physiotherapy 20.A patient with no known allergies is to receive penicillin
every 6 hours.When administering the medication, the nurse observes a fine rash on thepatients skin. The most appropriate nursing action would be
to:a.Withhold the moderation and notify the physicianb.Administer the medication and notify the physicianc.Administer
the medication with an antihistamined.Apply corn starch soaks to the rash 21.All of the following nursing interventions are correct
when using the Z-track method of drug injection except:a.Prepare the injection site with alcoholb.Use a needle thats a least
1 longc.Aspirate for blood before injectiond.Rub the site vigorously after the injection to promote absorption22.The correct method
for determining the vastus lateralis site for I.M.injection is to:a.Locate the upper aspect of the upper outer quadrant of the buttockabout 5 to 8
cm below the iliac crestb.Palpate the lower edge of the acromion process and the midpointlateral aspect of the arm

c.Palpate a 1 circular area anterior to the umbilicus d.Divide the area between the greater femoral trochanter and thelateral femoral
condyle into thirds, and select the middle third on theanterior of the thigh23.The mid-deltoid injection site is seldom used for I.M. injections
because it:a.Can accommodate only 1 ml or less of medicationb . B r u i s e s t o o e a s i l y c.Can be used only when the patient
is lying downd.Does not readily parenteral medication24.The appropriate needle size for insulin injection is:a . 1 8 G ,
1 l o n g b . 2 2 G , 1 l o n g c . 2 2 G , 1 l o n g d . 2 5 G , 5 / 8 l o n g 25.The appropriate needle gauge for intradermal injection
is:a . 2 0 G b . 2 2 G c . 2 5 G d . 2 6 G 26.Parenteral penicillin can be administered as an:a.IM injection or an IV
solutionb.IV or an intradermal injectionc.Intradermal or subcutaneous injectiond.IM or a subcutaneous injection 27.The
physician orders gr 10 of aspirin for a patient. The equivalent dose inmilligrams
is:a . 0 . 6 m g b . 1 0 m g c . 6 0 m g d . 6 0 0 m g 28.The physician orders an IV solution of dextrose 5% in water
at100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml?
a . 5 g t t / m i n u t e b . 1 3 g t t / m i n u t e c . 2 5 g t t / m i n u t e d . 5 0 g t t / m i n u t e 29.Which of the following is a sign or symptom of a
hemolytic reaction toblood transfusion?a . H e m o g l o b i n u r i a b . C h e s t p a i n c . U r t i c a r i a d.Distended neck veins30.Which of
the following conditions may require fluid restriction?a . F e v e r b.Chronic Obstructive Pulmonary Disease
c.
Renal Failure
d . D e h y d r a t i o n 31.All of the following are common signs and symptoms of phlebitis except:a.Pain or discomfort at the IV insertion
siteb.Edema and warmth at the IV insertion sitec.A red streak exiting the IV insertion sited.Frank bleeding at the insertion
site32.The best way of determining whether a patient has learned to instill ear medication properly is for the nurse to:a.Ask the patient if he/she
has used ear drops beforeb.Have the patient repeat the nurses instructions using her ownwordsc.Demonstrate the procedure to
the patient and encourage to askquestionsd.Ask the patient to demonstrate the procedure33.Which of the following types of medications
can be administered viagastrostomy tube?a.Any oral medications b.Capsules whole contents are dissolve in water c.Entericcoated tablets that are thoroughly dissolved in water d.Most tablets designed for oral use, except for extended-durationcompounds34.A
patient who develops hives after receiving an antibiotic is
exhibitingdrug:a . T o l e r a n c e b . I d i o s y n c r a s y c . S y n e r g i s m d . A l l e r g y 35.A patient has returned to his room after femoral
arteriography. All of thefollowing are appropriate nursing interventions except:a.Assess femoral, popliteal, and pedal pulses every
15 minutes for 2hoursb.Check the pressure dressing for sanguineous drainagec.Assess a vital signs every 15 minutes for 2
hoursd.Order a hemoglobin and hematocrit count 1 hour after the arteriography36.The nurse explains to a patient that a cough:a.Is
a protective response to clear the respiratory tract of irritantsb.Is primarily a voluntary actionc.Is induced by the administration
of an antitussive drugd.Can be inhibited by splinting the abdomen 37.An infected patient has chills and begins shivering. The best
nursingintervention is to:a.Apply iced alcohol sponges b.Provide increased cool liquidsc.Provide additional
bedclothes d.Provide increased ventilation
38.A clinical nurse specialist is a nurse who has:a.Been certified by the National League for Nursingb.Received
credentials from the Philippine Nurses Associationc.Graduated from an associate degree program and is a registeredprofessional
nursed.Completed a masters degree in the prescribed clinical area and isa registered professional nurse.39.The purpose of increasing urine
acidity through dietary means is to:a.Decrease burning sensatio nsb.Change the
urines colo r c.Change the urines concentrationd.Inhibit the growth of microorganisms40.Clay colored stools

indicate:a . U p p e r G I b l e e d i n g b.Imp en ding con stip ationc .A n effec t of medic atio n d . B i l e o b s t r u c t i o n 41.In which step
of the nursing process would the nurse ask a patient if themedication she administered relieved his pain?
a.
Assessment b . A n a l y s i s
c.
Planning
d.
Evaluation42.All of the following are good sources of vitamin A except:a . W h i t e p o t a t o e s b . C a r r o t s c . A p r i c o t s d . E g g
y o l k s 43.Which of the following is a primary nursing intervention necessary for allpatients with a Foley Catheter in place?a.Maintain the
drainage tubing and collection bag level with thepatients bladder b.Irrigate the patient with 1% Neosporin solution three times
a dailyc.Clamp the catheter for 1 hour every 4 hours to maintain the bladders elasticityd.Maintain the drainage tubing and
collection bag below bladder levelto facilitate drainage by gravity44.The ELISA test is used to:
a.
Screen blood donors for antibodies to human immunodeficiencyvirus(HIV)b.Test blood to be used for transfusion for HIV antibodies
c.
Aid in diagnosing a patient withAIDSd . A l l o f t h e a b o v e 45.The two blood vessels most commonly used for TPN infusion are
the:a.Subclav ian an d jugular veins b.Brachial and subclavian veins
c.Femoral and subclavian veinsd.Brachial and femoral veins 46.Effective skin disinfection before a surgical procedure includes
which of the following methods?a.Shaving the site on the day before surgeryb.Applying a topical antiseptic to the skin on
the evening beforesurgeryc.Having the patient take a tub bath on the morning of surgery d.Having the patient shower with an
antiseptic soap on the eveningv=before and the morning of surgery47.When transferring a patient from a bed to a chair, the nurse should usewhich
muscles to avoid back injury?a . A b d o m i n a l m u s c l e s b . B a c k m u s c l e s c . L e g m u s c l e s d . U p p e r
a r m m u s c l e s 48.Thrombophlebitis typically develops in patients with which of the followingconditions?a.Increases partial thromboplastin
timeb.Acute pulsus paradoxusc.An impaired or traumatized blood vessel walld.Chronic Obstructive Pulmonary Disease
(COPD)49.In a recumbent, immobilized patient, lung ventilation can become altered,leading to such respiratory complications as:a.Respiratory
acidosis, ateclectasis, and hypostatic pneumoniab.Appneustic breathing, atypical pneumonia and respiratory alkalosisc.CheyneStrokes respirations and spontaneous pneumothoraxd.Kussmails respirations and hypoventilation50.Immobility impairs bladder
elimination, resulting in such disorders asa.Increased urine acidity and relaxation of the perineal muscles,causing incontinenceb.Urine
retention, bladder distention, and infectionc.Diuresis, natriuresis, and decreased urine specific gravityd.Decreased calcium
and phosphate levels in the urine
ANSWERS AND RATIONALE FOUNDATION OF NURSING
1.
D
. In the circular chain of infection, pathogens must be able to leave their reservoir and be transmitted to a susceptible host through a portal of entry, such
as broken skin.
2.
C

. Respiratory isolation, like strict isolation, requires that the door to thedoor patients room remain closed. However, the patients room should bewell
ventilated, so opening the window or turning on the ventricular isdesirable. The nurse does not need to wear gloves for respiratoryisolation, but good
hand washing is important for all types of isolation.
3.
A
. Leukopenia is a decreased number of leukocytes (white blood cells),which are important in resisting infection. None of the other situationswould put the
patient at risk for contracting an infection; taking broad-spectrum antibiotics might actually reduce the infection risk.
4.
A
. Soaps and detergents are used to help remove bacteria because of their ability to lower the surface tension of water and act as emulsifyingagents. Hot
water may lead to skin irritation or burns.
5.
A
. Depending on the degree of exposure to pathogens, hand washingmay last from 10 seconds to 4 minutes. After routine patient contact, handwashing for
30 seconds effectively minimizes the risk of pathogentransmission.
6.
B
. The urinary system is normally free of microorganisms except at theurinary meatus. Any procedure that involves entering this system mustuse
surgically aseptic measures to maintain a bacteria-free state.
7.
C
. All invasive procedures, including surgery, catheter insertion, andadministration of parenteral therapy, require sterile technique to maintain asterile
environment. All equipment must be sterile, and the nurse and thephysician must wear sterile gloves and maintain surgical asepsis. In theoperating
room, the nurse and physician are required to wear sterilegowns, gloves, masks, hair covers, and shoe covers for all invasiveprocedures. Strict isolation
requires the use of clean gloves, masks,gowns and equipment to prevent the transmission of highly communicablediseases by contact or by airborne
routes. Terminal disinfection is thedisinfection of all contaminated supplies and equipment after a patient hasbeen discharged to prepare them for reuse
by another patient. Thepurpose of protective (reverse) isolation is to prevent a person withseriously impaired resistance from coming into contact who
potentiallypathogenic organisms.
8.
C
. The edges of a sterile field are considered contaminated. When sterileitems are allowed to come in contact with the edges of the field, the sterileitems
also become contaminated.
9.
B
. Hair on or within body areas, such as the nose, traps and holdsparticles that contain microorganisms. Yawning and hiccupping do notprevent
microorganisms from entering or leaving the body. Rapid eyemovement marks the stage of sleep during which dreaming occurs.
10.
D
. The inside of the glove is always considered to be clean, but not sterile

11.
A
. The back of the gown is considered clean, the front is contaminated.So, after removing gloves and washing hands, the nurse should untie theback of
the gown; slowly move backward away from the gown, holding theinside of the gown and keeping the edges off the floor; turn and fold thegown inside
out; discard it in a contaminated linen container; then washher hands again.
12.
B
. According to the Centers for Disease Control (CDC), blood-to-bloodcontact occurs most commonly when a health care worker attempts to capa used
needle. Therefore, used needles should never be recapped;instead they should be inserted in a specially designed puncture resistant,labeled container.
Wearing gloves is not always necessary whenadministering an I.M. injection. Enteric precautions prevent the transfer of pathogens via feces.
13.
A
. Nurses and other health care professionals previously believed thatmassaging a reddened area with lotion would promote venous return andreduce
edema to the area. However, research has shown that massageonly increases the likelihood of cellular ischemia and necrosis to the area.
14.
B
. Before a blood transfusion is performed, the blood of the donor andrecipient must be checked for compatibility. This is done by blood typing (atest
that determines a persons blood type) and cross-matching (aprocedure that determines the compatibility of the donors and recipientsblood after the
blood types has been matched). If the blood specimens areincompatible, hemolysis and antigen-antibody reactions will occur.
15.
A
. Platelets are disk-shaped cells that are essential for blood coagulation.A platelet count determines the number of thrombocytes in blood availablefor
promoting hemostasis and assisting with blood coagulation after injury.It also is used to evaluate the patients potential for bleeding; however, thisis not
its primary purpose. The normal count ranges from 150,000 to350,000/mm
3
. A count of 100,000/mm
3
or less indicates a potential for bleeding; count of less than 20,000/mm
3
is associated with spontaneousbleeding.
16.
D
. Leukocytosis is any transient increase in the number of white bloodcells (leukocytes) in the blood. Normal WBC counts range from 5,000
to100,000/mm
3
. Thus, a count of 25,000/mm
3
indicates leukocytosis.

