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 d . . I S V C b I M c . O r a l

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.

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 fourpoint 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.

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

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

A male client who has severeburnsis receiving H2 receptor antagonisttherapy. The nurse Incharge 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 protein synthesis.d.Enhance gas 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 feels warm. c.My ankle appears r e d d e r n o w . d.I need something stronger for pain relief 10.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.Hyperkalemiac. H ypo k a l e m i a d.Hypervolemi a 11.She finds out that some managers have benevolentauthoritative 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.Standard written order c . S t a n d i n g order 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.Loss of urge to defecatec.Hard, brown, formed stoolsd.Liquid or semi-liquid stools 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 forwardc . 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 highfiber, high-fat dietb.Provide high-protein, highcarbohydrate 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.Height and w e i g h t . c.Calcium and potassium levelsd . 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 Xray.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.Risk for i n f e c t i o n d.Deficient 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 -faire. c.Democratic. d.Situati 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 c . 1 . 5 c c b . 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 / hour b.55 cc/ hour c.24 cc/ hour d.66 cc/ 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 .B P 9 0 /5 0 ,

P u l s e 5 0 r e g ul ar c. B P 130 /80 , P ul se 1 0 0 r eg ul ar 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 .D i a gn osti c t est r es ul t s b . B i o g r a p h i c a l d a t e c.H i st or y of pr e s ent i l l n ess 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 midthigh.b .P i l l ows u n der t he l ow er l e gs. c . F o o t b o a r d d .H i p-

a b du ct or pi l l ow 34.Which stage of pressure ulcer development does the ulcer extend into thesubcutaneous tissue?a . S t a g e I b.Stage IIId.Stage IIc.Stage I V 35.When

neck 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

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 .S e co n d i nt e nt i on h e al i n g b.P r i mar y i nt e nt i o n h e al i n g c .T hi r d i nt e nt i on h e al i n g d . Fi r st i nt ent i o n h e al i n 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.Distended

 C b . 3 8 . 9 C d . 3 8

C c . 4 8 C 40.The nurse

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 drops/minuteb.32 drops/minutec . 2 0 dr o p s /m i n u t e d.18 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 catheter b.Call another nursec.Call the 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 . D or sal s ur f a ce of t he ha n dd .Ul nar s ur f a ce of t he ha n d 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

ormativec . 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 year b.Once per year c.E ver y 2 y e a r s d . On c e , t o e st a bl i sh b as el i ne 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. Re spi r at or y a ci d o si s b .R es pi r at or y al k al o si s c . M e t a b o l i c acidosisd.Metabolic 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

is assessing a 48-year-old 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

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.Massagin g 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.Lower 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.Hyperphosp hatemiad . 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 .N er v ou sne ss or p ar est he si a . c.Dr owsi ne ss or bl ur r e d vi si o n. d .T i n ni t us or di pl opi a. 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 .P r e par e for c ar di over si o 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 client.d.Behind the 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 .U r i ne o ut pu t: 45 ml / hr b . Ca pi l l ar y r ef i l l : 5 s e co n ds c . S e r u m p H : 7 . 3 2 d .B l o o d pr ess ur e: 90 /48 mm Hg 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 gogglesb.Gown and g l o v e s c.G l ov es a nd s ho e p r ot e ct or s d . G l o v e s a n d goggles 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. Si n g l e st r ai ght - l e g g ed c a ne c . Q u a d caned . 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 . Specificityc .Sen s i t i v it 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. O btai n i n for m e d c o ns e nt c.Provide equal treatment to all the subjects of the study.d.Release findings only to the participants of the study 69.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 es cr i pti v e c or r el a ti o nal b . E x p e r i m e n t c.Quasiexperimentd . 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 scheduleb . Q u e s t i o n n a i r e c.Use of laboratory

d a t a d . O b s e r v a t i o n 71.Moni ca 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.Quasie x p e r i m e n t c. Sol omo n F our gr o u p d esi g nd. P os t t est onl y de si gn 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 graphyc.Primary s o u r c e d . E n d n o t e s 73.Wh en 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 maleficenceb . B e ne f i c e n cec . J u s t i c e d.Sol i da 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 .R es po n de at s u per i or c . R e s i p s a loquitor d.Holdover doctrine 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 reissuance 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 .R ev i ew r el at e d l i t er a t ur e 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

effectb.Hawthorne effectc . H a l o effect d.Horns 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. Fl or e n ce N i ght i n gal e b. Ma d el e i n e L ei ni ng er c . A l b e r t M o o r e d.Sr. Callista 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 ntalc . Q u o t a d.Judg 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 standardsc .L ev el of s at i s fa cti on d .D e gr ee o f a c c ep tan c e 83.Which of the following theory addresses the four modes of adaptation?a . Ma del ei ne L ei ni ng er b . S r . C a l l i s t a Royc.Florence Nightingaled . 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.Unity of c o m m a n d c .D ow nwar d c o mmu ni c a ti o n 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.No n-maleficence 86.Nurse Reese is teaching a female client with peripheral vascular diseaseabout foot care; Nurse Reese should include which instruction?a .A vo i d w ear i n g c o tto n so ck s. b.Avoid using a nail clipper to cut toenails.c .A vo i d w ear i ng c a nva s sh oe s. 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 slicesb.Steamed broccolic . I c e c r e a m d.Ground beef 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.Si 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 epende nt c.Interdepe 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?

and nausea whilereceiving tube a.Assessmentb.Diagn os i s c.Implementationd . 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 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. Shak e t he vi al vi g or o usl y . 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. Dul l ne ss o ver t h e l i v 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 completec.Threatene 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.History of s y p h i l i s c .Hi st or y of g e ni t al h er p es d .H i st or y of d i a be te s mel l i tu s 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 weightb.Assessing for e d e m a c . Mo ni t or i n g a pi cal

p ul se d .M on i tor i n g t em per atur e 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 .D e cr ea se d cal or i c i nt ak eb .I n cr eas ed cal or i c i nt ak e c . D e c r e a s e d Insulind.Increase 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.E x c ess i ve fe tal a ct i vi t y. 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 .U r i n ar y ou t p ut 90 c c i n 2 ho ur s .b .A b s ent p at el l ar r efl ex es . c.Rapid respiratory rate above 40/min.d .R ap i d r i se i n b l o o d pr ess ur e . 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 . Mat er nal

t em per at ur e 1 0 1 .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 ent i l at or a ssi st an c e b . C V P readingsc.E KG t r a c i n g s d.Continuous CPR 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 .G i v e t he b a by a pa ci fi er . 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 .F e ed t he i n fan t wh en he c r i es . 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. Sk i m mi l k an d b a by f o od . b.W ho l e mi l k an d b a by fo od . c .Ir on - r i ch f or m ul a onl y . d.Iron-rich 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 monthsb.4

monthsc.8 monthsd.10 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 . Efficiencyc.Adequacy 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 .D epar tm ent of H eal t h b.P r ovi nc i al H eal t h O f fi ce c .R e gi o nal H eal t h

O f fi ce d . 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. M u ni ci pal H eal t h O ff i cer c . P u b l i c H e a l t h N u r s e d. A ny qu al i fi e d p h ysi c i an 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 aslesc . 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 . C o mmu ni t y or ga ni z at i o n c . C o m m u n i t y s t u d y d. C or e g r o up for mati on 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 pathogenesisb . P a t h o g e nesisc . 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. Intr au ter i n e f et al d eat h .b . P l a c e n t a accreta.c.Dysfunctional 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 .8 0 t o 100 b e at s /mi nu te b .100 to 12 0 b e at s /mi nu te c .120 to 16 0 b e at s /mi nu te d .160 to 18 0

b e ats /mi nu te 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. C ha ng e t he di a pe r m or e oft e n. 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 t r i a l s e ptal de f e ct b . P u l m o n i c s t e n o s i s c. V en tr i cul ar s e ptal de f e ctd .E nd oc ar di al c u sh i o n d ef e ct 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 . De cr eas e d ur i n e o ut pu t c . H y p e r r e f l e x i a d .I n cr ea se d r esp i r at or y

r at e 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 orrhagiac.Dys pa r euni 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. Ir o n bi n d i n g c a pa ci t y c . B l o o d t ypi ng d.Serum 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. Re spi r at or y a ci d osi s 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 previab.Abruptio placentaec . 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 ft er t he c hi l d h as be en bat h e c . A n y t i m e during the dayd.Early in 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 .Ir r i ta bi l i t y a nd s ei z ur e sb .D eh y dr ati o n a n d d i ar r he a c.B r ad y car di a a n d h y p ot e nsi on d .P e te ch i a e a n d h emat ur i a 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.Lo 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 chi ld, 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. B l ui sh c ol or t o t he l i ps . 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. St a bl e b l o o d pr ess ur e b . P a t a n t fontanellesc . 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.Baby l o t i o n c.Laundry d e t e r g e n t d .P ow d er w i t h c or nst ar ch 45.During tube feeding, how far above an infants

stomach should the nursehold the syringe with formula?a . 6 inchesb.12 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 tracingb. Community surveyc. Mass screening t e s t s d . I nt er vi ew o f s us pe c ts 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 em op hi l us i nfl u enz a e b . M o r b i l l i v i r u s c.