17.
A
. Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level), which is a potential sideeffect of
diuretic therapy. The physician usually orders supplementalpotassium to prevent hypokalemia in patients receiving diuretics. Anorexiais another
symptom of hypokalemia. Dysphagia means difficultyswallowing.
18.
A
. Pregnancy or suspected pregnancy is the only contraindication for achest X-ray. However, if a chest X-ray is necessary, the patient can wear a lead
apron to protect the pelvic region from radiation. Jewelry, metallicobjects, and buttons would interfere with the X-ray and thus should not beworn
above the waist. A signed consent is not required because a chest
X-ray is not an invasive examination. Eating, drinking and medications areallowed because the X-ray is of the chest, not the abdominal region.
19.
A
. Obtaining a sputum specimen early in this morning ensures anadequate supply of bacteria for culturing and decreases the risk of contamination from
food or medication.
20.
A
. Initial sensitivity to penicillin is commonly manifested by a skin rash,even in individuals who have not been allergic to it previously. Because of the
danger of anaphylactic shock, he nurse should withhold the drug andnotify the physician, who may choose to substitute another drug.Administering an
antihistamine is a dependent nursing intervention thatrequires a written physicians order. Although applying corn starch to therash may relieve
discomfort, it is not the nurses top priority in such apotentially life-threatening situation.
21.
D
. The Z-track method is an I.M. injection technique in which the patientsskin is pulled in such a way that the needle track is sealed off after theinjection.
This procedure seals medication deep into the muscle, therebyminimizing skin staining and irritation. Rubbing the injection site iscontraindicated
because it may cause the medication to extravasate intothe skin.
22.
D
. The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is viewed by many clinicians as the site of choice for I.M.injections
because it has relatively few major nerves and blood vessels.The middle third of the muscle is recommended as the injection site. Thepatient can be in a
supine or sitting position for an injection into this site.
23.
A
. The mid-deltoid injection site can accommodate only 1 ml or less of medication because of its size and location (on the deltoid muscle of thearm, close
to the brachial artery and radial nerve).
24.
D

. A 25G, 5/8 needle is the recommended size for insulin injectionbecause insulin is administered by the subcutaneous route. An 18G, 1 needle is
usually used for I.M. injections in children, typically in the vastuslateralis. A 22G, 1 needle is usually used for adult I.M. injections, whichare typically
administered in the vastus lateralis or ventrogluteal site.
25.
D
. Because an intradermal injection does not penetrate deeply into theskin, a small-bore 25G needle is recommended. This type of injection isused
primarily to administer antigens to evaluate reactions for allergy or sensitivity studies. A 20G needle is usually used for I.M. injections of oil-based
medications; a 22G needle for I.M. injections; and a 25G needle, for I.M. injections; and a 25G needle, for subcutaneous insulin injections.
26.
A
. Parenteral penicillin can be administered I.M. or added to a solutionand given I.V. It cannot be administered subcutaneously or intradermally.
27.
D
. gr 10 x 60mg/gr 1 = 600 mg
28.
C
. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute
29.
A
. Hemoglobinuria, the abnormal presence of hemoglobin in the urine,indicates a hemolytic reaction (incompatibility of the donors andrecipients
blood). In this reaction, antibodies in the recipients plasmacombine rapidly with donor RBCs; the cells are hemolyzed in either
circulatory or reticuloendothelial system. Hemolysis occurs more rapidly inABO incompatibilities than in Rh incompatibilities. Chest pain and
urticariamay be symptoms of impending anaphylaxis. Distended neck veins are anindication of hypervolemia.
30.
C
. In real failure, the kidney loses their ability to effectively eliminatewastes and fluids. Because of this, limiting the patients intake of oral andI.V. fluids
may be necessary. Fever, chronic obstructive pulmonarydisease, and dehydration are conditions for which fluids should beencouraged.
31.
D
. Phlebitis, the inflammation of a vein, can be caused by chemicalirritants (I.V. solutions or medications), mechanical irritants (the needle or catheter
used during venipuncture or cannulation), or a localized allergicreaction to the needle or catheter. Signs and symptoms of phlebitisinclude pain or
discomfort, edema and heat at the I.V. insertion site, and ared streak going up the arm or leg from the I.V. insertion site.
32.
D
. Return demonstration provides the most certain evidence for evaluatingthe effectiveness of patient teaching.
33.
D

. Capsules, enteric-coated tablets, and most extended duration or sustained release products should not be dissolved for use in agastrostomy tube. They
are pharmaceutically manufactured in these formsfor valid reasons, and altering them destroys their purpose. The nurseshould seek an alternate
physicians order when an ordered medication isinappropriate for delivery by tube.
34.
D
. A drug-allergy is an adverse reaction resulting from an immunologicresponse following a previous sensitizing exposure to the drug. Thereaction can
range from a rash or hives to anaphylactic shock.
Tolerance
to a drug means that the patient experiences a decreasing physiologicresponse to repeated administration of the drug in the same dosage.
Idiosyncrasy
is an individuals unique hypersensitivity to a drug, food, or other substance; it appears to be genetically determined.
Synergism
, is adrug interaction in which the sum of the drugs combined effects is greater than that of their separate effects.
35.
D
. A hemoglobin and hematocrit count would be ordered by the physicianif bleeding were suspected. The other answers are appropriate
nursinginterventions for a patient who has undergone femoral arteriography.
36.
A
. Coughing, a protective response that clears the respiratory tract of irritants, usually is involuntary; however it can be voluntary, as when apatient is
taught to perform coughing exercises. An antitussive druginhibits coughing. Splinting the abdomen supports the abdominal muscleswhen a patient
coughs.
37.
C
. In an infected patient, shivering results from the bodys attempt toincrease heat production and the production of neutrophils andphagocytotic action
through increased skeletal muscle tension andcontractions. Initial vasoconstriction may cause skin to feel cold to thetouch. Applying additional bed
clothes helps to equalize the body
temperature and stop the chills. Attempts to cool the body result in further shivering, increased metabloism, and thus increased heat production.
38.
D
. A clinical nurse specialist must have completed a masters degree in aclinical specialty and be a registered professional nurse. The NationalLeague of
Nursing accredits educational programs in nursing and providesa testing service to evaluate student nursing competence but it does notcertify nurses.
The American Nurses Association identifies requirementsfor certification and offers examinations for certification in many areas of nursing., such as
medical surgical nursing. These certification(credentialing) demonstrates that the nurse has the knowledge and theability to provide high quality
nursing care in the area of her certification. Agraduate of an associate degree program is not a clinical nurse specialist:however, she is prepared to
provide bed side nursing with a high degreeof knowledge and skill. She must successfully complete the licensingexamination to become a registered
professional nurse.
39.

D
. Microorganisms usually do not grow in an acidic environment.
40.
D
. Bile colors the stool brown. Any inflammation or obstruction that impairsbile flow will affect the stool pigment, yielding light, clay-colored stool.Upper
GI bleeding results in black or tarry stool. Constipation ischaracterized by small, hard masses. Many medications and foods willdiscolor stool for
example, drugs containing iron turn stool black.; beetsturn stool red.
41.
D
. In the evaluation step of the nursing process, the nurse must decidewhether the patient has achieved the expected outcome that wasidentified in the
planning phase.
42.
A
. The main sources of vitamin A are yellow and green vegetables (suchas carrots, sweet potatoes, squash, spinach, collard greens, broccoli, andcabbage)
and yellow fruits (such as apricots, and cantaloupe). Animalsources include liver, kidneys, cream, butter, and egg yolks.
43.
D
. Maintaing the drainage tubing and collection bag level with the patientsbladder could result in reflux of urine into the kidney. Irrigating the
bladder with Neosporin and clamping the catheter for 1 hour every 4 hours mustbe prescribed by a physician.
44.
D
. The ELISA test of venous blood is used to assess blood and potentialblood donors to human immunodeficiency virus (HIV). A positive ELISAtest
combined with various signs and symptoms helps to diagnoseacquired immunodeficiency syndrome (AIDS)
45.
D
. Tachypnea (an abnormally rapid rate of breathing) would indicate thatthe patient was still hypoxic (deficient in oxygen).The partial pressures
of arterial oxygen and carbon dioxide listed are within the normal range.Eupnea refers to normal respiration.
46.
D
. Studies have shown that showering with an antiseptic soap beforesurgery is the most effective method of removing microorganisms from theskin.
Shaving the site of the intended surgery might cause breaks in theskin, thereby increasing the risk of infection; however, if indicated,shaving, should be
done immediately before surgery, not the day before.
A topical antiseptic would not remove microorganisms and would bebeneficial only after proper cleaning and rinsing. Tub bathing mighttransfer
organisms to another body site rather than rinse them away.
47.
C
. The leg muscles are the strongest muscles in the body and should bear the greatest stress when lifting. Muscles of the abdomen, back, and upper arms
may be easily injured.

48.
C
. The factors, known as Virchows triad, collectively predispose a patientto thromboplebitis; impaired venous return to the heart,
bloodhypercoagulability, and injury to a blood vessel wall. Increased partialthromboplastin time indicates a prolonged bleeding time during fibrin
clotformation, commonly the result of anticoagulant (heparin) therapy. Arterialblood disorders (such as pulsus paradoxus) and lung diseases (such
asCOPD) do not necessarily impede venous return of injure vessel walls.
49.
A
. Because of restricted respiratory movement, a recumbent, immobilizepatient is at particular risk for respiratory acidosis from poor gasexchange;
atelectasis from reduced surfactant and accumulated mucus inthe bronchioles, and hypostatic pneumonia from bacterial growth causedby stasis of
mucus secretions.
50.
B
. The immobilized patient commonly suffers from urine retention causedby decreased muscle tone in the perineum. This leads to bladder distention
and urine stagnation, which provide an excellent medium for bacterial growth leading to infection. Immobility also results in morealkaline urine with
excessive amounts of calcium, sodium and phosphate,a gradual decrease in urine production, and an increased specific gravity.
MATERNAL AND CHILD HEALTH
1.For the client who is using oral contraceptives, the nurse informs the clientabout the need to take the pill at the same time each day to
accomplishwhich of the following?a.Decrease the incidence of nauseab.Maintain hormonal
levelsc . R e d u c e s i d e e f f e c t s d.Prevent drug interactions 2.When teaching a client about contraception. Which of the following
wouldthe nurse include as the most effective method for preventing sexuallytransmitted infections?
a . S p e r m i c i d e s b . D i a p h r a g m c . C o n d o m s d . V a s e c t o m y 3.When preparing a woman who is 2 days postpartum
for discharge,recommendations for which of the following contraceptive methods wouldbe avoided?
a . D i a p h r a g m b . F e m a l e c o n d o m c.Oral contraceptivesd . R h y t h m m e t h o d
4.
For which of the following clients would the nurse expect that anintrauterine device would
not
be recommended?a . W o m a n o v e r a g e 3 5 b . N u l l i p a r o u s w o m a n c.Promiscuous young adult d . P o s t p a r t u m c l i e n t 5.A
client in her third trimester tells the nurse, Im constipated all the time!Which of the following should the nurse recommend?
a . D a i l y e n e m a s b . L a x a t i v e s c.Increased fiber intaked.Decreased fluid intake 6.Which of the following would the
nurse use as the basis for the teachingplan when caring for a pregnant teenager concerned about gaining toomuch weight during pregnancy?
a.10 pounds per trimester b.1 pound per week for 40 weeksc. pound per week for 40 weeksd.A total gain of 25 to
30 pounds 7.The client tells the nurse that her last menstrual period started on January14 and ended on January 20. Using Nageles rule,
the nurse determinesher EDD to be which of the following?a . S e p t e m b e r 2 7
b . O c t o b e r 2 1 c . N o v e m b e r 7 d . D e c e m b e r 2 7 8.When taking an obstetrical history on a pregnant client who states, I
hada son born at 38 weeks gestation, a daughter born at 30 weeks gestationand I lost a baby at about 8 weeks, the nurse should record her obstetrical
history as which of the following?a . G 2 T 2 P 0 A 0 L 2 b . G 3 T 1 P 1 A 0 L 2 c . G 3 T 2 P 0 A 0 L 2 d . G 4 T 1 P 1 A 1

L 2 9.When preparing to listen to the fetal heart rate at 12 weeks gestation, thenurse would use which of the following?a.Stethoscope
placed midline at the umbilicusb.Doppler placed midline at the suprapubic region c.Fetoscope placed midway between
the umbilicus and the xiphoidprocessd.External electronic fetal monitor placed at the umbilicus10.When developing a plan of care for a client
newly diagnosed withgestational diabetes, which of the following instructions would be thepriority?a . D i e t a r y
i n t a k e b . M e d i c a t i o n c . E x e r c i s e d . G l u c o s e m o n i t o r i n g 11.A client at 24 weeks gestation has gained 6 pounds in 4 weeks.
Which of the following would be the priority when assessing the client?
a . G l u c o s u r i a b . D e p r e s s i o n c . H a n d / f a c e e d e m a d . D i e t a r y i n t a k e 12.A client 12 weeks pregnant come to the emergency
department withabdominal cramping and moderate vaginal bleeding. Speculumexamination reveals 2 to 3 cms cervical dilation. The nurse
woulddocument these findings as which of the following?a.Threatened abortionb . I m m i n e n t a b o r t i o n c . C o m p l e t e
a b o r t i o n d . M i s s e d a b o r t i o n 13.Which of the following would be the priority nursing diagnosis for a clientwith an ectopic pregnancy?
a . R i s k f o r i n f e c t i o n b . P a i n c . K n o w l e d g e D e f i c i t d.Anticipatory Grieving
14.Before assessing the postpartum clients uterus for firmness and positionin relation to the umbilicus and midline, which of the following should
thenurse do first?a.Assess the vital signsb.Administer analgesiac.Ambulate her in the halld.Assist
her to urinate15.Which of the following should the nurse do when a primipara who islactating tells the nurse that she has sore nipples?a.Tell her
to breast feed more frequentlyb.Administer a narcotic before breast feedingc.Encourage her to wear a nursing
brassiered.Use soap and water to clean the nipples 16.The nurse assesses the vital signs of a client, 4 hours postpartum that areas follows:
BP 90/60; temperature 100.4F; pulse 100 weak, thready; R 20per minute. Which of the following should the nurse do first?a.Report the
temperature to the physicianb.Recheck the blood pressure with another cuff c.Assess the uterus for firmness and
positiond.Determine the amount of lochia17.The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which of the
following assessments would warrant notification of the physician?a.A dark red discharge on a 2-day postpartum clientb.A pink to
brownish discharge on a client who is 5 days postpartumc.Almost colorless to creamy discharge on a client 2 weeks after deliveryd.A
bright red discharge 5 days after delivery18.A postpartum client has a temperature of 101.4F, with a uterus that istender when palpated,
remains unusually large, and not descending asnormally expected. Which of the following should the nurse assess next?
a . L o c h i a b . B r e a s t s c . I n c i s i o n d . U r i n e 19.Which of the following is the priority focus of nursing practice with thecurrent
early postpartum discharge?a.Promoting comfort and restoration of healthb.Exploring the emotional status of the
familyc.Facilitating safe and effective self-and newborn cared.Teaching about the importance of family planning
20.
Which of the following actions would be l
east
effective in maintaining aneutral thermal environment for the newborn?a.Placing infant under radiant warmer after
bathingb.Covering the scale with a warmed blanket prior to weighingc.Placing crib close to nursery window for family viewing
d.Covering the infants head with a knit stockinette 21.A newborn who has an asymmetrical Moro reflex response should befurther assessed
for which of the following?a.Talipes equinovarus b . F r a c t u r e d c l a v i c l e c.Congenital
hypothyroidism d.Increased intracranial pressure22.During the first 4 hours after a male circumcision, assessing for which of the following
is the priority?a . I n f e c t i o n b . H e m o r r h a g e c . D i s c o m f o r t d . D e h y d r a t i o n 23.The mother asks the nurse. Whats wrong with
my sons breasts? Whyare they so enlarged? Whish of the following would be the best responseby the nurse?a.The breast tissue is inflamed from
the trauma experienced withbirthb.A decrease in material hormones present before birth causesenlargement,c.You should discuss

this with your doctor. It could be a malignancyd.The tissue has hypertrophied while the baby was in the uterus24.Immediately after
birth the nurse notes the following on a male newborn:respirations 78; apical hearth rate 160 BPM, nostril flaring; mild intercostalretractions; and
grunting at the end of expiration. Which of the followingshould the nurse do?a.Call the assessment data to the physicians
attentionb.Start oxygen per nasal cannula at 2 L/min.c.Suction the infants mouth and naresd.Recognize this as normal
first period of reactivity25.The nurse hears a mother telling a friend on the telephone about umbilicalcord care. Which of the following statements
by the mother indicateseffective teaching?a.Daily soap and water cleansing is bestb.Alcohol helps it dry and kills germsc.An
antibiotic ointment applied daily prevents infectiond.He can have a tub bath each day26.A newborn weighing 3000 grams and
feeding every 4 hours needs 120calories/kg of body weight every 24 hours for proper growth anddevelopment. How many ounces of 20 cal/oz formula
should this newbornreceive at each feeding to meet nutritional needs?a . 2 o u n c e s b . 3 o u n c e s c . 4 o u n c e s d . 6 o u n c e s
27.The postterm neonate with meconium-stained amniotic fluid needs caredesigned to especially monitor for which of the following?
a.Resp irato ry pro blem sb.Gastrointestin al p roblemsc .I ntegum en tary p roblems d.Elimin ation p roblems 28.When
measuring a clients fundal height, which of the following techniquesdenotes the correct method of measurement used by the nurse?a.From the
xiphoid process to the umbilicusb.From the symphysis pubis to the xiphoid processc.From the symphysis pubis to
the fundusd.From the fundus to the umbilicus29.A client with severe preeclampsia is admitted with of BP 160/110,proteinuria, and severe
pitting edema. Which of the following would bemost important to include in the clients plan of care?a . D a i l y
w e i g h t s b.Seizure precaution sc.Right lateral positio ning d . S t r e s s r e d u c t i o n 30.A postpartum primipara asks the nurse,
When can we have sexualintercourse again? Which of the following would be the nurses bestresponse?a.A nytime you both wan t to. b.As
soon as choose a contraceptive method.c.When the discharge has stopped and the incision is healed.d.After your
6 weeks examination.31.When preparing to administer the vitamin K injection to a neonate, thenurse would select which of the following sites as
appropriate for theinjection?a . D e l t o i d m u s c l e b.A nterio r femo ris musc lec.Vastus lateralis muscled .Gluteus m ax imus
muscle 32.When performing a pelvic examination, the nurse observes a red swollenarea on the right side of the vaginal orifice. The nurse would
documentthis as enlargement of which of the following?a . C l i t o r i s b . P a r o t i d g l a n d c . S k e n e s g l a n d d . B a r t h o l i n s
g l a n d 33.To differentiate as a female, the hormonal stimulation of the embryo thatmust occur involves which of the following?a.Increase in
maternal estrogen secretionb.Decrease in maternal androgen secretionc.Secretion of androgen by the fetal
gonadd.Secretion of estrogen by the fetal gonad
34.A client at 8 weeks gestation calls complaining of slight nausea in themorning hours. Which of the following client interventions should the
nursequestion?a.Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water b.Eating a few low-sodium
crackers before getting out of bedc.Avoiding the intake of liquids in the morning hoursd.Eating six small meals a day instead
of thee large meals35.The nurse documents positive ballottement in the clients prenatal record.The nurse understands that this indicates which of
the following?a.Palpable contractions on the abdomenb.Passive movement of the unengaged fetusc.Fetal kicking felt by the
clientd.Enlargement and softening of the uterus36.During a pelvic exam the nurse notes a purple-blue tinge of the cervix.The nurse
documents this as which of the following?a . B r a x t o n - H i c k s
s i g n b . C h a d w i c k s s i g n c . G o o d e l l s s i g n d . M c D o n a l d s s i g n 37.During a prenatal class, the nurse explains the rationale for
breathingtechniques during preparation for labor based on the understanding thatbreathing techniques are most important in achieving which of
thefollowing?a.Eliminate pain and give the expectant parents something to dob.Reduce the risk of fetal distress by
increasing uteroplacentalperfusionc.Facilitate relaxation, possibly reducing the perception of paind.Eliminate pain so that less analgesia
and anesthesia are needed38.After 4 hours of active labor, the nurse notes that the contractions of aprimigravida client are not strong

enough to dilate the cervix. Which of thefollowing would the nurse anticipate doing?a.Obtaining an order to begin IV oxytocin
infusionb.Administering a light sedative to allow the patient to rest for severalhour c.Preparing for a cesarean section for failure to
progressd.Increasing the encouragement to the patient when pushing begins39.A multigravida at 38 weeks gestation is admitted with
painless, bright redbleeding and mild contractions every 7 to 10 minutes. Which of thefollowing assessments should be avoided?a . M a t e r n a l v i t a l
s i g n b . F e t a l h e a r t r a t e c.Contraction monitoring d . C e r v i c a l d i l a t i o n
40.Which of the following would be the nurses most appropriate response toa client who asks why she must have a cesarean delivery if she has
acomplete placenta previa?a.You will have to ask your physician when he returns.b.You need a cesarean to prevent
hemorrhage.c.The placenta is covering most of your cervix.d.The placenta is covering the opening of the uterus and
blockingyour baby.41.The nurse understands that the fetal head is in which of the followingpositions with a face presentation?a . C o m p l e t e l y
f l e x e d b.Completely extendedc . P a r t i a l l y e x t e n d e d d . P a r t i a l l y f l e x e d 42.With a fetus in the left-anterior breech presentation,
the nurse wouldexpect the fetal heart rate would be most audible in which of the followingareas?a.Above the maternal umbilicus and to the
right of midlineb.In the lower-left maternal abdominal quadrantc.In the lower-right maternal abdominal quadrantd.Above
the maternal umbilicus and to the left of midline 43.The amniotic fluid of a client has a greenish tint. The nurse interprets thisto be the result
of which of the following?a . L a n u g o b . H y d r a m n i o c . M e c o n i u m d . V e r n i x 44.A patient is in labor and has just been told
she has a breech presentation.The nurse should be particularly alert for which of the following?
a . Q u i c k e n i n g b.Ophthalmia neonatorumc . P i c a d.Prolapsed umbilical cord 45.When describing dizygotic twins to a
couple, on which of the followingwould the nurse base the explanation?a.Two ova fertilized by separate spermb.Sharing of a common
placentac.Each ova with the same genotyped.Sharing of a common chorion 46.Which of the following refers to the single cell
that reproduces itself after conception?a . C h r o m o s o m e b . B l a s t o c y s t c . Z y g o t e d . T r o p h o b l a s t
47.In the late 1950s, consumers and health care professionals beganchallenging the routine use of analgesics and anesthetics during childbirth.Which of
the following was an outgrowth of this concept?a.Labor, delivery, recovery, postpartum (LDRP)b . N u r s e - m i d w i f e r y c.Clin ic al
n urse sp ecialistd.Prep ared childbirth 48.A client has a midpelvic contracture from a previous pelvic injury due to amotor vehicle accident as
a teenager. The nurse is aware that this couldprevent a fetus from passing through or around which structure duringchildbirth?
a . S y m p h y s i s p u b i s b . S a c r a l p r o m o n t o r y c . I s c h i a l s p i n e s d . P u b i c a r c h 49.When teaching a group of adolescents about
variations in the length of themenstrual cycle, the nurse understands that the underlying mechanism isdue to variations in which of the following phases?
a . M e n s t r u a l p h a s e b.Proliferative phase c . S e c r e t o r y p h a s e d . I s c h e m i c p h a s e 50.When teaching a group of adolescents
about male hormone production,which of the following would the nurse include as being produced by theLeydig cells?a.Folliclestimulating hormoneb . T e s t o s t e r o n e c .Leuteinizin g ho rmo ne d.Gonadotropin releasing hormone
ANSWERS AND RATIONALE MATERNAL AND CHILD HEALTH
1.
B
. Regular timely ingestion of oral contraceptives is necessary to maintainhormonal levels of the drugs to suppress the action of the hypothalamusand
anterior pituitary leading to inappropriate secretion of FSH and LH.Therefore, follicles do not mature, ovulation is inhibited, and pregnancy
isprevented. The estrogen content of the oral site contraceptive may causethe nausea, regardless of when the pill is taken. Side effects and
druginteractions may occur with oral contraceptives regardless of the time thepill is taken.
2.