S t e pt oc o c cu s p n eu mo ni a e d. Ne i sse r i a m en i n gi t i di s 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 mucosab.Buccal m u c o s a c.Skin on the abdomend . 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 secondsb. 6 secondsc. 9 secondsd. 10 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 ere dehydrationc.Severe p n e u m o n i a d .S ev ere f e br i l e d i se as e 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 infantsc.55 infants d.65 infants 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 polio vaccinec . 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 .Us e o f m ol l us ci ci de sb .B ui l di n g of f o ot br i d g es c.P r op er u se o f sa ni t ar y t oi l et s 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 .I na bi l i t y t o cl os e e y el i ds c .T hi ck en e d p ai nf ul n er v es d .Si nk i ng of th e n os e br i dg e 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 .P er f or m a t our n i qu et t est . b. A sk w h er e t he fa mi l y r esi de s. c .G et a s pe ci m e n f or bl o od sme ar . 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.Inability to drinkb.High grade f e v e r c. Si gn s o f sev er e d e h y dr ati on d .C o ug h f or m or e t ha n 30 d ay s 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 5month 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. N o si gn s of d e h y dr at i on b . S o m e dehydrationc.Severe d e h y d r a t i o n d . T he d at a i s i ns uf fi ci ent . 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.Insignifica nt 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.At 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 monthsb.6 monthsc . 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 extrauterine 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. T o ass es s for p r ol aps e d cor d c. To a sse ss f et al p osi t i o 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 yo u h av e a n y al l er gi es ? 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.Calm the n e o n a t e . b. N ot i f y t h e p h ysi c i an . c.Provide oxygen via face mask as ordered d.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 .H um i d i fy t h e o xy g en . 85. Which of the following is normal newborn calorie intake?a.11 0 to 1 3 0 cal or i es p er k g. b.30 to 40 calories per lb of body weight.c . A t l eas t 2 m l p er f ee di n g d .9 0 t o 100 c al or i es p er k g 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 weeksb.18 to 22 weeksc. 30 to 32 w eek s d.38 to 40

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 .di am ni ot i c d i ch or i oni c twi ns c . di am ni ot i c m on o ch or i oni c t w i n 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.D igital or speculum examinationc .E xt er n al fet al m oni t or i n g 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 n cr e as e d t i da l vol um eb .I n cr ea se d e xp i r at or y

v ol u me c.Decreased inspiratory capacityd.Decreased oxygen consumption90. Emily has gestational diabetes and it is usually managed by which of thefollowing therapy?a . D i e t b .Lo n ga cti n g i n sul i n 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.Hy pertensionc . 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 nti h yp er t e n si v e a g ent s b . D i u r e t i c agentsc . 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 y dr al az i ne (A pr es ol i n e ) 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.A sy mpt om at i c b a ct er i ur i ab .B a ct er i al v agi n osi s c.Pyelonephritisd.Urina ry tract infection (UTI)96. Rh isoimmunization in a pregnant client develops during which of thefollowing conditions?a.Rhpositive 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 positionb.Squatting

positionc . S u p i n e position 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 .L et har g y 2 da ys a ft er b i r t h. 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 postpartum. 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 inversionb . U t e r i n e a t o n y c.Uterine involutiond.Uterine discomfort

and left homonymous hemianopsia?a .O n t he c l i en t s r i g ht si de b .O n t h e c l i en t s l ef t si de c .Di r e ct l y i n fr o nt o f t he cl i e nt d.W h er e t h e c l i en t l i k e 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,

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 liquidb.Solid formedc.Loose, 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 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 post-myocardial 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 .A dmi ni st er t w o q u i ck bl o 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 o pe r ati n g r o om . c.After the ileostomy begin to function.d.When the client is able to begin selfcare 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.Fever and c h i l l s c .He mo pt ysi s a n d D ys p nea d.Pleuritic chest pain and cough12. A male client

has active tuberculosis (TB). Which of the following symptomswill be exhibit?a .C h est a nd l ow er b a ck pa i n b.Chills, fever, night sweats, and hemoptysisc.Fever of more than 104F (40 C) and nausead .H ea da c h e an d p h ot o p ho bi a 13. Mark, a 7-yearold 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 .B r o n chi al p n eu mo ni a 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.Respiratory arrestc . S e i z u r e d.Wake u p o n h i s o w n 15. A 77-yearold 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. De cr ease d r esi du al v ol u me d .D e cr e as ed vi t al c a pa ci t y 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. R ep or t i n c i d e nts o f d i ar r he a. b .A voi d foo d s h i gh i n vi ta mi n K c.Use a straight razor when shaving.d. Tak e as pi r i n to p ai n r el i e f. 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 . Le avi ng t h e ha i r i nt a ct b . S h a v i n g t h e a r e a c .C l i p pi n g th e h ai r i n t he ar ea 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.Loss of e s t r o g e n c. N eg ati v e

c al ci um b al a n ce 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 .A vo i d fo c usi n g on h i s w ei ght . b. In cr ease hi s a ct i vi t y l e vel . c . F o l l o w a r e g u l a r d i e t . d.Continue leading a high-stress 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.Hemorrhoidect 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 . K e ep r o om s br i g ht l y l i t . d.Avoiding straining during bowel movement or bending at the waist.25. George should be taught about testicular examinations during:a.w h en s ex ual a ct i vi t y

st ar ts b . A f t e r a g e 69c.After age 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 salinesoaked sterile dressing on the wound.c . Tak e a b l o o d p r e ssur e a nd p ul s e.d .P ul l t he d ehi s ce n ce cl ose d . 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 cracklesc.Coarse cracklesd.Friction 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 .T h e swe l l i ng ha s d e cr ea se d . 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. In f ec ti o n o f t h e l un 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. L eav e h i m t o

g e t assi st a n ce 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 i l y h i st or y of d i s eas es . 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 cl ients mouth with hydrogen peroxide.35. A 77year-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 . My o car di al i nf ar c ti o n ( 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 33year-old day-care worker c.A 43-yesr-old homeless man with a history of alcoholismd.A 54 - y ear - ol d b u si n ess ma n 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 .T o c o n fi r m t he di a g nosi s

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 .B eta - adr e ner g i c b l o ck er s b . B r o n c h o d i l a t o r sc.Inhaled steroidsd . O r a l s t e r o i d s 39. Mr. Vasquez 56year-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 . C hr o n i c o bstr u cti v e b r o n chi ti s 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.P r e par e ox yg e n tr eat me nt 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 . Cr ow d r e d bl o o d c e l l s 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.E l ev at e d t hr o mb o cy t e co u nt s 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-yearold client who was admitted 1 day ago withthrombophlebitis and is receiving L.V. heparind.The

75-year-old client who was admitted 1 hour ago with newonsetatrial 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.Opioidsc.Cocain 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 nodes48. 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 otherapyc . 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. " Ke e p t he st oma un c ov er e d . "b. " K ee p t he st om a dr y . " c."Have a family member perform stoma care initially until you get usedto the procedure."d . " Ke ep t he st oma moi s t . " 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 cancer b .Lun g cancer c.Brain c a n c e r d . C o l on a nd r e ct al ca n cer 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 . hoar se n ess a nd d y sp ha gi a. 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 causespneumonia.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.Carcinoembryoni c antigen (CEA)c . S i g m o i d o s c o p y d.A bdominal 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.Reproductive t r a c t d .W hi t e bl oo d c e l l s ( WB C s) 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 cl i ent l i es st i l l .b .T h e cl i e nt ask s q u est i o 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 . Tr au mat i c ar t hr i t i s c. Int er mi t t en t

ar t hr i t i s 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 64year-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 76-yearold 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 returnc.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 .It a p pear s

o nl y i n me n b.It appears on the distal interphalangeal jointc.It appears on the proximal interphalangeal jointd.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 semide ( L a s i x ) c . c o l c h i c i n e s d.ca lcium 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 cortexb . P a n c r e a s c . A d r enal 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 intakec . R e s t r i c t i n g f l u i d s d.Administering glucosecontaining 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 . ur i n e gl u c os e l ev el . b .f asti n g bl ood g l uc os e l e vel . c .s er um f r u ct osa mi n e l ev 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 amb . N o o n c . 4 : 0 0 p m d.10:00 producing which substances?a.Glucocorticoids and androgensb.Catecholamines and epinephrinec.Mineralocorticoi ds and catecholaminesd.Norepinephr ine 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 p m 75. The adrenal cortex is responsible for

immediately.Which electrolyte disturbance most commonly follows thyroid surgery?a . H y p o c a l c e m i a b . Hyponatremiac.Hyperk alemia 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 .A ci d p ho sp h at as e l ev el b .S er um cal ci t on i n l ev el c. A l k a l i n e p h os ph atas e l ev 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 . Na use a, v omi t i n g , a n d a n or e xi a d. It ch i n g , r a sh , an d j a u nd i c e 79. In

teaching a female client who is HIVpositive 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.fine motor t r e m o r s . c .r es pi r at or y a ci d osi s . d. bi l ater al h e ar i n g l oss .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.Ly m p h o c y t e 85. In an individual with Sjgren's syndrome, nursing care should focus on:a. mo i st ur e r epl a cem e nt .b . el e ctr ol yte

b al a n ce . c .n utr i ti o nal s u ppl em en tati on . d.ar r h yt h mi a ma na gem e nt . 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.quanti fication of T-

lymphocytes.c.enzyme-linked immunosorbent assay (ELISA).d .We st er n b l o t t e st w i t h E L ISA . 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.Straw 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-yearold with a collapsed lung due to an accident; no drainagenoted in the previous eight hours.d.A 62year-old who had an abdominalperineal 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 .I ns er t a F ol e y c at h eter

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.