C
. Condoms, when used correctly and consistently, are the most effectivecontraceptive method or barrier against bacterial and viral sexuallytransmitted
infections. Although spermicides kill sperm, they do notprovide reliable protection against the spread of sexually transmittedinfections, especially
intracellular organisms such as HIV. Insertion andremoval of the diaphragm along with the use of the spermicides maycause vaginal irritations, which
could place the client at risk for infectiontransmission. Male sterilization eliminates spermatozoa from the ejaculate,but it does not eliminate bacterial
and/or viral microorganisms that cancause sexually transmitted infections.
3.
A
. The diaphragm must be fitted individually to ensure effectiveness.Because of the changes to the reproductive structures during pregnancyand
following delivery, the diaphragm must be refitted, usually at the 6weeks examination following childbirth or after a weight loss of 15 lbs or more. In
addition, for maximum effectiveness, spermicidal jelly should beplaced in the dome and around the rim. However, spermicidal jelly shouldnot be
inserted into the vagina until involution is completed atapproximately 6 weeks. Use of a female condom protects the reproductivesystem from the
introduction of semen or spermicides into the vagina andmay be used after childbirth. Oral contraceptives may be started within thefirst postpartum
week to ensure suppression of ovulation. For the couplewho has determined the females fertile period, using the rhythm method,avoidance of
intercourse during this period, is safe and effective.
4.
C
. An IUD may increase the risk of pelvic inflammatory disease, especiallyin women with more than one sexual partner, because of the increasedrisk of
sexually transmitted infections. An UID should not be used if thewoman has an active or chronic pelvic infection, postpartum infection,endometrial
hyperplasia or carcinoma, or uterine abnormalities. Age is nota factor in determining the risks associated with IUD use. Most IUD usersare over the age
of 30. Although there is a slightly higher risk for infertilityin women who have never been pregnant, the IUD is an acceptable optionas long as the riskbenefit ratio is discussed. IUDs may be insertedimmediately after delivery, but this is not recommended because of theincreased risk and rate of
expulsion at this time
5.
C
. During the third trimester, the enlarging uterus places pressure on theintestines. This coupled with the effect of hormones on smooth musclerelaxation
causes decreased intestinal motility (peristalsis). Increasingfiber in the diet will help fecal matter pass more quickly through theintestinal tract, thus
decreasing the amount of water that is absorbed. As aresult, stool is softer and easier to pass. Enemas could precipitate pretermlabor and/or electrolyte
loss and should be avoided. Laxatives may causepreterm labor by stimulating peristalsis and may interfere with theabsorption of nutrients. Use for more
than 1 week can also lead to laxativedependency. Liquid in the diet helps provide a semisolid, soft consistencyto the stool. Eight to ten glasses of fluid per
day are essential to maintainhydration and promote stool evacuation.
6.
D
. To ensure adequate fetal growth and development during the 40 weeksof a pregnancy, a total weight gain 25 to 30 pounds is recommended: 1.5pounds
in the first 10 weeks; 9 pounds by 30 weeks; and 27.5 pounds by40 weeks. The pregnant woman should gain less weight in the first andsecond trimester
than in the third. During the first trimester, the clientshould only gain 1.5 pounds in the first 10 weeks, not 1 pound per week. Aweight gain of pound
per week would be 20 pounds for the totalpregnancy, less than the recommended amount.
7.

B
. To calculate the EDD by Nageles rule, add 7 days to the first day of thelast menstrual period and count back 3 months, changing the year appropriately.
To obtain a date of September 27, 7 days have been addedto the last day of the LMP (rather than the first day of the LMP), plus 4months (instead of 3
months) were counted back. To obtain the date of November 7, 7 days have been subtracted (instead of added) from thefirst day of LMP plus November
indicates counting back 2 months (insteadof 3 months) from January. To obtain the date of December 27, 7 dayswere added to the last day of the LMP
(rather than the first day of theLMP) and December indicates counting back only 1 month (instead of 3months) from January.
8.
D.
The client has been pregnant four times, including current pregnancy(G). Birth at 38 weeks gestation is considered full term (T), while birthform 20
weeks to 38 weeks is considered preterm (P). A spontaneousabortion occurred at 8 weeks (A). She has two living children (L).
9.
B.
At 12 weeks gestation, the uterus rises out of the pelvis and is palpableabove the symphysis pubis. The Doppler intensifies the sound of the fetalpulse rate
so it is audible. The uterus has merely risen out of the pelvisinto the abdominal cavity and is not at the level of the umbilicus. The fetalheart rate at this age
is not audible with a stethoscope. The uterus at 12weeks is just above the symphysis pubis in the abdominal cavity, notmidway between the umbilicus
and the xiphoid process. At 12 weeks theFHR would be difficult to auscultate with a fetoscope. Although theexternal electronic fetal monitor would
project the FHR, the uterus has notrisen to the umbilicus at 12 weeks.
10.
A.
Although all of the choices are important in the management of diabetes, diet therapy is the mainstay of the treatment plan and shouldalways be the
priority. Women diagnosed with gestational diabetesgenerally need only diet therapy without medication to control their bloodsugar levels. Exercise, is
important for all pregnant women and especiallyfor diabetic women, because it burns up glucose, thus decreasing bloodsugar. However, dietary intake,
not exercise, is the priority. All pregnantwomen with diabetes should have periodic monitoring of serum glucose.However, those with gestational
diabetes generally do not need dailyglucose monitoring. The standard of care recommends a fasting and 2-hour postprandial blood sugar level every 2
weeks.
11.
C.
After 20 weeks gestation, when there is a rapid weight gain,preeclampsia should be suspected, which may be caused by fluidretention manifested by
edema, especially of the hands and face. Thethree classic signs of preeclampsia are hypertension, edema, andproteinuria. Although urine is checked for
glucose at each clinic visit, thisis not the priority. Depression may cause either anorexia or excessivefood intake, leading to excessive weight gain or loss.
This is not, however,the priority consideration at this time. Weight gain thought to be caused byexcessive food intake would require a 24-hour diet recall.
However,excessive intake would not be the primary consideration for this client atthis time.
12.
B.
Cramping and vaginal bleeding coupled with cervical dilation signifiesthat termination of the pregnancy is inevitable and cannot be prevented.Thus, the
nurse would document an imminent abortion. In a threatenedabortion, cramping and vaginal bleeding are present, but there is nocervical dilation. The
symptoms may subside or progress to abortion. In acomplete abortion all the products of conception are expelled. A missedabortion is early fetal
intrauterine death without expulsion of the productsof conception.

13.
B.
For the client with an ectopic pregnancy, lower abdominal pain, usuallyunilateral, is the primary symptom. Thus, pain is the priority. Although
thepotential for infection is always present, the risk is low in ectopicpregnancy because pathogenic microorganisms have not been introducedfrom
external sources. The client may have a limited knowledge of thepathology and treatment of the condition and will most likely experiencegrieving, but
this is not the priority at this time.
14.
D.
Before uterine assessment is performed, it is essential that the womanempty her bladder. A full bladder will interfere with the accuracy of theassessment
by elevating the uterus and displacing to the side of themidline. Vital sign assessment is not necessary unless an abnormality inuterine assessment is
identified. Uterine assessment should not causeacute pain that requires administration of analgesia. Ambulating the clientis an essential component of
postpartum care, but is not necessary prior to assessment of the uterus.
15.
A.
Feeding more frequently, about every 2 hours, will decrease the infantsfrantic, vigorous sucking from hunger and will decrease breastengorgement,
soften the breast, and promote ease of correct latching-onfor feeding. Narcotics administered prior to breast feeding are passedthrough the breast milk to
the infant, causing excessive sleepiness. Nipplesoreness is not severe enough to warrant narcotic analgesia. Allpostpartum clients, especially lactating
mothers, should wear a supportivebrassiere with wide cotton straps. This does not, however, prevent or reduce nipple soreness. Soaps are drying to the
skin of the nipples andshould not be used on the breasts of lactating mothers. Dry nipple skinpredisposes to cracks and fissures, which can become sore
and painful.
16.
D.
A weak, thready pulse elevated to 100 BPM may indicate impendinghemorrhagic shock. An increased pulse is a compensatory mechanism of the body in
response to decreased fluid volume. Thus, the nurse shouldcheck the amount of lochia present. Temperatures up to 100.48F in thefirst 24 hours after
birth are related to the dehydrating effects of labor andare considered normal. Although rechecking the blood pressure may be acorrect choice of action, it
is not the first action that should beimplemented in light of the other data. The data indicate a potentialimpending hemorrhage. Assessing the uterus for
firmness and position inrelation to the umbilicus and midline is important, but the nurse shouldcheck the extent of vaginal bleeding first. Then it would
be appropriate tocheck the uterus, which may be a possible cause of the hemorrhage.
17.
D.
Any bright red vaginal discharge would be considered abnormal, butespecially 5 days after delivery, when the lochia is typically pink tobrownish. Lochia
rubra, a dark red discharge, is present for 2 to 3 daysafter delivery. Bright red vaginal bleeding at this time suggests latepostpartum hemorrhage, which
occurs after the first 24 hours followingdelivery and is generally caused by retained placental fragments or bleeding disorders. Lochia rubra is the normal
dark red dischargeoccurring in the first 2 to 3 days after delivery, containing epithelial cells,erythrocyes, leukocytes and decidua. Lochia serosa is a pink to
brownishserosanguineous discharge occurring from 3 to 10 days after delivery thatcontains decidua, erythrocytes, leukocytes, cervical mucus,
andmicroorganisms. Lochia alba is an almost colorless to yellowish dischargeoccurring from 10 days to 3 weeks after delivery and containingleukocytes,
decidua, epithelial cells, fat, cervical mucus, cholesterolcrystals, and bacteria.
18.

A.
The data suggests an infection of the endometrial lining of the uterus.The lochia may be decreased or copious, dark brown in appearance, andfoul
smelling, providing further evidence of a possible infection. All theclients data indicate a uterine problem, not a breast problem. Typically,transient fever,
usually 101F, may be present with breast engorgement.Symptoms of mastitis include influenza-like manifestations. Localizedinfection of an episiotomy
or C-section incision rarely causes systemicsymptoms, and uterine involution would not be affected. The client data do
not include dysuria, frequency, or urgency, symptoms of urinary tractinfections, which would necessitate assessing the clients urine.
19.
C.
Because of early postpartum discharge and limited time for teaching,the nurses priority is to facilitate the safe and effective care of the clientand
newborn. Although promoting comfort and restoration of health,exploring the familys emotional status, and teaching about family planningare
important in postpartum/newborn nursing care, they are not the priorityfocus in the limited time presented by early post-partum discharge.
20.
C.
Heat loss by radiation occurs when the infants crib is placed too near cold walls or windows. Thus placing the newborns crib close to theviewing window
would be least effective. Body heat is lost throughevaporation during bathing. Placing the infant under the radiant warmer after bathing will assist the
infant to be rewarmed. Covering the scale witha warmed blanket prior to weighing prevents heat loss through conduction.A knit cap prevents heat loss
from the head a large head, a large bodysurface area of the newborns body.
21.
B.
A fractured clavicle would prevent the normal Moro response of symmetrical sequential extension and abduction of the arms followed byflexion and
adduction. In talipes equinovarus (clubfoot) the foot is turnedmedially, and in plantar flexion, with the heel elevated. The feet are notinvolved with the
Moro reflex. Hypothyroiddism has no effect on theprimitive reflexes. Absence of the Moror reflex is the most significantsingle indicator of central
nervous system status, but it is not a sign of increased intracranial pressure.
22.
B.
Hemorrhage is a potential risk following any surgical procedure.Although the infant has been given vitamin K to facilitate clotting, theprophylactic dose is
often not sufficient to prevent bleeding. Althoughinfection is a possibility, signs will not appear within 4 hours after thesurgical procedure. The primary
discomfort of circumcision occurs duringthe surgical procedure, not afterward. Although feedings are withheld prior to the circumcision, the chances of
dehydration are minimal.
23.
B.
The presence of excessive estrogen and progesterone in the maternal-fetal blood followed by prompt withdrawal at birth precipitates breastengorgement,
which will spontaneously resolve in 4 to 5 days after birth.The trauma of the birth process does not cause inflammation of thenewborns breast tissue.
Newborns do not have breast malignancy. Thisreply by the nurse would cause the mother to have undue anxiety. Breasttissue does not hypertrophy in
the fetus or newborns.
24.
D.

The first 15 minutes to 1 hour after birth is the first period of reactivityinvolving respiratory and circulatory adaptation to extrauterine life. Thedata given
reflect the normal changes during this time period. The infantsassessment data reflect normal adaptation. Thus, the physician does notneed to be
notified and oxygen is not needed. The data do not indicate thepresence of choking, gagging or coughing, which are signs of excessivesecretions.
Suctioning is not necessary
25.
B.
Application of 70% isopropyl alcohol to the cord minimizesmicroorganisms (germicidal) and promotes drying. The cord should bekept dry until it falls
off and the stump has healed. Antibiotic ointmentshould only be used to treat an infection, not as a prophylaxis. Infantsshould not be submerged in a tub
of water until the cord falls off and thestump has completely healed.
26.
B.
To determine the amount of formula needed, do the followingmathematical calculation. 3 kg x 120 cal/kg per day = 360 calories/dayfeeding q 4 hours =
6 feedings per day = 60 calories per feeding: 60calories per feeding; 60 calories per feeding with formula 20 cal/oz = 3ounces per feeding. Based on the
calculation. 2, 4 or 6 ounces areincorrect.
27.
A.
Intrauterine anoxia may cause relaxation of the anal sphincter andemptying of meconium into the amniotic fluid. At birth some of themeconium fluid
may be aspirated, causing mechanical obstruction or chemical pneumonitis. The infant is not at increased risk for gastrointestinal problems. Even
though the skin is stained with meconium,it is noninfectious (sterile) and nonirritating. The postterm meconium-stained infant is not at additional risk
for bowel or urinary problems.
28.
C.
The nurse should use a nonelastic, flexible, paper measuring tape,placing the zero point on the superior border of the symphysis pubis andstretching the
tape across the abdomen at the midline to the top of thefundus. The xiphoid and umbilicus are not appropriate landmarks to usewhen measuring the
height of the fundus (McDonalds measurement).
29.
B.
Women hospitalized with severe preeclampsia need decreased CNSstimulation to prevent a seizure. Seizure precautions provideenvironmental safety
should a seizure occur. Because of edema, dailyweight is important but not the priority. Preclampsia causes vasospasmand therefore can reduce uteroplacental perfusion. The client should beplaced on her left side to maximize blood flow, reduce blood pressure, andpromote diuresis. Interventions to
reduce stress and anxiety are veryimportant to facilitate coping and a sense of control, but seizureprecautions are the priority.
30.
C.
Cessation of the lochial discharge signifies healing of the endometrium.Risk of hemorrhage and infection are minimal 3 weeks after a normalvaginal
delivery. Telling the client anytime is inappropriate because thisresponse does not provide the client with the specific information she isrequesting.
Choice of a contraceptive method is important, but not thespecific criteria for safe resumption of sexual activity. Culturally, the 6-weeks examination has
been used as the time frame for resuming sexualactivity, but it may be resumed earlier.
31.

C
. The middle third of the vastus lateralis is the preferred injection site for vitamin K administration because it is free of blood vessels and nervesand is
large enough to absorb the medication. The deltoid muscle of anewborn is not large enough for a newborn IM injection. Injections into thismuscle in a
small child might cause damage to the radial nerve. The
anterior femoris muscle is the next safest muscle to use in a newborn butis not the safest. Because of the proximity of the sciatic nerve, the
gluteusmaximus muscle should not be until the child has been walking 2 years.
32.
D
. Bartholins glands are the glands on either side of the vaginal orifice.The clitoris is female erectile tissue found in the perineal area above theurethra.
The parotid glands are open into the mouth. Skenes glands openinto the posterior wall of the female urinary meatus.
33.
D
. The fetal gonad must secrete estrogen for the embryo to differentiateas a female. An increase in maternal estrogen secretion does not
effectdifferentiation of the embryo, and maternal estrogen secretion occurs inevery pregnancy. Maternal androgen secretion remains the same asbefore
pregnancy and does not effect differentiation. Secretion of androgen by the fetal gonad would produce a male fetus.
34.
A
. Using bicarbonate would increase the amount of sodium ingested,which can cause complications. Eating low-sodium crackers would beappropriate.
Since liquids can increase nausea avoiding them in themorning hours when nausea is usually the strongest is appropriate. Eatingsix small meals a day
would keep the stomach full, which often decreasenausea.
35.
B
. Ballottement indicates passive movement of the unengaged fetus.Ballottement is not a contraction. Fetal kicking felt by the client
representsquickening. Enlargement and softening of the uterus is known asPiskaceks sign.
36.
B
. Chadwicks sign refers to the purple-blue tinge of the cervix. BraxtonHicks contractions are painless contractions beginning around the 4
th
month. Goodells sign indicates softening of the cervix. Flexibility of theuterus against the cervix is known as McDonalds sign.
37.
C
. Breathing techniques can raise the pain threshold and reduce theperception of pain. They also promote relaxation. Breathing techniques donot
eliminate pain, but they can reduce it. Positioning, not breathing,increases uteroplacental perfusion.
38.
A
. The clients labor is hypotonic. The nurse should call the physical andobtain an order for an infusion of oxytocin, which will assist the uterus tocontact
more forcefully in an attempt to dilate the cervix. Administeringlight sedative would be done for hypertonic uterine contractions. Preparingfor cesarean

section is unnecessary at this time. Oxytocin would increasethe uterine contractions and hopefully progress labor before a cesareanwould be necessary.
It is too early to anticipate client pushing withcontractions.
39.
D
. The signs indicate placenta previa and vaginal exam to determinecervical dilation would not be done because it could cause hemorrhage.Assessing
maternal vital signs can help determine maternal physiologicstatus. Fetal heart rate is important to assess fetal well-being and shouldbe done.
Monitoring the contractions will help evaluate the progress of labor.
40.
D
. A complete placenta previa occurs when the placenta covers theopening of the uterus, thus blocking the passageway for the baby. Thisresponse explains
what a complete previa is and the reason the babycannot come out except by cesarean delivery. Telling the client to ask thephysician is a poor response
and would increase the patients anxiety.Although a cesarean would help to prevent hemorrhage, the statementdoes not explain why the hemorrhage
could occur. With a completeprevia, the placenta is covering all the cervix, not just most of it.
41.
B
. With a face presentation, the head is completely extended. With avertex presentation, the head is completely or partially flexed. With a brow(forehead)
presentation, the head would be partially extended.
42.
D
. With this presentation, the fetal upper torso and back face the left upper maternal abdominal wall. The fetal heart rate would be most audibleabove the
maternal umbilicus and to the left of the middle. The other positions would be incorrect.
43.
C.
The greenish tint is due to the presence of meconium. Lanugo is thesoft, downy hair on the shoulders and back of the fetus. Hydramniosrepresents
excessive amniotic fluid. Vernix is the white, cheesy substancecovering the fetus.
44.
D.
In a breech position, because of the space between the presenting partand the cervix, prolapse of the umbilical cord is common. Quickening isthe
womans first perception of fetal movement. Ophthalmia neonatorumusually results from maternal gonorrhea and is conjunctivitis. Pica refers tothe oral
intake of nonfood substances.
45.
A.
Dizygotic (fraternal) twins involve two ova fertilized by separate sperm.Monozygotic (identical) twins involve a common placenta, same genotype,and
common chorion.
46.
C.
The zygote is the single cell that reproduces itself after conception. Thechromosome is the material that makes up the cell and is gained fromeach parent.
Blastocyst and trophoblast are later terms for the embryoafter zygote.

47.
D.
Prepared childbirth was the direct result of the 1950s challenging of theroutine use of analgesic and anesthetics during childbirth. The LDRP wasa much
later concept and was not a direct result of the challenging of routine use of analgesics and anesthetics during childbirth. Roles for nurse midwives and
clinical nurse specialists did not develop from thischallenge.
48.
C.
The ischial spines are located in the mid-pelvic region and could benarrowed due to the previous pelvic injury. The symphysis pubis, sacralpromontory,
and pubic arch are not part of the mid-pelvis.
49.
B.
Variations in the length of the menstrual cycle are due to variations inthe proliferative phase. The menstrual, secretory and ischemic phases donot
contribute to this variation.
50.
B
. Testosterone is produced by the Leyding cells in the seminiferoustubules. Follicle-stimulating hormone and leuteinzing hormone are
released by the anterior pituitary gland. The hypothalamus is responsiblefor releasing gonadotropin-releasing hormone
MEDICAL SURGICAL NURSING
1.
Marco who was diagnosed with brain tumor was scheduled for craniotomy. Inpreventing the development of cerebral edema after surgery, the
nurseshould expect the use of:a . D i u r e t i c s b . A n t i h y p e r t e n s i v e c . S t e r o i d s d . A n t i c o n v u l s a n t s
2.
Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel
should:a.Increase the flow of normal salineb.Assess the pain further c . N o t i f y t h e b l o o d b a n k d . O b t a i n v i t a l s i g n s .
3.
Nurse Maureen knows that the positive diagnosis for HIV infection is madebased on which of the following:a.A history of high risk sexual
behaviors.b.Positive ELISA and western blot testsc.Identification of an associated opportunistic infectiond.Evidence of
extreme weight loss and high fever
4.
Nurse Maureen is aware that a client who has been diagnosed with chronicrenal failure recognizes an adequate amount of high-biologic-value
proteinwhen the food the client selected from the menu was:a . R a w c a r r o t s b . A p p l e j u i c e c . W h o l e w h e a t b r e a d d . C o t t a g e
cheese
5.
Kenneth who has diagnosed with uremic syndrome has the potential todevelop complications. Which among the following complications should
thenurse anticipates:a.Flapping hand tremorsb.An elevated hematocrit level c . H y p o t e n s i o n d . H y p o k a l e m i a
6.

A client is admitted to the hospital with benign prostatic hyperplasia, the nursemost relevant assessment would be:a.Flank pain radiating in the
groinb.Distention of the lower abdomenc . P e r i n e a l e d e m a d . U r e t h r a l d i s c h a r g e
7.
A client has undergone with penile implant. After 24 hrs of surgery, the clientsscrotum was edematous and painful. The nurse
should:a.Assist the client with sitz bathb.Apply war soaks in the scrotumc.Elevate the scrotum using a soft support
d.Prepare for a possible incision and drainage.
8.
Nurse hazel receives emergency laboratory results for a client with chest painand immediately informs the physician. An increased myoglobin
levelsuggests which of the following?a . L i v e r d i s e a s e b . M y o c a r d i a l d a m a g e c . H y p e r t e n s i o n d . C a n c e r
9.
Nurse Maureen would expect the a client with mitral stenosis woulddemonstrate symptoms associated with congestion in
the:a . R i g h t a t r i u m b . S u p e r i o r v e n a c a v a c . A o r t a d . P u l m o n a r y
10.
A client has been diagnosed with hypertension. The nurse priority nursingdiagnosis would be:a.Ineffective health maintenanceb.Impaired
skin integrityc.Deficient fluid volumed . P a i n
11.
Nurse Hazel teaches the client with angina about common expected sideeffects of nitroglycerin including:a . h i g h b l o o d
pressureb.stomach crampsc . h e a d a c h e d.shortness of breath
12.
The following are lipid abnormalities. Which of the following is a risk factor for the development of atherosclerosis and PVD?a.High levels of low
density lipid (LDL) cholesterolb.High levels of high density lipid (HDL)
cholesterolc.Low concentration triglyceridesd.Low levels of LDL cholesterol.
13.
Which of the following represents a significant risk immediately after surgeryfor repair of aortic aneurysm?a.Potential wound
infection b.Potential ineffective copingc.Potential electrolyte balance d.Potential alteration in renal perfusion
14.
Nurse Josie should instruct the client to eat which of the following foods toobtain the best supply of Vitamin B12?a . d a i r y
productsb.v eget ables c . G r a i n s d . B r o c c o l i
15.
Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the following physiologic functions?
a . B o w e l f u n c t i o n b.Perip heral sensatio n c . B l e e d i n g t e n d e n c i e s d . I n t a k e a n d o u t p u t
16.
Lydia is scheduled for elective splenectomy. Before the clients goes tosurgery, the nurse in charge final assessment would
be:a . s i g n e d c o n s e n t b . v i t a l s i g n s c . n a m e b a n d d . e m p t y b l a d d e r
17.
What is the peak age range in acquiring acute lymphocytic leukemia (ALL)?a . 4 t o 1 2 y e a r s . b . 2 0 t o 3 0 y e a r s c . 4 0 t o 5 0
y e a r s d.60 60 70 years