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

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.Hy 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

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 diseaseb.Hypertension 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 mus c.Leuk openi a d.Pol ycythemia 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.A dm i ni ster K a ye xal at e b. Re str i ct f oo d s h i gh i n pr ote i n 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 . Ri g ht u p per ar m a n d p eni s 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 12L/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 waterseal 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. Re d u ce i n ci si o nal p ai n. b.Facilitate ventilation of the left lung.c.Equalize pressure in the pleural space.d . In cr eas e v eno us r et ur n 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 deep-breathing 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 pokalemia.c.hyperkale m i a . d . h y p e r c a l c e m i a . 17.M s. 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 beeliminated 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 11/8") 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 .S q uam ous ce l l c ar ci no ma b . M u l t i p l e myelomac . 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 pr e ve nt c o n fus i o 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 us c ul t a t e b ow el s ou n ds. b .P al p at e t he ab do me n .c . C han g e t he c l i en t' s p osi ti o n. d .In s er t a r e ctal t ub e . 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 bentc .P r on e wi t h t he t or s o e l e vat e d 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 .A ppl yi n g k n e e s pl i nt s b .E l e vati n g th e fo ot o f t he be d 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.Ur i ne o ut pu t o f 2 0 ml / ho ur . c.W hi t e p ul m on ar y s e cr e ti o 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 .T ur n h i m f r e q ue ntl y . b.Perform passive range-of-motion (ROM) exercises.c . Re d u ce t h e c l i en t' s fl ui d i ntak e. 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 .B e t a a dr en er gi c b l o ck er s b. Ca l c i um ch an n el b l o ck er 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.Raised 10 degreesc.Raised 30 degreesd.Supine 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.B et a - a dr e n er gi c b l o ck er s b. Ca l c i um ch an n el b l o ck er 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 highdensity lipoprotein (HDL) leveland an elevated low-density lipoprotein (LDL) level. Which of the followingdietary modifications is not appropriate for this client?a .Fi b er i ntak e o f 25 to 3 0 g d ai l y 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 H g c . 9 5 H g d . 9 0

m m m m m m H g 37. 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.Idi opathic 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 .A c et yl s al i c yl i c a ci d

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

(A SA ) b . C o r t i c o s t e r o i d s c . Methotrezated . 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 logousc.Syngeneicd. 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 VIIIa42. Instructions for a client with systemic lupus erythematosus (SLE) wouldinclude information about which of the following blood dyscrasias?a.Dr es sl er s s y ndr om e b . P o l y c y t h e m i a c . E ss en ti al t hr o mb o cy to pe ni a d . V on Wi l l e br a nd s d i s eas e 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 ght s w e a t c . S p l e n o m e g a l y d. P er si st e nt h y pot h er mi a 44. Francis with leukemia has neutropenia. Which of the following

functions mustfrequently assessed?a . B l o o d pressureb . B o w e l soundsc.H ea r t s ounds d.Breath 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.Renal d y s f u n c t i o n d. M yo car di a l i r r i t abi l i t y 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 yearsb . 5 t o 7 yearsc . 1 0 y e a r s d.More than 10 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 .E l ev at e d f i br i n og e n l ev el s c.Low levels of fibrin degradation productsd .R e du c ed p r ot hr o mbi n ti m e 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 kle cell anemiac . L e u k e m i a d.Ho 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 positiveb . A R h positivec.A Rhnegatived.O Rhpositive

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 ti f y t he p h ysi c i an 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 . C hr o n i c o bstr u cti v e b r o n chi ti s 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 . C hr o n i c o bstr u cti v e b r o n chi ti s 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 m m H g 57. m m H g c . 4 0 H g d . 8 0

a c i d o s i s b .M eta bo l i c al k al o si s c . R e s p i r a t o r y acidosis d . R esp i r at or y al k al o si s 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.Pulmonary embolismc.Respiratory f a i l u r e d .R h eum atoi d ar t hr i t i s 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.E l ev at ed w hi t e bl oo d c e l l co unt 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 .Im pai r e d cl ot t i ng m e ch ani sm b . V a r i x formationc.Inadequate 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. In cr ease d u r i n e o ut put b.Altered level of consciousnessc .D ec r eas e d t en d on r efl ex 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.

Timothys arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80mm Hg; Pao2 46 mm Hg; HCO324mEq/L; Sao2 81%. This ABG resultrepresents which of the following conditions?a . M e t a b o l i c

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.Obtain vital

s i g n s c .A sk th e cl i en t to l i ft 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. Car di a c c at h eter i z ati on 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 shockb.Cardiogenic shockc.Distributive s h o c k d .M y o car di al i nf ar c ti o 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 enzymesd.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 oxygenatedc . N o r m a l d.Si gnificant; the client has alveolar hypoventilation72. When prioritizing care, which of the following clients should the nurse Oliviaassess first? a.A 17-year-old clients 24hours 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 diverticulitis73. 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 .D e cr e ase s i nf e cti on c .D e cr e as es i nfl amma ti o n 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 lifethreatening complications?a . E x o p h t h a l m osb.Thyroid stormc.Myxedema c o m a d.Tibial 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 .P i tti n g ed e ma o f t he l e gs b.A n i r r eg u l ar a pi cal pu l se c . D r y m u c o u s membranesd.Frequent 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 levelsc.Above-normal urine osmolality level, below-normal serum osmolalityleveld.Belownormal 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 insipidusc.Hypoparathyr o i d i s m d .Hy p er par at h yr oi di s m80. 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 hours83. 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 thyroidstimulating hormone (TSH) level after 30minutes during the TSH stimulation testb.A de cr e as e d T SH l e ve l c.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 U100isophane 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. S er um k eto n e bo di es c . 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 lownormal range88. Patrick is treated in the emergency department for a Colles' fracturesustained during a fall. What is a Colles' fracture?a .Fr a ct ur e of t he d i st al r a di u sb .Fr a c t u r e of t he ol ecr an on c .Fr a ct ur e of t he hu mer us 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 . Cal ci um an d p h os ph or o us c .P h osp h or o u s

a n d p otas si u md .P o ta ssi um a n d so di um 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 onchitis d . P n e u m o n i a 91. A 67-yearold 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 attackb.Atelectasisc. B r onchi t i s d.Fat 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.Chronic bronchitisc . P n e u m o n i a d .S po nta n eo us p n eu mot h or ax 93. A 62-year-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.Pn eumoniac . P n e u m o t h o r a x d.T uberculosis (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. Lo ss o f l u n g p ar en c hy ma 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 acidosisb.Metabolic alkalosisc.Respiratory a c i d o s i s d .R es pi r at or y al k al o si s 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.Adequate suctionc.Inadequate suctiond.Kinked chest 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.

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 .Restatingc.Explorin 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 .T he cl i en t i s d i sr up ti v e. b .T he cl i en t i s h ar m ful t o s el f . c .T he c l i e nt i s har m f ul to oth er s. 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 .P er c e pt u al d i s or d er s . b . I m p e n d i n g c o m a . c . Re c en t al coh ol i nt ak e. d .D epr es si o n w i t h m ut i s m. 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

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 c . 3 . 5 m l b . 2 . 4 m l d . 4 . 2

m l 100. Nurse Alexandra teaches a client about elastic stockings. Which of thefollowing statements, if made

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.Oedipal 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 .S h or t - a ct i n g

a ne st he si a b.Decreased oral and respiratory secretions.c .Sk el etal m us cl e p ar al ysi s. 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.Flat a f f e c t b.Expressing 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 l l ow i ng t h e cl i e nt t i me t o h eal . 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 obsessivecompulsive 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. Se ver e a nxi et y an d f ear . c .D epr es si o n an d w ei ght l oss . 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 tsb.Anticholinergicsc . A n t i p s y c h o t i c s d.Mood 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 d a y s b . 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 i s t or y of g ai nf ul e m pl o ym en t 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 lifethreatening. 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 hetaminesc . 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.Nurs e 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 ations c.Loose associationsd . N e o l o g i s ms 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.H i g hl y i mp or ta nt or f am ous . 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 ical thinkingc . 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.A g gr e ssi v e b e hav i or b . P a r a n o i d thoughts 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 nt r ol e ati n g i mp ul s es . c.Identify anxiety-causing situationsd .E at o nl y t hr e e

m eal s p er d ay . 30.Rudolf is admitted for an overdose of amphetamines. When assessing theclient, the nurse should expect to see:a .T en si o n a nd i r r i t abi l i t y b . S l o w pul sec.H ypot en si on 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 .P os t ur al h y p ot e nsi on c.Confusion for

a time after treatmentd.Complete loss of memory for a time33.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 st ageb.Denial s t a g e c.Bargaining stage 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 nightb.Staying in the s u n c .I n ge sti ng wi n es a n d c h e es es 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 .P a ni c- l ev el a nxi et y c . S e v e r e - l e v e l a n x i e t y d. Mo d er at e - l ev el a nxi et y 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.Diver s e i n t e r e s t d .O ver m et i c ul o us ne ss 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 stimulid.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 tc.Empathyd.Presen 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 weeksb.4 to 6

weeksc.4 to 6 mont hs d.6 to 12 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 itd.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 . ph en el z i ne ( Nar di l ) b. c hl or di az ep oxi d e ( Li br i um) c .l i t hi um c ar bo nat e ( Li t ha n e) d. i mi pr ami n e ( T ofr a ni l ) 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. Tar di v e d y sk i n es i a. 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 problemresolves.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 . C y cl ot h ymi c d i s or d er .b .A t y pi cal a ff e cti ve di s or der . c . M a j o r d e p r e s s i o n . d .D yst hy mi c d i s or d er . 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 mi xe d i n 250 ml o f wat er b .1 5 g mi xe d i n 5 00 ml o f wa ter c .30 g mi xe d i n 2 5 0 ml of wa ter d. 6 0 g mi xe d i n 500 ml o f wat er 54.What herbal medication for depression, widely used in Europe, is nowbeing prescribed in the United

States?a . G i n k g o bilobab.E chi na c ea c.St. John'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.Chlorided.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. Im pai r ed c o mmu ni ca ti o 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 ni b i s w i t h dr aw a l c . C o c a i n e

withdrawald.Opioid 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.Reactionf o r m a t i o n d. I n t el l e ct ual i z a t i on 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.Blurred v i s i o n d.Fecal 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 n cr ea se i n a p pet i te c .Sl e epi n ess a n d l et har gy d .B r a d y car di a a n d d i ar r he a 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.Moderate 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 . P r ovi d e s af et y m eas ur es 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.Marij 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.Insidious o n s e t c . Cl o u di n g o f c o ns ci ou sn es sd .S e ns or y p er c ep t ua l c ha n 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 phobiac.Claustrophobi a d . X e n o p h o b i a 71.Nurse Myrna develops a countertransference 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 . G i v e t he c l i en t C og e nti n 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 ce c.

Countertransferenced . 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 . Situationalb. Adventitiousc. Developmentald . Internal 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 depressiond . H y p er 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 .I nt el l e ct u al i z at i o n b . T r a n s f e r e n c e c.Triangulationd. Spl 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 nv er si on d i s or d er b . H y p o c h o n d r i a s isc. 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. Co nv er si on d i s or d 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. S

o mat i z at i o n di sor d er 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. Tr i az ol am ( H al ci o n )b .P ar oxe t i ne (P axi l ) \ c . F l u o x e t i n e ( P r o z a c ) d .R i s per i d on e ( Ri s p er d al ) 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 ve l ost m y ph ob i a for wa ter 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.B e havi or al d i ffi c ul ti es c .C o gni ti v e i m pai r me nt 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 dementiad.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 . M e tabolic acidosis c.Drug i n t o x i c a t i o n d .He pat i c e n c ep hal o pat hy 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 hallucination90. 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.Concrete thinkingc.Ideas of referenced.Loose 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 st r i oni 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 smokesd.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 . B el i ef i n s u per s ti ti on c .S how o f t em per t antr ums d . Co ns tan t n e e d f or att ent i o n 95. Tommy, with dependent personality disorder is working to increase his selfesteem. 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 rashd.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.Egosyntonicityd . 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 .D i sor ga ni z ed s p ee c 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 ionalizationc . 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

Posted on Saturday, January 09, 2010 No Comments

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!

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.

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 Tips from NLE Topnotchers high and reach the top. Never ever let any doubt creep into

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.

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)

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.

While studying:
1. Set realistic goals and reach them. Prioritize concepts and procedures. Concept map helps

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, highcarbohydrate 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 themidthigh. Rationale:

A trochanter roll, properly placed, provides resistance to theexternal rotation of the hip. 34. Answer : (C) Stage III Rationale: Clinically, a deep crater or without undermining of adjacenttissue is noted. 35. Answer: (A) Second intention 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 method in the following equation.75 mg/X ml = 100 mg/1 mlTo solve for X, cross-multiply:75 mg x 1 ml = X ml x 100 mg75 = 100X75/100 = X0.75 ml (or ml) = X 38. Answer: (D) Its a measure of effect, not a standard measure of weight or quantity. Rationale: An insulin unit is a measure of effect, not a standard measureof weight or quantity. Different drugs measured in units may have norelationship to one another 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 one of 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 prevent leaks 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 povidoneiodinesolution, 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 nurse should 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 at the 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: 45 ml/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 does notnecessarily reflect the current client status. In addition, it may 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 around the bathing area. 60. Answer: (C) Use a sterile 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 weight on 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 correct an 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 client safety 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 predispose the client tohypotension.

At the time of the transfer from the surgery table to thestretcher, the client is still 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 excretions may occur. Shoe protectors are not necessary. 65. Answer : (C) Quad cane Rationale: Crutches and a walker can be difficult to maneuver for a clientwith weakness on one side. A cane is better suited for client withweakness of the arm and leg on one side. 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) Left side-lying with the head of the bed elevated 45 degrees. Rationale : To facilitate removal of 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 sit up, 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) Keep the 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 incidence of 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-experiment is done when randomization and control of the variables are not possible. 72. Answer: ( C) Primary source Rationale: This refers to a primary 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 original researcher . 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 ipsa loquitor Rationale : Res ipsa loquitor 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 can investigate violations of the nursing law andcode of ethics Rationale: Quasi-judicial power means that the Board of Nursing has theauthority to investigate violations of the nursing law and 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 since the license hasbeen revoked. 77. Answer:

(B) Review related literature Rationale: After formulating and delimiting the research problem, theresearcher conducts a review of 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 of an intervention done to improve the workingconditions of the workers on their productivity. It resulted 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

: Judgment sampling 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 a 5-point summated scale used to determine thedegree of agreement or disagreement of the respondents to a statementin a study

83. Answer: (B)Sr. Callista Roy Rationale: Sr. Callista Roy developed the Adaptation Model whichinvolves the physiologic mode, 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 consent means 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 is tobe

done or not exemplifies the bioethical principle of autonomy. 86. Answer: (C) Avoid wearing canvas shoes. Rationale: The client should 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 : Meat is 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 left lateral

Rationale: The Sims' left lateral position is the most common positionused to administer a cleansing enema because it allows gravity to aid theflow of fluid along the curve of the sigmoid colon. If the client can'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 independent intervention, whereasconsulting with the physician and pharmacist to change a client'smedication because of adverse reactions represents 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 lifethreatening 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 semiFowler 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) 4 hours Rationale: A unit of packed RBCs may be given over a period of between1 and 4 hours. It shouldn't infuse for longer than 4 hours because the riskof contamination and sepsis increases after that time. Discard or return tothe blood bank any blood not given within 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 halflife, 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 does itminimize transcription errors or reinforce 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 result in 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 of hydatidiform moleincludes elevated levels of human chorionic gonadotropin, vaginalbleeding, larger than normal uterus for gestational age, failure to detectfetal heart activity even with sensitive instruments, excessive nausea andvomiting, and early development of pregnancyinduced hypertension.Fetal activity would not be noted. 6. Answer: (B) Absent patellar reflexes Rationale:

Absence of patellar reflexes is an indicator of hypermagnesemia, which requires administration of calcium gluconate. 7. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines. Rationale: Fetus at station plus two indicates that the presenting part is 2cm below the plane of the ischial spines. 8. Answer: (A) Contractions every 1 minutes lasting 70-80 seconds. Rationale: Contractions every 1 minutes lasting 7080 seconds, 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 effect of calcium gluconate administration iscardiac arrest. Continuous

monitoring of cardiac activity (EKG) throughtadministration of calcium gluconate is an essential part of care. 10. Answer : (D) First low transverse 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 a crying 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 elbow restraints.

Rationale : Soft restraints from the upper arm to the wrist prevent theinfant from touching her lip but allow him to 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 prone position 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) Allow the 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 at age 5 months 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 6 months,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 area in PHN consists of a 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 selfreliance 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 fetal death. Rationale:

Intrauterine fetal death, abruptio placentae, septic shock, andamniotic fluid embolism may trigger normal clotting mechanisms; if clottingfactors are depleted, DIC may occur. Placenta accreta, dysfunctionallabor, and premature rupture of the membranes aren't associated withDIC. 27. Answer: (C) 120 to 160 beats/minute Rationale : A rate of 120 to 160 beats/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) Endocardial cushion defect Rationale

: Endocardial cushion defects 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: Menorrhagia is an excessive menstrual period. 32. Answer: (C) Blood typing Rationale : Blood type would be a critical value to have because the risk of blood loss 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 2 year old infant with stridorous breath sounds, sitting up inhis mothers arms and drooling. Rationale : The infant with the airway emergency should be treated first,because of the risk of epiglottitis. 35. Answer: (A) Placenta previa 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 aredeveloped 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 SIDSi n i n fa n c y. The r i sk o f as pi r a t i o n i s sl i gh tl y i n cr e ase d wi t h t he s u pi n e 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 becomesash e n or

m ottl e d. Th e n eo nat e w i t h a n i n f e cti o n wi l l usu al l y s ho w a decrease in activity level or lethargy. 72. Answer: (D) Polycythemia probably due to chronic fetal hypoxia Rationale : T he s mal l - for - g est at i o n n e on ate i s at r i sk for d e vel o pi n g polycythemia during the transitional period in an attempt to decreaseh y p o x i a . T h e neonates are also at increased risk for 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 epidermisma y b e c om e d es qu am at e d . T h es e n eo nat es ar e u su al l y v er y al er t . 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 r e spi r ator y r at e 4 0 t o 6 0 b r e ath s /mi n ut e i s nor mal f or a neonate during the transitional period. Nasal flaring, respiratory rate morethan 60 breaths/minute, and audible grunting are signs of respiratorydistress. 76. Answer: (C) Keep the cord dry and open to air Rationale: Keeping the cord dry and open to air helps reduce infectionand hastens drying. Infants arent given tub bath but are sponged off untilt he c or d f al l s of f . P etr ol e um j el l y p r e ve nts t he c or d fr o m d r yi n g a nd encourages infection. Peroxide could be painful and isnt recommended. 77.

Answer : (B) Conjunctival hemorrhage Rationale : Conjunctival hemorrhages are commonly seen in neonatessecondary 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. Fetalwell-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: Parental interaction will provide the nurse with 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 bonding. Willingness to touch and hold the 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 fourthdegreelaceration. 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 airwayw i t h a

b ul b s yr i ng e . A ft er t he ai r w ay i s c l ear an d t he n e on ate ' s c ol or 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 i sn 't wi thi n a n ur s e 's s c op e o f pr a cti ce t o p er for m an di nt er pr e t a b e dsi d e ul tr as ou n d u n d er t he se c on di ti o ns and wi t h out specialized training. Observing for pooling of strawcolored fluid, checkingvaginal discharge with nitrazine paper,

and observing for flakes of vernixar e a p pr o pr i ate a sse ssm e nts f or d e t er m i ni n g wh et her a c l i en t ha s ruptured membranes. 84. Answer : (C) Monitor partial pressure of oxygen (Pao2) levels. Rationale: Monitoring PaO 2 levels and the reducing k ee p P aO 2 w i t hi n n or mal l i mi ts r ed u c es th e r i sk of r e t i n o p a t h y o f prematurity in a premature infant 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 consistent blood glucose level and provide enough calories 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: T h e t yp e o f pl ac e nt a t hat d e vel o ps i n m o noz yg ot i c t w i ns 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 diamnioticmonochorionic twins. Cleavage that occurs between days 8 to 13 result

o x y g e n c on c e ntr ati on t o

inmonoamniotic monochorionic twins. 88. Answer: (D) Ultrasound Rationale: O n c e th e mo th er a nd t h e f et us ar e st abi l i z e d , u l tr as o un d evaluation of the placenta should be done to determine the cause of thebleeding. Amniocentesis is contraindicated in placenta previa. A digital or sp ec u l um e xami na ti o n sh o ul dn t b e d o n e as th i s ma y l ea d t o s ev er e 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 tidal volume 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 r o g r e s s e s . T h e inspiratory capacity increases during pregnancy. Thei n c r e a s e d oxygen consumption in the pregnant client i s 1 5 % t o 2 0 % greater than in the nonpregnant state. 90. Answer : (A) Diet Rationale : Clients with gestational diabetes are usually managed by dieta l o n e t o c o n t r o l t h e i r glucose intolerance. Oral hypoglycemic drugs a r e contraindicated in pregnancy. Long-acting insulin usually isnt needed for blood

glucose control in the client with gestational diabetes. 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 r u g o t h e r than magnesium are preferred for sustained h y p e r t e n s i o n . Magnesium doesnt help prevent hemorrhage in preeclamptic clients. 92. Answer : (C) I.V. fluids Rationale: A sickle cell crisis during pregnancy is usually m a n a g e d b y exchange transfusion oxygen, and L.V. Fluids. The client usually needs

as t r o n g e r a n a l g e s i c t h a n acetaminophen to control the pain of a c r i s i s . Antihypertensive drugs usually arent necessary. Diuretic wouldnt be usedunless fluid overload resulted. 93. A n s w er: (A) Calcium gluconate (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 i e n t s . R h o ( D ) immune globulin is given to women with Rhnegativeb l o o d t o prevent antibody formation from RHpositive 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 positive PPD result would be an indurated w h 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 flat circumcised 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 causesymptoms. Bacterial vaginosis causes milky white vaginal discharge butno systemic symptoms. 96.