18.
Marie with acute lymphocytic leukemia suffers from nausea and headache.These clinical manifestations may indicate all of the following
excepta.effects of radiation b.chemotherap y side effects c . m e n i n g e a l i r r i t a t i o n d . g a s t r i c d i s t e n s i o n
19.
A client has been diagnosed with Disseminated Intravascular Coagulation(DIC). Which of the following is contraindicated with the client?
a.Adm in is terin g H eparin b.Administerin g Coum adin c.Treatin g the underlyin g c aus e d.Replacing depleted
blood products
20.
Which of the following findings is the best indication that fluid replacement for the client with hypovolemic shock is adequate?a.Urine
output greater than 30ml/hr b.Respiratory rate of 21 breaths/minutec.Diastolic blood pressure greater than 90
mmhgd.Systolic blood pressure greater than 110 mmhg
21.
Which of the following signs and symptoms would Nurse Maureen include inteaching plan as an early manifestation of laryngeal cancer?
a . S t o m a t i t i s b.Airway obstructionc . H o a r s e n e s s d . D y s p h a g i a
22.
Karina a client with myasthenia gravis is to receive immunosuppressivetherapy. The nurse understands that this therapy is effective because
it:a.Promotes the removal of antibodies that impair the transmission of impulsesb.Stimulates the production of acetylcholine at
the neuromuscular junction.
c.Decreases the production of autoantibodies that attack the acetylcholine receptors.d.Inhibits the breakdown of acetylcholine at
the neuromuscular junction.
23.
A female client is receiving IV Mannitol. An assessment specific to safeadministration of the said drug is:a . V i t a l s i g n s q 4 h b . W e i g h i n g
d a i l y c . U r i n e o u t p u t h o u r l y d.Level of con sciousness q4 h
24.
Patricia a 20 year old college student with diabetes mellitus requestsadditional information about the advantages of using a pen like insulindelivery
devices. The nurse explains that the advantages of these devicesover syringes includes:a.Acc urate dos e deliveryb.Sho rter
inj ectio n tim e c.Lower cost with reusable insulin cartridgesd.Use of smaller gauge n eedle.
25.
A male clients left tibia is fractures in an automobile accident, and a cast isapplied. To assess for damage to major blood vessels from the fracture tibia,the
nurse in charge should monitor the client for:a.Swelling of the left thigh b.Increased skin temperature of the footc.Prolonged
reperfusion of the toes after blanchingd.Inc reased blood pressure
26.
After a long leg cast is removed, the male client should:a.Cleanse the leg by scrubbing with a brisk motionb.Put leg through full range
of motion twice dailyc.Report any discomfort or stiffness to the physiciand.Elevate the leg when sitting for long periods of
time.
27.
While performing a physical assessment of a male client with gout of thegreat toe, NurseVivian should assess for additional tophi (urate deposits)
onthe:a . B u t t o c k s b . E a r s c . F a c e d . A b d o m e n

28.
Nurse Katrina would recognize that the demonstration of crutch walking withtripod gait was understood when the client places weight on the:a.Palms
of the hands and axillary regionsb . P a l m s o f t h e h a n d c . A x i l l a r y r e g i o n s d.Feet, wh ich are set apart
29.
Mang Jose with rheumatoid arthritis states, the only time I am without pain iswhen I lie in bed perfectly still. During the convalescent stage, the nurse
incharge with Mang Jose should encourage:a.Active joint flexion and extension
b.Continued immobility until pain subsidesc.Range of motion exercises twice dailyd.Flexion exercises three times daily
30.
A male client has undergone spinal surgery, the nurse should:a.Observe the clients bowel movement and voiding patternsb.Logroll the client to prone positionc.Assess the clients feet for sensation and circulationd.Encourage client to drink plenty of
fluids
31.
Marina with acute renal failure moves into the diuretic phase after one weekof therapy. During this phase the client must be assessed for signs
of developing:a . H y p o v o l e m i a b . r e n a l f a i l u r e c . m e t a b o l i c a c i d o s i s d . h y p e r k a l e m i a
32.
Nurse Judith obtains a specimen of clear nasal drainage from a client with ahead injury. Which of the following tests differentiates mucus
fromcerebrospinal fluid (CSF)?a . P r o t e i n b . S p e c i f i c g r a v i t y c . G l u c o s e d . M i c r o o r g a n i s m
33.
A 22 year old client suffered from his first tonic-clonic seizure. Uponawakening the client asks the nurse, What caused me to have a seizure?Which of the
following would the nurse include in the primary cause of tonicclonic seizures in adults more the 20 years?
a.Electro lyte imbalan ce b . H e a d t r a u m a c . E p i l e p s y d . C o n g e n i t a l d e f e c t
34.
What is the priority nursing assessment in the first 24 hours after admission of the client with thrombotic CVA?a.Pupil size and papillary
responseb . c h o l e s t e r o l l e v e l c . E c h o c a r d i o g r a m d . B o w e l s o u n d s
35.
Nurse Linda is preparing a client with multiple sclerosis for discharge from thehospital to home. Which of the following instruction is most appropriate?
a.Practice using the mechanical aids that you will need when futuredisabilities arise.b.Follow good health habits to change the course
of the disease.c.Keep active, use stress reduction strategies, and avoid fatigue.d.You will need to accept the necessity for a quiet and
inactive lifestyle.
36.
The nurse is aware the early indicator of hypoxia in the unconscious client is:a . C y a n o s i s b.Inc reased respiration s
c.Hypertensiond.Restlessness
37.
A client is experiencing spinal shock. Nurse Myrna should expect the functionof the bladder to be which of the following?
a . N o r m a l b . A t o n i c c . S p a s t i c d.Uncontrolled
38.

Which of the following stage the carcinogen is irreversible?a . P r o g r e s s i o n

stageb.Initiation stagec.Regression staged.Promotion stage
39.
Among the following components thorough pain assessment, which is themost significant?a . E f f e c t b . C a u s e c . C a u s i n g
factorsd .I n te n s i ty
40.
A 65 year old female is experiencing flare up of pruritus. Which of the clientsaction could aggravate the cause of flare ups?a.Sleeping in cool and
humidified environmentb.Daily baths with fragrant soap c.Using clothes made from 100% cottond. Increasing fluid
intake
41.
Atropine sulfate (Atropine) is contraindicated in all but one of the followingclient?a.A client with high blood b.A client with bowel
obstructionc . A c l i e n t w i t h g l a u c o m a d . A c l i e n t w i t h U . T . I
42.
Among the following clients, which among them is high risk for potentialhazards from the surgical experience?a . 6 7 - y e a r - o l d c l i e n t b . 4 9 year-old clientc.33-year-old clientd.15-year-old client
43.
Nurse Jon assesses vital signs on a client undergone epidural anesthesia.Which of the following would the nurse assess next?
a . H e a d a c h e b.Bladder distensionc . D i z z i n e s s d.Ability to move legs
44.
Nurse Katrina should anticipate that all of the following drugs may be used inthe attempt to control the symptoms of Meniere's disease
except:a . A n t i e m e t i c s
b . D i u r e t i c s c . A n t i h i s t a m i n e s d.Glucocorticoids
45.
Which of the following complications associated with tracheostomy tube?a.Increased cardiac output b.Acute respiratory distress
syndrome (ARDS)c.Increased blood pressured.Damage to laryngeal nerves
46.
Nurse Faith should recognize that fluid shift in an client with burn injury resultsfrom increase in the:a.Total volume of circulating whole
bloodb.Total volume of intravascular plasmac.Permeability of capillary walls d.Permeability of kidney tubules
47.
An 83-year-old woman has several ecchymotic areas on her right arm. Thebruises are probably caused by:a.increased capillary fragility and
permeabilityb.increased blood supply to the skinc . s e l f i n f l i c t e d i n j u r y d . e l d e r a b u s e
48.
Nurse Anna is aware that early adaptation of client with renal carcinoma is:a . N a u s e a a n d v o m i t i n g b . f l a n k p a i n c . w e i g h t
g a i n d.intermittent hematuria
49.
A male client with tuberculosis asks Nurse Brian how long the chemotherapymust be continued. Nurse Brians accurate reply would be:a . 1 t o
3 w e e k s b . 6 t o 1 2 m o n t h s c . 3 t o 5 m o n t h s d.3 years and more
50.

A client has undergone laryngectomy. The immediate nursing priority wouldbe:a.Keep trachea free of secretionsb.Monitor for signs of
infectionc.Provide emotional support d.Promote means of communication
ANSWERS AND RATIONALE MEDICAL SURGICAL NURSING
1.
C
. Glucocorticoids (steroids) are used for their anti-inflammatory action, whichdecreases the development of edema.
2.
A
. The blood must be stopped at once, and then normal saline should beinfused to keep the line patent and maintain blood volume.
3.
B
. These tests confirm the presence of HIVantibodies that occur in responseto the presence of the human immunodeficiency virus (HIV).
4.
D
. One cup of cottage cheese contains approximately 225 calories, 27 g of protein, 9 g of fat, 30 mg cholesterol, and 6 g of carbohydrate. Proteins of high
biologic value (HBV) contain optimal levels of amino acids essential for life.
5.
A
. Elevation of uremic waste products causes irritation of the nerves, resultingin flapping hand tremors.
6.
B
. This indicates that the bladder is distended with urine, therefore palpable.
7.
C
. Elevation increases lymphatic drainage, reducing edema and pain.
8.
B
. Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred.
9.
D
. When mitral stenosis is present, the left atrium has difficulty emptying itscontents into the left ventricle because there is no valve to prevent back
wardflow into the pulmonary vein, the pulmonary circulation is under pressure.
10.
A
. Managing hypertension is the priority for the client with hypertension.Clients with hypertension frequently do not experience pain, deficient
volume,or impaired skin integrity. It is the asymptomatic nature of hypertension thatmakes it so difficult to treat.
11.
C

. Because of its widespread vasodilating effects, nitroglycerin oftenproduces side effects such as headache, hypotension and dizziness.12.A. An increased
in LDL cholesterol concentration has been documented atrisk factor for the development of atherosclerosis. LDL cholesterol is notbroken down into the
liver but is deposited into the wall of the blood vessels.
13.
D
. There is a potential alteration in renal perfusion manifested by decreasedurine output. The altered renal perfusion may be related to renal
arteryembolism, prolonged hypotension, or prolonged aortic cross-clamping duringthe surgery.
14.
A
. Good source of vitamin B12 are dairy products and meats.
15.
C
. Aplastic anemia decreases the bone marrow production of RBCs, whiteblood cells, and platelets. The client is at risk for bruising and
bleedingtendencies.
16.
B.
An elective procedure is scheduled in advance so that all preparations canbe completed ahead of time. The vital signs are the final check that must
becompleted before the client leaves the room so that continuity of care andassessment is provided for.
17.
A
. The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of age. It is uncommon after 15 years of age.
18.
D
. Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. Itdoes invade the central nervous system, and clients experience headachesand
vomiting from meningeal irritation.
19.
B
. Disseminated Intravascular Coagulation (DIC) has not been found torespond to oral anticoagulants such as Coumadin.
20.
A
. Urine output provides the most sensitive indication of the clients responseto therapy for hypovolemic shock. Urine output should be consistently
greater than 30 to 35 mL/hr.
21.
C
. Early warning signs of laryngeal cancer can vary depending on tumor location. Hoarseness lasting 2 weeks should be evaluated because it is oneof the
most common warning signs.
22.
C