Answer: (B) Rh-positive fetal blood crosses into 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 cellscr oss i nto t h e mat er nal c i r c ul ati on a n d sti mu l at e m at er nal a nt i bo d y 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 aortaan d i n f er i or v en a cava b y t h e f etu s. Thi s, i n tur n, i nhi bi t s mat er n 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 advantage of gravity. The standing position 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: Neonates of heroinaddicted mothers are p h y s i c a l l y dependent on the drug and experience withdrawal when the drug is nol on g er su p pl i e d . S i g ns o f her oi n wi th dr aw al i n cl u d e i r r i ta bi l i ty ,

p o or 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: T h e n or mal i nv ol u t i o nal p r o c ess r et ur ns t h e u t er us t o t h e 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. Uterineinvolution 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 softformed 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 a short 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 pressures are equalized,which avoids trauma to the neurons. 10. Answer: (C) The client is oriented when aroused from sleep, and goesback to sleep immediately. Rationale: This finding suggest that 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, night sweats, 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 lowgrade fevers, not higher 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

: Narcotics can cause respiratory arrest if given in largequantities. Its unlikely the client will have asthma attack or a seizure or wake up on his own. 15. Answer: (D) Decreased vital capacity Rationale : Reduction in vital capacity is a normal physiologic changesinclude decreased elastic recoil of the 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 razorshould 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 lowcholesterol, 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 salinesoaked 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 not treated 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 a cough 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 school student, day-care worker, and businessman probably have a much low risk 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 falsenegative skin test results. A chest 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 bronchoconstriction is the cause of reduced airflow. Beta-adrenergic blockers arent used to

treat asthma and can cause bronchoconstriction. 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 chronic obstructive 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 withnew-onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem) Rationale : The client with atrial fibrillation has the greatest potential tobecome unstable and is on L.V. medication that requires

close monitoring.A ft er a sse ssi n g thi s cl i e nt, th e n ur s e s ho ul d ass es s t he c l i en t wi th thrombophlebitis who is receiving a heparin infusion, and then the 58y e ar - ol d cl i en t a dmi t te d 2 d a ys a go wi th he ar t f ai l ur e ( hi s si gns an ds ym pto ms ar e r e sol vi n g a nd do n t r eq ui r e i mm e di at e at t e nti on ). Th e lowest priority is the 89-year-old with endstage right-sided heart failure,who requires timeconsuming 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 her about cocaine use. Cocaine 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, andm yo car d i al i nf ar c ti o n . B ar bi tur at e o ver d os e ma y tr i gge r r es pi r at or y d epr es si o n a n d sl ow p ul s e . O pi o i d s c a n c a us e mar k ed r es pi r at or y 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: The usual treatment for vaginal cancer is e x t e r n a l o r intravaginal radiation therapy. Less often, surgery is 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 client should begin performing stoma care withoutassistance as soon as possible to gain independence in selfc 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 theface. Chest pain, dyspnea, cough, weight loss, and fever are associatedwith pleural tumors. Arm and shoulder pain and atrophy of the arm andh an d m us cl es on t h e a ff e ct e d si de s u gg est P a n coa st 's t umor , a l un g tumor involving the first thoracic and eighth cervical nerves within thebrachial 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: PSA stands for prostatespecific antigen, which is u s e d 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 anesthetics don't cause hematuria. 55. Answer: (C) Sigmoidoscopy

Rationale: Used to visualize the lower GI tract, sigmoidoscopy a n d proctoscopy aid in the detection of twothirds of all colorectal cancers.S t o o l H e m a t e s t detects blood, which is a sign of colorectal 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 of colorectal cancer. 56. Answer : (B) A fixed nodular mass with dimpling of the overlying skin Rationale: A fixed nodular mass with dimpling of the overlying s k i n i s common during late stages of breast cancer. Many women have slightlya s y m m e t r i c a l

breasts. Bloody nipple discharge is a sign of i n t r a d u c t a 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 a watch 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 u r y t o t h e c l i e n t

and (if they fly off) to others. The client must lie stillduring the MRI but can talk to those performing the test by w a y o f t h 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 a v a i l a b l e e a t . a r e b u t S u p p l e m e n t s

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 Xrays 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 at risk. Strenuous exercise won't cause fractures. 60. Answer: (C) Joint flexion of less than 50% Rationale: Arthroscopy is contraindicated in clients w i t h j o i n t f l e x i o n o f less than 50% because of technical problems in inserting the instrumenti n t o t h e j o i n t t o see it clearly. Other contraindications for this p r o c e d u r 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 arthritis is a rare, benign condition marked by 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 s a l i n e s o l u t i o n y i e l d s 50 units of heparin per milliliter of solution. T h 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 return and may cause 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 as t r o k e b u t i s

more likely to occur in the lower extremities. A s t r o k e i s 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 women. Bouchards node appears on the 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 withosteoarthritis 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 7 0 /3 0 i n sul i n p r e par a t i o n i s 7 0 % N P H a n d 3 0 % r e g ul ar insulin. Therefore, a correct substitution requires mixing 21 U of NPH and9 U of regular insulin. The other choices are incorrect dosages for theprescribed insulin.

68. Answer: (C) colchicines Rationale: A disease characterized by joint inflammation (especially inthe 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 totreat gout. 69. Answer : (A) Adrenal cortex

Rationale: Excessive secretion of aldosterone in the adrenal cortex isresponsible for the client's hypertension. This hormone acts on the renalt u b ul e , w her e i t p r om ot es r e ab sor pti on of s o di u m an d e x cr eti o n o f potassium and hydrogen ions. The pancreas mainly secretes hormonesi n v o l v e d in fuel metabolism. The adrenal medulla secretes t h e catecholamines epinephrine and norepinephrine. The parathyroidssecrete parathyroid hormone. 70. Answer : (C) They debride the wound and promote healing by secondaryintention Rationale: F or t h i s cl i e nt , we t - t o- dr y d r e ssi ng s ar e mos t

a p pr o pr i at e be ca us e t he y c l ea n th e f oot ul c er b y d e br i di ng ex ud at e an d n e cr o ti ctissue, thus promoting healing by secondary intention. Moist, transparentdr essi n gs c o nta i n exu da te a nd p r ov i d e a m oi st w ou n d e nv i r o nm ent .H y dr o co l l oi d d r e ssi ng s pr ev en t t h e e ntr an c e o f mi cr oor ga ni s ms a nd minimize wound discomfort. Dry sterile dressings protect the wound frommechanical trauma and promote healing. 71. Answer: (A) Hyperkalemia Rationale: In adrenal insufficiency, the client has hyperkalemia due t o reduced aldosterone secretion. BUN increases as the glomerular filtrationr a t e reduced. is

Hyponatremia caused by

is

reduced

a l d o s t e r o n e secretion. Reduced cortisol secretion leads to impaired glyconeogenesisa n d r e d u c t i o n g l y c o g e n t h e l i v e r m u s c l e , c a u s i n g hypoglycemia. 72. Answer: (C) Restricting fluids Rationale: To reduce water retention in a client with the SIADH, 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 o f i n a n d a

tosome of the hemoglobin and stays attached during the 120day life spano f r e d b l o o d cells, glycosylated hemoglobin levels provide i n f o r m a t i o n about blood glucose levels during the previous 3 months. Fasting bloodg l u c o s e a n d u r i n e glucose levels only give information about g l u 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 hoursa f t e r administration. Because the nurse administered N P H i n s u l i n a t 7 a.m., the client is at greatest risk for hypoglycemia from 3 p.m. to 7 p.m.

75. Answer : (A) Glucocorticoids and androgens Rationale: The have the adrenal two cortex glands divisions,

or magnesium a b n o r m a l i t i e s . Hyponatremia may occur if the client inadvertently received too much fluid;however, this can happen to any surgical client receiving I.V. fluid therapy,n o t t h y r o i d 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 ise l e v a t e d . Therefore, it can't be used as a general indicator of cancer.However, it is helpful in monitoring cancer treatment because the levelu s u a l l y f a l l s t o normal within 1 j u s t o n e f r o m r e c o v e r i n g

month if treatment is successful. Anelevated acid phosphatase level may indicate prostate cancer. A n elevated alkaline phosphatase level may reflect bone metastasis. 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 (AIDS). Nausea, vomiting, and anorexia may be signs o f hepatitis B. Itching, rash, and jaundice may result from an allergic o r hemolytic reaction.

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: Hypocalcemia may follow thyroid surgery if the p a r a t h y r o i d glands were removed accidentally. Signs and symptoms of hypocalcemiam a y be delayed for up to 7 days after surgery. Thyroid surgery doesn'tdirectly cause serum sodium, potassium,

s u r g e r y .

H y p e r k a l e m i a

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 via the transplacental route, but a Cesarean 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 mother who's HIV positive can give birth to a baby who's H I V negative. 80. Answer: (C) "Avoid sharing such articles as toothbrushes and razors." Rationale: The human immunodeficiency

virus (HIV), which c a u s e s AIDS, i s m o s t concentrated in the blood. For this r e a s o n , t h e c l i e n t shouldn't share personal articles that may be bloodcontaminated, 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: Pallor, tachycardia, and a sore tongue are all characteristicf i n d i n g s i n pernicious anemia. Other clinical manifestations 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't characteristic findings in pernicious anemia 82. Answer: ( B ) A dmi ni st er e pi n ep hr i ne , as pr es cr i b ed , a n d pr ep ar e t o intubate the client if necessary. Rationale: To reverse anaphylactic shock, the nurse first s h o u l d a d mi n i st er e pi n ep hr i ne , a p ot en t b r o n ch o di l at or as p r e scr i b e d. Th e 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 outputmonitoring; however, administering epinephrine is the first priority. 83. Answer: (D) bilateral hearing loss. Rationale: Prolonged use of aspirin and other salicylates sometimescauses bilateral hearing loss of 30 to 40 decibels. Usually, this adverseeffect resolves within 2 weeks after the therapy is discontinued. Aspirindoesn'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.A da pti v e i mm un i t y i s m e di at e d b y B a nd T l ym ph o c yte s an d can b e acquired actively or passively. The neutrophil is crucial to phagocytosis.T h e ba sop hi l p l a ys a n i m por t ant r o l e i n t he r el eas e o f i nfl amma tor ym e di at or s. T h e mo no c yt e f un c t i on s i n p h ag o cy tos i s a nd m on ok i ne production. 85. Answer: (A) moisture replacement. Rationale: Sjogren's syndromei s a n a ut oi mm un e di sor de r l ea di ng t o 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 aproblem 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" hor s e bar n " s mel l i n g di ar r hea . S u c ce ss ful tr eat me nt b e gi ns wi t h a n a c c u r a t e diagnosis, which includes a stool test. T h e E L I S A t e s t i s diagnostic for human immunodeficiency

virus (HIV) and isn't indicated hemogram may be useful in the aren't diagnostic for specific the abdomen may provide useful information about

with ELISA. Rational e: HIV 87. Answer: infection is (D) Western detected blot test by analyzin
inthis case. An electrolyte panel and overallevaluation of a client but causes of diarrhea.A flat plate of bowelfunction but isn't indicated in the case of "horse barn" smelling diarrhea

g blood for antibodi es toHIV, which form approxi mately 2 to 12

weeks after exposure to HIV anddeno te infection . The Western blot test

electrop horesis of antibody proteins is more than 98%

accurate in detecting HIV antibodi es whenuse d in conjunct ion with

the ELISA. It isn't specific when used alone. Erosette immunof luoresce

nce is used to detect viruses in general; it doesn'tc onfirm HIV inf

ection. Quantifi cation o f Tlympho cytes is a useful monitori ng test but isn't

diagnost ic for HIV. The ELISA test detects HIVanti body particles

but may yield inaccurat e results; a positive ELISA resultmu st be confirme

d by the Western blot test. 88. Answer: (C) Abn ormally low hem atocrit ( HCT) an

d hemog lobin (H b)levels Rational e: Low preopera tive HCT and Hb

levels indicate the client mayrequ ire a blo od trans fusion b efore su rgery. If the HC

T and H b levels decrease during surgery because of blood loss, the potential need for

atransfus ion increases . Possible renal failure is indicated by elevated

BUNor creatini ne level s. Urine constit uents ar en't fou nd in th e blood. Coagulat

ion is determ ined by the presence of appro priate clotting factors,n ot

electrolyt es. 89. Answer: (A) Platelet count, prothro mbin time,

and partial thrombo plastinti me Rational e: The diagnosi s of DIC

is based on the results of laborato rystudie s of prot hrombin time, pl atelet co

unt, thr ombin ti me, part ialthrom boplastin time, and fibrinoge n level as well as client

history and other ass essment factors. Blood glucose levels, WBC count,

calcium levels, andpotas sium levels aren't used to confirm a

diagnosis of DIC. 90. Answer: (D) Strawber ries Rational e:

Commo n food allergens include berries, peanuts, Brazil nuts,cash ews, shellfish,

and eggs. Bread, carrots, and oranges rarely causealle rgic

reactions . 91. Answer: (B) A client with cast on the right leg who

states, I have a funnyfee ling in my right leg. Rational e: It may indicate

neurovas cular compro mise, requires immediat eassessm ent. 92. Answer

: (D) A 62-yearold who had an abdomin alperineal resection threeday s ago;

client complain ts of chills. Rational e : The client is at risk for

peritonit is; should be assessed for furth er symptom s and infection.

93. Answer : (C) The client spontane ously flexes his wrist when

the bloodpre ssure is obtained. Rational e: Carpal spasms indicate

hypocalc emia. 94. Answer: (D) Use comfort measures and pillows to

position the client. Rational e: Using comfort measure s and pillows

to position the client is anonpharmac ological methods of pain relief. 95.

Answer: (B) Warm the dialysate solution. Rational e: Cold dialysate

increases discomf ort. The solution should bewarm ed to bo dy temp erature i n warm

er or he ating pa d; dont usemicr owave oven. 96. Answer: (C) The client

holds the cane with his left hand, moves the caneforw ard followed

by the right leg, and then moves the left leg. Rational e: The cane acts as a

support and aids in weight bearing for theweak er right leg. 97.

Answer: (A) Ask the womans family to provide personal items such asphotos

or memento s. Rational e: Photos and mement os provide

visual stimulati on to reducese nsory deprivati on. 98. Answer:

(B) The client lifts the walker, moves it forward 10 inches, andthen takes

several small steps forward. Rational e: A walker needs to be picked

up, placed down on all legs. 99. Answer: (C) Isolation from their

families and familiar surround ings. Rational e: Gradual loss of sight,

hearing, and taste interfere s with normalfu nctioning . 100. Answer:

(A) Encoura ge the client to perform pursed lip breathing .

Rational e: Purse lip breathing prevents the collapse of lung unit and helpsclie

nt control rate and depth of breathing TEST IVAnsw ers and Rati onale

Care of Clients with Ph ysiologic andPsyc hosocial Alterati ons 1. Answer:

(C) Hyperten sion Rational e: Hyperte nsion, al ong wit h fever, and tend

erness o ver theg rafted kidney, reflects acute rejection. 2. Answer: (A) Pain

Rational e : Sharp, severe pain (renal colic) radiating toward the

genitalia and thigh is caused by uretheral distentio n and smooth muscle

spasm;re lief form pain is the priority. 3. Answer: (D) Decrease the size

and vasculari ty of the thyroid gland. Rational e: Lugols solution provides

iodine, which aids in decreasi ng thevascu larity of the thyroid gland,

which limits the risk of hemorrh age whensur gery is performe d.

4. Answer: (A) Liver Disease Rational e: The clie nt with l iver dis ease has

a decre ased abi lity tom etabolize carbohyd rates because of a decrease d ability

to form glycogen (glycoge nesis) and to form glucose from glycogen .

5. Answer: (C) Leukope nia Rational e : Leuko penia, a reductio

n in WB Cs, is a systemic effect o f chemot herapy as a result of myelosu

ppressio n. 6. Answer: (C) Avoid foods that in the past

caused flatus. Rational e : Foods that bothered a person preoperat ively will

continue to doso after a colostom y. 7. Answer: (B) Keep the irrigatin

g containe r less than 18 inches above thestoma . Rational e:

This height permits the solution to flow slowly with little forceso

that excessiv e peristalsi s is not immediat ely precipitat ed. 8.

Answer: (A) Administ er Kayexala te Rational e: Kayexal ate,a

potassiu m exchang e resin, permits sodium to beexc hanged for potassiu

m in the intestine, reducing the serum potassiu mlevel. 9. Answer:

(B) 28 gtt/min Rational e: This is the correct flow rate; multiply

the amount to be infused(2 000 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 Rational e: The percenta ge designat

ed for each burned part of the bodyusin g the rule of nines: Head and neck

9%; Right upper extremit y 9%; Leftuppe r extremit y 9%; Anterior

trunk 18%; Posterior trunk 18%; Right lower ex tremity 18%; Left

lower extremit y 18%; Perineu m 1%. 11. Answer: (C)

Bleeding from ears Rationa le: The nurse needs to perform a thorough

assessme nt that couldindi cate alteration s in cerebral function, increased intracran

ial pressures ,fractures and bleeding. Bleeding from the ears occurs only with

basal skullfract ures that can easily contribut e to increased intracran ial

pressure andbrain herniatio n. 12. Answer: (D) may engage in

contact sports Rationa le: The client should be advised by the

nurse to avoid contactsp orts. This will prevent trauma to the area of the pacemak

er generator . 13. Answer : (A) Oxygen at 12L/min is given

to maintain the hypoxic stimulusf or breathing . Rational e:

COPD causes a chronic CO2 retention that renders themedul la insensiti

ve to the CO2 stimulati on for breathing . The hypoxic stateof the client then

becomes the stimulus for breathing . Giving the clientoxy gen in low

concentr ations will maintain the clients hypoxic drive. 14. Answer:

(B) Facilitate ventilatio n of the left lung. Rationa le: Since only a partial

pneumon ectomy is done, there is a needto promote expansio n of this remainin g Left

lung by positioni ng the clienton the opposite unoperat ed side. 15. Answer:

(A) Food and fluids will be withheld for at least 2 hours. Rationa le:

Prior to bronchos copy, the doctors sprays the back of thethroat with anestheti

c to minimize the gag reflex and thus facilitate theinserti on of the bronchos cope.

Giving the client food and drink after theproce dure 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) hyperkal emia.

Rational e: Hyperkal emia is a common complica tion of acute renal failure.It'

s lifethreateni ng if immediat e action isn't taken to reverse it. Theadmi

nistration of glucose and regular insulin, with sodium bicarbon ate

if necess ary, can temporar ily prevent cardiac arrest by moving potassiu minto the

cells and temporar ily reducing serum potassiu m levels.Hy pernatre mia,

hypokale mia, and hypercal cemia don't usually occur withacut e renal failure

and aren't treated with glucose, insulin, or sodiumbi carbonat e.