. Steroids decrease the bodys immune response thus decreasing theproduction of antibodies that attack the acetylcholine receptors at
theneuromuscular junction
23.
C
. The osmotic diuretic mannitol is contraindicated in the presence of inadequate renal function or heart failure because it increases theintravascular
volume that must be filtered and excreted by the kidney.
24.
A
. These devices are more accurate because they are easily to used andhave improved adherence in insulin regimens by young people because
themedication can be administered discreetly.
25.
C
. Damage to blood vessels may decrease the circulatory perfusion of thetoes, this would indicate the lack of blood supply to the extremity.
26.
D.
Elevation will help control the edema that usually occurs.
27.
B.
Uric acid has a low solubility, it tends to precipitate and form deposits atvarious sites where blood flow is least active, including cartilaginous tissuesuch
as the ears.
28.
B
. The palms should bear the clients weight to avoid damage to the nerves inthe axilla.
29.
A
. Active exercises, alternating extension, flexion, abduction, and adduction,mobilize exudates in the joints relieves stiffness and pain.
30.
C.
Alteration in sensation and circulation indicates damage to the spinal cord,if these occurs notify physician immediately.
31.
A
. In the diuretic phase fluid retained during the oliguric phase is excretedand may reach 3 to 5 liters daily, hypovolemia may occur and fluids should
bereplaced.
32.
C
. The constituents of CSF are similar to those of blood plasma. Anexamination for glucose content is done to determine whether a body fluid isa mucus
or a CSF. A CSF normally contains glucose.
33.
B

. Trauma is one of the primary cause of brain damage and seizure activity inadults. Other common causes of seizure activity in adults include
neoplasms,withdrawal from drugs and alcohol, and vascular disease.
34.
A
. It is crucial to monitor the pupil size and papillary response to indicatechanges around the cranial nerves.
35.
C
. The nurse most positive approach is to encourage the client with multiplesclerosis to stay active, use stress reduction techniques and avoid
fatiguebecause it is important to support the immune system while remaining active.
36.
D
. Restlessness is an early indicator of hypoxia. The nurse should suspecthypoxia in unconscious client who suddenly becomes restless.
37.
B
. In spinal shock, the bladder becomes completely atonic and will continueto fill unless the client is catheterized.
38.
A
. Progression stage is the change of tumor from the preneoplastic state or low degree of malignancy to a fast growing tumor that cannot be reversed.
39.
D
. Intensity is the major indicative of severity of pain and it is important for theevaluation of the treatment.
40.
B.
The use of fragrant soap is very drying to skin hence causing the pruritus.
41.
C.
Atropine sulfate is contraindicated with glaucoma patients because itincreases intraocular pressure.
42.
A
. A 67 year old client is greater risk because the older adult client is morelikely to have a less-effective immune system.
43.
B
. The last area to return sensation is in the perineal area, and the nurse incharge should monitor the client for distended bladder.
44.
D
. Glucocorticoids play no significant role in disease treatment.
45.
D

. Tracheostomy tube has several potential complications including bleeding,infection and laryngeal nerve damage.
46.
C
. In burn, the capillaries and small vessels dilate, and cell damage cause therelease of a histamine-like substance. The substance causes the capillarywalls
to become more permeable and significant quantities of fluid are lost.
47.
A
. Aging process involves increased capillary fragility and permeability. Older adults have a decreased amount of subcutaneous fat and cause an
increasedincidence of bruise like lesions caused by collection of extravascular blood inloosely structured dermis.
48.
D
. Intermittent pain is the classic sign of renal carcinoma. It is primarily due tocapillary erosion by the cancerous growth.
49.
B.
Tubercle bacillus is a drug resistant organism and takes a long time to beeradicated. Usually a combination of three drugs is used for minimum of
6months and at least six months beyond culture conversion.
50.
A.
Patent airway is the most priority; therefore removal of secretions isnecessary.
PSYCHIATRIC NURSING
1.Marco approached Nurse Trish asking for advice on how to deal with hisalcohol addiction. Nurse Trish should tell the client that the only
effectivetreatment for alcoholism is:a . P s y c h o t h e r a p y b.Alcoholics anonymous
(A.A.)c . T o t a l a b s t i n e n c e d . A v e r s i o n T h e r a p y 2.Nurse Hazel is caring for a male client who experience false sensoryperceptions
with no basis in reality. This perception is known as:a . H a l l u c i n a t i o n s b . D e l u s i o n s c . L o o s e
a s s o c i a t i o n s d . N e o l o g i s m s 3.Nurse Monet is caring for a female client who has suicidal tendency.When accompanying the client to
the restroom, Nurse Monet shoulda . G i v e h e r p r i v a c y b . A l l o w h e r t o u r i n a t e c.Open the window and allow her to get some
fresh air d . O b s e r v e h e r
4.
Nurse Maureen is developing a plan of care for a female client withanorexia nervosa. Which action should the nurse include in the plan?a.Provide
privacy during meals b.Set-up a strict eating plan for the clientc.Encourage client to exercise to reduce anxiety d.Restrict
visits with the family 5.A client is experiencing anxiety attack. The most appropriate nursingintervention should include?a.Turning
on the televisionb.Leaving the client alone c.Staying with the client and speaking in short sentencesd.Ask the client to
play with other clients6.A female client is admitted with a diagnosis of delusions of GRANDEUR.This diagnosis reflects a belief that one
is:a . B e i n g K i l l e d b.Highly famous and importantc.Responsible for evil world d.Connected to client unrelated
to oneself 7.A 20 year old client was diagnosed with dependent personality disorder.Which behavior is not likely to be evidence of ineffective
individual coping?a.Recurrent self-destructive behavior b.Avoiding relationshipc.Showing interest in solitary
activitiesd.Inability to make choices and decision without advise 8.A male client is diagnosed with schizotypal
personality disorder. Whichsigns would this client exhibit during social situation?

a . P a r a n o i d t h o u g h t s b . E m o t i o n a l a f f e c t c . I n d e p e n d e n c e n e e d d.Aggressive behavior 9.Nurse Claire is caring for

a client diagnosed with bulimia. The mostappropriate initial goal for a client diagnosed with bulimia is?a.Encourage to avoid
foodsb.Identify anxiety causing situationsc.Eat only three meals a dayd.Avoid shopping plenty of groceries10. Nurse Tony
was caring for a 41 year old female client. Which behavior bythe client indicates adult cognitive development?a.Generates new levels
of awarenessb.Assumes responsibility for her actionsc.Has maximum ability to solve problems and learn new
skillsd.Her perception are based on reality11.A neuromuscular blocking agent is administered to a client before ECTtherapy. The Nurse
should carefully observe the client for?a.Respiratory difficulties b . N a u s e a a n d v o m i t i n g c . D i z z i n e s s
d.
Seizures12.A 75 year old client is admitted to the hospital with the diagnosis of dementia of the Alzheimers type and depression. The symptom that
isunrelated to depression would be?a.Apathetic response to the environmentb.I dont know answer to
questionsc.Shallow of labile effectd.Neglect of personal hygiene 13.Nurse Trish is working in a mental health facility; the nurse
priority nursingintervention for a newly admitted client with bulimia nervosa would be to?a.Teach client to measure I & O b.Involve client
in planning daily mealc.Observe client during mealsd.Monitor client continuously 14.Nurse Patricia is aware that the major
health complication associated withintractable anorexia nervosa would be?a.Cardiac dysrhythmias resulting to cardiac
arrestb.Glucose intolerance resulting in protracted hypoglycemiac.Endocrine imbalance causing cold amenorrhead.Decreased
metabolism causing cold intolerance15.Nurse Anna can minimize agitation in a disturbed client by?
a.Increasing stimulation b.limiting unnecessary interactionc.increasing appropriate sensory perceptiond.ensuring
constant client and staff contact
16.A 39 year old mother with obsessive-compulsive disorder has becomeimmobilized by her elaborate hand washing and walking rituals. NurseTrish
recognizes that the basis of O.C. disorder is often:a.Problems with being too conscientiousb.Problems with anger and
remorsec.Feelings of guilt and inadequacyd.Feeling of unworthiness and hopelessness17.Mario is complaining to other clients about
not being allowed by staff tokeep food in his room. Which of the following interventions would be mostappropriate?a.Allowing a snack to be kept
in his roomb.Reprimanding the clientc.Ignoring the clients behavior d.Setting limits on the behavior 18.Conney with
borderline personality disorder who is to be discharge soonthreatens to do something to herself if discharged. Which of the followingactions by the
nurse would be most important?a.Ask a family member to stay with the client at home temporarilyb.Discuss the meaning of the clients
statement with her c.Request an immediate extension for the clientd.Ignore the clients statement because its a sign
of manipulation19.Joey a client with antisocial personality disorder belches loudly. A staff member asks Joey, Do you know why people find
you repulsive? thisstatement most likely would elicit which of the following client reaction?
a . D e p e n s i v e n e s s b . E m b a r r a s s m e n t c . S h a m e d . R e m o r s e f u l n e s s 20.Which of the following approaches would be most
appropriate to use witha client suffering from narcissistic personality disorder when discrepanciesexist between what the client states and what actually
exist?a . R a t i o n a l i z a t i o n b.Supportive confrontation c . L i m i t s e t t i n g d . C o n s i s t e n c y 21.Cely is experiencing alcohol
withdrawal exhibits tremors, diaphoresis andhyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Whichof the medications would the
nurse expect to administer?a . N a l o x o n e ( N a r c a n ) b.Benzlropine (Cogentin) c . L o r a z e p a m
( A t i v a n ) d.Haloperidol (Haldol)22.Which of the following foods would the nurse Trish eliminate from the dietof a client in alcohol
withdrawal?a . M i l k b . O r a n g e J u i c e

c . S o d a d . R e g u l a r C o f f e e 23.Which of the following would Nurse Hazel expect to assess for a clientwho is exhibiting late signs of heroin
withdrawal?a.Yawning & diaphoresisb.Restlessness & Irritabilityc.Constipation & steatorrhead.Vomiting and
Diarrhea24.To establish open and trusting relationship with a female client who hasbeen hospitalized with severe anxiety, the nurse in charge
should?a.Encourage the staff to have frequent interaction with the clientb.Share an activity with the clientc.Give client feedback
about behavior d.Respect clients need for personal space
25.
Nurse Monette recognizes that the focus of environmental (MILIEU)therapyis to:a.Manipulate the environment to bring about positive
changes inbehavior b.Allow the clients freedom to determine whether or not they will beinvolved in activitiesc.Role play life events
to meet individual needsd.Use natural remedies rather than drugs to control behavior 26.Nurse Trish would expect a child with a diagnosis
of reactive attachmentdisorder to:a.Have more positive relation with the father than the mother b.Cling to mother & cry on
separationc.Be able to develop only superficial relation with the others d.Have been physically abuse 27.When teaching
parents about childhood depression Nurse Trina shouldsay?a.It may appear acting out behavior b.Does not respond to conventional
treatmentc.Is short in duration & resolves easilyd.Looks almost identical to adult depression 28.Nurse Perry is aware that
language development in autistic childresembles:a . S c a n n i n g s p e e c h b . S p e e c h l a g c . S h u t t e r i n g d . E c h o l a l i a 29.A 60 year
old female client who lives alone tells the nurse at thecommunity health center I really dont need anyone to talk to. The TV ismy best friend. The
nurse recognizes that the client is using the defensemechanism known as?a . D i s p l a c e m e n t b . P r o j e c t i o n
c . S u b l i m a t i o n d . D e n i a l 30.When working with a male client suffering phobia about black cats, NurseTrish should anticipate that a
problem for this client would be?a.Anxiety when discussing phobiab.An ger to ward the feared obj ectc.Denyin g that th e
pho bia exist d.Distortion of reality when completing daily routines 31.Linda is pacing the floor and appears extremely anxious. The duty
nurseapproaches in an attempt to alleviate Lindas anxiety. The mosttherapeutic question by the nurse would be?a.Wo uld yo u like to watch
TV?b.Would you like me to talk with you?c .Are you feeling upset now? d . I g n o r e t h e c l i e n t 32.Nurse Penny is aware that the
symptoms that distinguish post traumaticstress disorder from other anxiety disorder would be:a.Avoidance of situation & certain activities
that resemble the stressb.Depression and a blunted affect when discussing the traumaticsituationc.Lack of interest in family
& othersd.Re-experiencing the trauma in dreams or flashback 33.Nurse Benjie is communicating with a male client with substanceinducedpersisting dementia; the client cannot remember facts and fills in the gapswith imaginary information. Nurse Benjie is aware that this is typical
of?a . F l i g h t o f i d e a s b.Associative loosen ess c . C o n f a b u l a t i o n d . C o n c r e t i s m 34.Nurse Joey is aware that the signs &
symptoms that would be mostspecific for diagnosis anorexia are?a.Excessive weight loss, amenorrhea & abdominal distensionb.Slow pulse,
10% weight loss & alopeciac.Compulsive behavior, excessive fears & nausead.Excessive activity, memory lapses & an
increased pulse35.A characteristic that would suggest to Nurse Anne that an adolescent mayhave bulimia would be:a.Frequent regurgitation &
re-swallowing of foodb.Previous history of gastritisc . B a d l y s t a i n e d t e e t h d . P o s i t i v e b o d y i m a g e 36.Nurse Monette is
aware that extremely depressed clients seem to do bestin settings where they have:a . M u l t i p l e s t i m u l i b . R o u t i n e A c t i v i t i e s c .Min im al
d ecision making
d . V a r i e d A c t i v i t i e s 37.To further assess a clients suicidal potential. Nurse Katrina should beespecially alert to the client expression
of:a.Frus tration & fear of death b . A n g e r & r e s e n t m e n t c . A n x i e t y & l o n e l i n e s s d.Help less ness
& hopeless ness 38.A nursing care plan for a male client with bipolar I disorder should include:a.Providing a
structured environmentb.Designing activities that will require the client to maintain contactwith realityc.Engaging the client in
conversing about current affairsd.Touching the client provide assurance39.When planning care for a female client using ritualistic