17. Answer : (A) This conditio n puts her at a higher

risk for cervical cancer;t herefore , she should have a Papanic olaou

(Pap) smear annually . Rationa le: Women with condylo

mata acumina ta are at risk for cancer of the c ervix a nd vulv a. Yearl

y Pap s mears a re very importa nt for e arlydet ection. Becaus e condy

lomata acumin ata is a virus, t here is noperm anent cure. Because

condylo mata acumina ta can occur on the vulva,a condom won't

protect sexual partners . HPV can be transmit ted to other pa rts of the

body, such as the mouth, orophar ynx, and larynx. 18.

Answer : (A) The left kidney usually is slightly higher

than the right one. Rationa le: The left kidney usually is

slightly higher than the right one. Anadre nal glan d lies at op each

kidney. The av erage ki dney m easures approxi mately 11 cm (4-3/8")

long, 5 to 5.8 cm (2" to 2") wide, and 2.5cm (1") thick.

The kidneys are located retroper itoneall y, in the posterio r aspect

of the abdome n, on either side of the vertebra l column.

They liebetwe en the 12th thoracic and 3rd lumbar vertebra e.

19. Answer : (C) Blood urea nitrogen (BUN) 100

mg/dl and serum creatini ne6.5 mg/dl. Rationa le:

The normal BUN level ranges 8 to 23 mg/dl; the normal

serumcr eatinine level ranges from 0.7 to 1.5 mg/dl. The test

results in option Care abnorma lly elevated , reflectin

g CRF and the kidneys' decrease d abilityto remov e nonpr otein ni

trogen waste f rom the blood. CRF ca usesdec reased pH and increase

d hydroge n ions not vice versa. CRF alsoincr eases

serum levels of potassiu m, magnesi um, and phospho rous, anddecr

eases serum levels of calcium. A uric acid analysis of 3.5 mg/dl

fallswit hin the normal range of 2.7 to 7.7 mg/dl; PSP excretio

n of 75% alsofalls with the normal range of 60% to 75%. 20.

Answer : (D) Alt eration in the s ize, sha pe, and organi zation

of differ entiated cells Rationa le: Dysplasi a

refers t o an alt eration in the s ize, sha pe, and organiz ation of differe

ntiated cells. T he pres ence of compl etelyun differen tiated tumor

cells that don't resembl e cells of the tissues of their ori

gin is called anaplasi a. An increase in the number of

normal cells in anorma l arrang ement i n a tiss ue or a n organ

is calle d hyperpla sia. Replace ment of one type of fully differen

tiated cell by another in tissuesw here the second type normall

y isn't found is called metapla sia. 21. Answer :

(D) Kaposi's sarcoma Rationa le: Kaposi's sarcoma is the most

common cancer associat ed withAI DS. Squamo us cell carcino

ma, multiple myelom a, and leukemi a mayocc ur in anyone

and aren't associat ed specific ally with AIDS. 22.

Answer : (C) To prevent cerebros pinal fluid (CSF) leakage

Rational e: The clie nt receiv ing a su barachn oid bloc k require s special positioni

ng to prevent CSF leakage and headach e and to ensure proper a nesthetic

distributi on. Proper positioni ng doesn't help prevent confusio n,seizure

s, or cardiac arrhythm ias. 23. Answer: (A) Ausculta te bowel sounds.

Rational e: If abdomin al distentio n is accompa nied by nausea,

the nursemu st first auscultat e bowel sounds. If bowel sounds are absent,

the nurse should suspect gastric or small intestine dilation and these findings

mustbe reported to the physicia n. Palpatio n should be avoid ed postoper

ativelyw ith abdomin al distentio n. If peristalsi s is absent, changing

positions andinsert ing a rectal tube won't relieve the client's

discomfo rt. 24. Answer: (B) Lying on the left side with knees bent

Rational e: For a colonosc opy, 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 el evated, or bent over wit h handst

ouching the floor wouldn't allow proper visualiza tion of the large intestine. 25.

Answer: (A) Blood supply to the stoma has been interrupt ed

Rational e: An ileostom y stoma forms as the ileu m is brought through

theabdo minal wall to the surface skin, creating an artificial opening

for wasteeli mination . The sto ma shou ld appea r cherry red, indi cating a dequatea

rterial perfusio n. A dusky stoma suggests decrease d perfusio n,

whichma y result from interrupt ion of the stoma's blood supply and may

lead totissue damage or necrosis. A dusky stoma isn't a normal finding.

Adjustin gthe ost omy bag wou ldn't affe ct stoma color, w hich dep ends on blood

supply to the area. An intestinal obstructi on also wouldn't change stomacol or.

26. Answer: (A) Applying knee splints Rational e: Applying knee

splints prevents leg contractu res by holding the joints in a position of

function. Elevatin g the foot of the bed can't preventc ontractu res because

this action doesn't hold the joints in a position of functi on. Hyperext

ending a body part for an extended time is inapprop riatebeca use it can cause

contract ures. Performi ng shoulder rangeofmotione xercises can

prevent contractu res in the shoulder s, but not in the legs. 27. Answer:

(B) Urine output of 20 ml/hour. Rational e: A urine output of less

than 40 ml/hour in a client with burnsind icates a fluid volume deficit.

This client's PaO

100 mm Hg). White 2 pulmona value ry falls secretio within ns also thenorm arenorm al range al. The c (80 to lient's re

ctal tem perature isn't sign ificantly elevated andprob ably results from the fluid

volume deficit. 28. Answer: (A) Turn him frequentl y. Rational e:

The most importan t intervent ion to prevent pressure ulcers isfreque

nt positi on chan ges, whi ch reliev e pressu re on th e skin a ndunderl ying tiss ues.

If pressu re isn't relieved, capillari es become occluded ,reducin g circulati

on and oxygena tion of the tissues and resulting in celldeat h and ul

cer form ation. D uring pa ssive ROM ex ercises, t he nurse moves each joint

through its range of moveme nt, which improve s jointmob ility and

circulati on to the affected area but doesn't prevent pressure ulcers. Adequat e hydrati

on is nec essary to maintai n health y skin and ensure tissue repair. A footboar

d prevents plantar flexion and footdrop bymainta ining the foot in a dorsiflex

ed position. 29. Answer: (C) In l ong, eve n, outw ard, and downw ard stro

kes in t hedirecti on of hair growth Rational e: When applying a topical

agent, the nurse should begin at themidli ne and u se long, even, ou tward, a nd down

ward str okes in t hedirecti on of hair growth. This applicati on pattern

reduces the risk of follicl eirritatio n and skin inflamm ation. 30. Answer

: (A) Beta adrenergi c blockers Rational e:

Betaadrenerg ic blockers work by blocking beta receptors inthe m yocardi

um, red ucing th e respo nse to c atechol amines andsym pathetic nerve stimulati

on. They protect the myocard ium, helping toreduce the risk of another

infractio n by decreasi ng myocard ial oxygend emand. Calcium channel

blockers reduce the workloa d of the heart bydecrea sing the heart rate.

Narcotic s reduce myocard ial oxygen demand, promote vasodilat ion, and decrease

anxiety. Nitrates reduce myocard ialoxyge n consump tion bt decreasi ng left

ventricul ar end diastolic pressure( preload) and systemic vascular resistanc e

(afterloa d). 31. Answer : (C) Raised 30 degrees

Rational e: Jugular venous pressure is measure d with a centimet er

ruler to obtain the vertical distance between the sternal angle and the

point of highe st pulsatio n with the head of the bed inclined between

15 to 30degre es. Increase d pressure cant be seen when the client is

supine or when the head of the bed is raised 10 degrees because the point

thatmark s the pressure level is above the jaw (therefor e, not visible). In

highFow lers position, the veins would be barely discernib le above the clavicle.

32. are Answer: administ (D) ered to increase Inotropic the force agents of Rational theheart e: s contra Inotropic ctions, t agents hereby i

ncreasin g ventri cular co ntractilit y andulti mately increasin g cardiac output. Beta-

adrenergi c blockers and calciumc hannel blockers decrease the heart rate and

ultimatel y decrease d theworkl oad of the heart. Diuretics are

administ ered to decrease the overallva scular volume, also decreasin g the

workload of the heart. 33.

Answer : (B)

Less than 30% of calories form fat Rationa le :

A client with low serum HDL and high serum LDL levels shouldg

et less than 30% of daily calories from fat. The other modific

ations areappr opriate for this client. 34. Answer :

(C) The emerg ency de partme nt nurs e calls up the l atestele ctrocard

iogram results to check the clients progress

The em ergency depart ment n urse is no long er direc Rationa tlyinvol le: ved

with the clients care and thus has no legal right to informa tionabo

ut his present conditio n. Anyone directly involve d in his care

(such asthe telemetr y nurse and the on-call physicia n) has the right

to informa tionabo ut his conditio n. Because the client

requeste d that the nurse updatehi s wife on his conditio n, doing

so doesnt breach confiden tiality. 35. Answer :

(B)

Rationa le: Check ET tube endotrac placeme heal nt tube should placeme be nt. confirm ed as

soon as the clientarr ives in t he emer gency d epartme nt. Onc e the ai

rways i s secure d,oxyge nation and ventilati on should be

confirm ed using an endtidal carbond ioxide monitor and pulse

oximetr y. Next, the nurse should make sureL.V . access is esta

blished. If the c lient ex perienc es sym ptomati cbradyc ardia, atropine

is adminis tered as ordered 0.5 to 1 mg every 3 to 5minute

s to a total of 3 mg. Then the nurse should try to find the

cause of the clients arrest by obtainin g an ABG sample.

Amioda rone is indicate dfor ventricu lar tachyca rdia, ventricu

lar fibrillati on and atrial flutter notsymp tomatic bradycar dia.