behavior, NurseGina must recognize that the ritual:a.Helps the client focus on the inability to deal with realityb.Helps the
client control the anxietyc.Is under the clients conscious controld.Is used by the client primarily for secondary gains 40.A
32 year old male graduate student, who has become increasinglywithdrawn and neglectful of his work and personal hygiene, is brought tothe psychiatric
hospital by his parents. After detailed assessment, adiagnosis of schizophrenia is made. It is unlikely that the client willdemonstrate:a . L o w s e l f
e s t e e m b . C o n c r e t e t h i n k i n g c.Effectiv e self boun daries d . W e a k e g o 41.A 23 year old client has been admitted with a
diagnosis of schizophreniasays to the nurse Yes, its march, March is little woman. Thats literal youknow. These statement
illustrate:a . N e o l o g i s m s b . E c h o l a l i a c . F l i g h t o f i d e a s d.Loo sening of ass ociation 42.A long term goal for a paranoid
male client who has unjustifiably accusedhis wife of having many extramarital affairs would be to help the clientdevelop:a.In sigh t into his
beh av io r b . B e t t e r s e l f c o n t r o l c . F e e l i n g o f s e l f w o r t h d . F a i t h i n h i s w i f e 43.A male client who is experiencing disordered
thinking about food beingpoisoned is admitted to the mental health unit. The nurse uses whichcommunication technique to encourage the client to eat
dinner?a.Focusing on self-disclosure of own food preference
b.Using open ended question and silencec.Offering opinion about the need to eatd.Verbalizing reasons that the client may
not choose to eat44.Nurse Nina is assigned to care for a client diagnosed with CatatonicStupor. When Nurse Nina enters the clients room, the client
is found lyingon the bed with a body pulled into a fetal position. Nurse Nina should?a.Ask the client direct questions to encourage
talkingb.Rake the client into the dayroom to be with other clients c.Sit beside the client in silence and occasionally ask openendedquestiond.Leave the client alone and continue with providing care to the other clients45.Nurse Tina is caring for a client with delirium
and states that look at thespiders on the wall. What should the nurse respond to the client?a.Youre having hallucination, there are no spiders
in this room at allb.I can see the spiders on the wall, but they are not going to hurtyouc.Would you like me to kill the
spidersd.I know you are frightened, but I do not see spiders on the wall46.Nurse Jonel is providing information to a community group
about violencein the family. Which statement by a group member would indicate a needto provide additional information?a.Abuse occurs more in
low-income familiesb.Abuser Are often jealous or self-centeredc.Abuser use fear and intimidationd.Abuser usually
have poor self-esteem47.During electroconvulsive therapy (ECT) the client receives oxygen bymask via positive pressure ventilation. The nurse
assisting with thisprocedure knows that positive pressure ventilation is necessary because?a.Anesthesia is administered during the
procedureb.Decrease oxygen to the brain increases confusion and disorientationc.Grand mal seizure activity depresses
respirationsd.Muscle relaxations given to prevent injury during seizure activitydepress respirations.48.When planning the discharge of a
client with chronic anxiety, Nurse Chrisevaluates achievement of the discharge maintenance goals. Which goalwould be most appropriately having been
included in the plan of carerequiring evaluation?a.The client eliminates all anxiety from daily situationsb.The client ignores feelings
of anxietyc.The client identifies anxiety producing situationsd.The client maintains contact with a crisis counselor 49.Nurse
Tina is caring for a client with depression who has not responded toantidepressant medication. The nurse anticipates that what treatmentprocedure may
be prescribed
a.Neurolep tic
medicatio nb.Short term seclusio n c . P s y c h o s u r g e r y d.Electro conv ulsive therap y50.Mario is ad mitted to th e em e
rgency room with drug-included an xiety related to over ingestion of prescribed antipsychotic medication. The mostimportant piece
of information the nurse in charge should obtain initially isthe:a.Length of time on the med. b.Name of the ingested medication
& the amount ingestedc .Reaso n for the suicide attemp t d.Name of the nearest relative & their phone number
ANSWERS AND RATIONALE PSYCHIATRIC NURSING

1.
C
. Total abstinence is the only effective treatment for alcoholism
2.
A
. Hallucinations are visual, auditory, gustatory, tactile or olfactoryperceptions that have no basis in reality.
3.
D
. The Nurse has a responsibility to observe continuously the acutely suicidalclient. The Nurse should watch for clues, such as communicating
suicidalthoughts, and messages; hoarding medications and talking about death.
4.
B.
Establishing a consistent eating plan and monitoring clients weight areimportant to this disorder.
5.
C
. Appropriate nursing interventions for an anxiety attack include using shortsentences, staying with the client, decreasing stimuli, remaining calm
andmedicating as needed.
6.
B
. Delusion of grandeur is a false belief that one is highly famous andimportant.
7.
D
. Individual with dependent personality disorder typically showsindecisiveness submissiveness and clinging behavior so that others willmake
decisions with them.
8.
A
. Clients with schizotypal personality disorder experience excessive socialanxiety that can lead to paranoid thoughts
9.
B
. Bulimia disorder generally is a maladaptive coping response to stress andunderlying issues. The client should identify anxiety causing situation
thatstimulate the bulimic behavior and then learn new ways of coping with theanxiety.
10.
A
. An adult age 31 to 45 generates new level of awareness.
11.
A
. Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine)produces respiratory depression because it inhibits contractions of
respiratorymuscles.
12.

C
. With depression, there is little or no emotional involvement therefore littlealteration in affect.
13.
D
. These clients often hide food or force vomiting; therefore they must becarefully monitored.
14.
A
. These clients have severely depleted levels of sodium and potassiumbecause of their starvation diet and energy expenditure, these electrolytes
arenecessary for cardiac functioning.
15.
B
. Limiting unnecessary interaction will decrease stimulation and agitation.
16.
C
. Ritualistic behavior seen in this disorder is aimed at controlling guilt andinadequacy by maintaining an absolute set pattern of behavior.
17.
D
. The nurse needs to set limits in the clients manipulative behavior to helpthe client control dysfunctional behavior. A consistent approach by the staff
isnecessary to decrease manipulation.
18.
B
. Any suicidal statement must be assessed by the nurse. The nurse shoulddiscuss the clients statement with her to determine its meaning in terms
of suicide.
19.
A
. When the staff member ask the client if he wonders why others find himrepulsive, the client is likely to feel defensive because the question isbelittling.
The natural tendency is to counterattack the threat to self image.
20.
B
. The nurse would specifically use supportive confrontation with the client topoint out discrepancies between what the client states and what
actuallyexists to increase responsibility for self.
21.
C
. The nurse would most likely administer benzodiazepine, such as lorazepan(ativan) to the client who is experiencing symptom: The clients
experiencessymptoms of withdrawal because of the rebound phenomenon when thesedation of the CNS from alcohol begins to decrease.
22.
D

. Regular coffee contains caffeine which acts as psychomotor stimulantsand leads to feelings of anxiety and agitation. Serving coffee top the clientmay
add to tremors or wakefulness.
23.
D
. Vomiting and diarrhea are usually the late signs of heroin withdrawal,along with muscle spasm, fever, nausea, repetitive, abdominal cramps
andbackache.
24.
D
. Moving to a clients personal space increases the feeling of threat, whichincreases anxiety.
25.
A
. Environmental (MILIEU) therapyaims at having everything in the clientssurrounding area toward helping the client.
26.
C
. Children who have experienced attachment difficulties with primarycaregiver are not able to trust others and therefore relate superficially
27.
A
. Children have difficulty verbally expressing their feelings, acting outbehavior, such as temper tantrums, may indicate underlying depression.
28.
D
. The autistic child repeat sounds or words spoken by others.
29.
D
. The client statement is an example of the use of denial, a defense thatblocks problem by unconscious refusing to admit they exist
30.
A
. Discussion of the feared object triggers an emotional response to theobject.
31.
B
. The nurse presence may provide the client with support & feeling of control.
32.
D
. Experiencing the actual trauma in dreams or flashback is the major symptom that distinguishes post traumatic stress disorder from other
anxietydisorder.
33.
C
. Confabulation or the filling in of memory gaps with imaginary facts is adefense mechanism used by people experiencing memory deficits.
34.
A

. These are the major signs of anorexia nervosa. Weight loss is excessive(15% of expected weight)
35.
C
. Dental enamel erosion occurs from repeated self-induced vomiting.
36.
B
. Depression usually is both emotional & physical. A simple daily routine isthe best, least stressful and least anxiety producing.
37.
D
. The expression of these feeling may indicate that this client is unable tocontinue the struggle of life.
38.
A
. Structure tends to decrease agitation and anxiety and to increase theclients feeling of security.
39.
B
. The rituals used by a client with obsessive compulsive disorder helpcontrol the anxiety level by maintaining a set pattern of action.
40.
C
. A person with this disorder would not have adequate self-boundaries
41.
D
. Loose associations are thoughts that are presented without the logicalconnections usually necessary for the listening to interpret the message.
42.
C
. Helping the client to develop feeling of self worth would reduce the clientsneed to use pathologic defenses.
43.
B
. Open ended questions and silence are strategies used to encourageclients to discuss their problem in descriptive manner.
44.
C
. Clients who are withdrawn may be immobile and mute, and requireconsistent, repeated interventions. Communication with withdrawn clientsrequires
much patience from the nurse. The nurse facilitates communicationwith the client by sitting in silence, asking open-ended question and pausingto
provide opportunities for the client to respond.
45.
D
. When hallucination is present, the nurse should reinforce reality with theclient.
46.
A

. Personal characteristics of abuser include low self-esteem, immaturity,dependence, insecurity and jealousy.
47.
D
. A short acting skeletal muscle relaxant such as succinylcholine (Anectine)is administered during this procedure to prevent injuries during seizure.
48.
C
. Recognizing situations that produce anxiety allows the client to prepare tocope with anxiety or avoid specific stimulus.
49.
D
. Electroconvulsive therapy is an effective treatment for depression that hasnot responded to medication
50.
B
. In an emergency, lives saving facts are obtained first. The name and theamount of medication ingested are of outmost important in treating
thispotentially life threatening situation.