36. Use the Answer followin g : formula (C) 95 to mm Hg calculat Rationa e le: MAPM AP =

systolic +2 (diastoli c)3MAP =126 mm Hg + 2 (80 mm Hg)3M

AP=286 mm HG3M AP=95 mm Hg 37. Answer :

(C) Electroc ardiogra m, complet e blood count, testing for

occultbl ood, compreh ensive serum metaboli c panel. Rationa le:

An electroc ardiogra m evaluate s the complai nts of chest

pain,lab oratory tests determi nes anemia, and the stool test for

occult bloodde termine s blood in the stool. Cardiac monitor ing,

oxygen, and creatine kinase and lactate dehydro genase levels

are appropr iate for a cardiac primary problem .A basic

metabol ic panel and alkaline phospha tase andaspa rtate aminotr

ansferas e levels assess liver function . Prothro mbin time,par

tial thro mbopla stin tim e, fibrin ogen an d fibrin split pr oducts are

measure d to veri fy bleed ing dysc rasias, An elect roencep halogra mevaluat es brain

electrical activity. 38. Answer : (D) Hep arinassociat ed thro mbosis

and thro mbocyto penia(H ATT) Rational e: HATT may occur after

CABG surgery due to heparin usedurin g surger y. Altho ugh DIC and ITP cause pl

atelet ag gregatio n andble eding, neither is common in a client after

revascul arization surgery. Pancytop enia is a reduction in all blood cells. 39.

Answer : (B) Corticost eroids Rational e : Corticost eroid

therapy can decrease antibody producti on andphag ocytosis of the antibody

-coated platelets, retaining more functioni ngplatele ts. Methotre xate can caus

e thrombo cytopeni a. Vitamin K is used totr eat an excessiv e

anticoag ulate state from warfarin overload , and ASAdecr eases platelet

aggregati on. 40. Answer : (D) Xenogen eic Rational e:

An xenogen eic transplan t is between is between human andanot

her spec ies. A sy ngeneic transpla nt is bet ween id entical t wins,all ogeneic transpla

nt is bet ween tw o human s, and a utologo us is atra nsplant from the same

individua l. 41. Answer : (B) Rational e: Tissue t hrombo

plastin i s release d when damage d tissuec omes in contact with clotting factors.

Calcium is released to assist theconve rsion of factors X to Xa. Conversi on of

factors XII to XIIa and VIII toVIIIa are part of the intrinsic pathway. 42.

Answer : (C) Essential thrombo cytopeni a Rational e:

Essential thrombo cytopeni a is linked to immunol ogic disorders ,such as SLE and

human immuno deficienc y vitus. The disorder known asvon Willebra nds

disease is a type of hemophi lia and isnt linked to SLE.Mo derate to severe

anemia is associat ed with SLE, not polycyth ermia.Dr esslers syndrom e is

pericardi tis that occurs after a myocardi al infarctio nand isnt

linked to SLE. 43. Answer : (B) Night sweat Rational e:

In stage 1, sympto ms include a single enlarged lymph node(us ually), u

nexplain ed fever, night s weats, m alaise, a nd gener alizedpr uritis. Althoug h

splenom egaly may be present in some clients, nightsw eats are generall y more p

revalent. Pericard itis isnt associat ed with Hodgkin s diseas e, nor is hypother mia. Mo

reover, s plenome galy and pericardi tis arent sympto ms. Persisten t hypother

mia is associ ated with Hodgkin s but isnt an early sign of the disease.

44. Answer : (D) Breath sounds Rational e: Pneumon ia, both

viral and fungal, is a common cause of deathin clients with neutrope nia, so

frequent assessme nt of respirato ry rate andbreat h sounds is requir ed. Alth ough ass

essing bl ood pres sure, bo welsoun ds, and heart sounds is importan t, it wont

help detect pneumon ia. 45. Answer : (B) Muscle spasm

Rational e: Back pain or parest hesia in the lower extremiti es may

indicatei mpendin g spinal cord compres sion from a spinal tumor. This

should berecogn ized and treated promptly as progressi on of the tumor may

result inparaple gia. The other options, which reflect parts of the nervous

system,a rent usually affected by MM. 46. Answer : (C)10 years

Rational e: Epiderm iologic s tudies sh ow the aver age time from initialco

ntact with HIV to the develop ment of AIDS is 10 years. 47. Answer

: (A) Low platelet count Rational e: In DIC, platelets and clotting

factors are consume d, resulting inmicrot hrombi a nd exces sive blee ding. As

clots for m, fibrin ogen lev elsdecre ase and the prot hrombin time in creases. Fibrin d

egenerat ionprodu cts increase as fibrinoly sis takes places. 48. Answer

: (D) Hodgkin s disease Rational e: Hodgkin s disease

typically causes fever night sweats, weightlo ss, and lymph mode enlarge

ment. Influenz a doesnt last for months. Clients with sickle cell

anemia manifest signs and sympto ms of chronica nemia w ith pallo r of the

mucous membra ne, fatig ue, and decrease dtoleran ce for exercise; they dont

show fever, night sweats, weight loss or lymp h node enlarge ment. L

eukemi a doesn t cause lymph nodeenl argement . 49. Answer :

(C) A Rhnegative Rational e: Human blood can sometim es

contain an inherited D antigen. Persons with the D antigen have Rh-

positive blood type; those lacking theantig en have Rhnegative blood.

Its importa nt that a person with Rhnegative blood r eceives Rhnegative

blood. I f Rhpositive blood is administ ered to an Rhnegative person, the

recipient develops antiRhagglu tinins, a nd sub s equent tr ansfusio ns with Rh-

positive blood m aycause serious reactions with clumping and hemolysi s of red

blood cells. 50. Answer: (B) I will call my doctor if Stacy has

persisten t vomitin g anddiarr hea. Rational e: Persiste nt (more

than 24 hours) v omiting, anorexi a, anddi arrhea are signs of toxicity and the

patient should stop the medicati on and notify the health care

provider. The other manifest ations are expected side effects of

chemoth erapy. 51. Answer: (D) This is only tempora ry; Stacy will re-

grow new hair in 36months, but may be different in texture.

Rational e: This is the appropri ate response . The nurse should

help themoth er how to cope with her own feel ings regardin g the childs

disease soas not to affect the child negativel y. When the hair grows back, it is still

of the same color and texture. 52. Answer: (B) Apply viscous Lidocain

e to oral ulcers as needed. Rational e: Stomatiti s can cause pain and this can

be relieved by applyingt opical anestheti cs such as lidocaine before

mouth care. When the patientis already comforta ble, the nurse can

proceed with providin g the patientw ith oral r inses of saline so lution mixed w

ith equal part of water or hydroge n peroxi de mixed w ater in 1: 3 concen trations t

o promo te oralhy giene. Every 24 hours. 53. Answer : (C) Immedia tely

discontin ue the infusion Rational e: Edema or swelling at the IV site is a

sign that the needle hasbeen dislodge d and the IV solution is leaking

into the tissues causing theedem a. The patient feels pain as the nerves

are irritated by pressure andthe IV solution. The first action of the nurse

would be to discontin ue theinfusi on right away to prevent further edema

and other complica tion. 54. Answer : (C) Chronic obstructi ve

bronchiti s Rational e: Clients with chronic obstructi ve bronchiti

s appear bloated; theyhave large barrel chest and peripher al edema,

cyanotic nail beds, and attimes, circumor al cyanosis. Clients with

ARDS are acutely short of breathan d freque ntly nee d intuba tion for mechani

cal venti lation an d largea mount o f oxygen . Clients with ast hma don t exhibi t charact

eristics of chroni c disease, and clients with emphyse ma appear

pink and cachectic . 55. Answer : (D) Emphyse ma

Rational e: Because of the large amount of energy it takes to breathe,

clients with emphyse ma are usually cachecti c. Theyre pink and usuallyb

reathe through pursed lips, hence the term puffer. Clients with ARDSar

e usually acutely short of breath. Clients with asthma dont have anyparti

cular cha racteristi cs, and clien ts with chr onic obstructi ve bronchiti

sare bloated and cyanotic in appearan ce. 56. Answer :D

80 mm Hg Rational e: A client about to go into respirato ry arrest will have

inefficie ntventila tion and will be retain ing carbon dioxide. The value

expected wouldbe around 80 mm Hg. All other values are lower than expected.

57. Becaus HCO3Answer e Paco2 is is high normal, : (C) at 80 the Respirat mm Hg client ory and th has acidosis e metab respirat Rationa olicmea ory le: sure, acidosis

. The pH isless th an 7.35, academ ic, whic h elimin ates met abolic a

nd respi ratoryal kalosis as possibil ities. If the HCO3was

below 22 mEq/L the clientw ould have metaboli

c acidosis. 58. Answer

Rationa le: The client was : (C) reacting Respirat to the ory drug failure with

respirat ory signs of impe nding anaphyl axis, which could

lead to eventual ly respirat ory failure. Althoug h the signs

are also related to an asthma attack or a pulmon aryemb olism, c

onsider the new drug fi rst. Rhe umatoi d arthrit is does ntmani fest

these signs. 59. Answer : (D) Elevated serum aminotr

ansferas e Rationa le: Hepatic cell death causes release

of liver enzyme s alaninea minotra nsferase (ALT), aspartat e amino

transfer ase (AST) a nd lactated ehydrog enase (LDH) into the

circulati on. Liver cirrhosi s is a chronic andirrev ersible disease

of the liver ch aracteri zed by gene ralized inflamm ationand fibrosis

of the liver tissues. 60. Answer : (A) Impaire d

clotting mechani sm Rationa le: Cirrhosi s of the liver results

in decre ased Vitamin K absorpti onand formatio n of clotting

factors resulting in impaire d clotting mechani sm. 61.

Answer : (B) Altered level of conscio usness Rationa le:

Change s in behavio r and level of conscio usness are the firstsins

of hepatic encepha lopathy. Hepatic encepha lopathy is caused

by liver fail ure and develop s when the liver is unable to

convert protein metabol icprodu ct ammoni a to urea. This

results in accumul ation of ammoni a andothe r 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. Rationa le: Lactulos e is given to a patients

with hepatic encepha lopathy toreduce absorpti on of ammoni a in the

intestine s by binding with ammoni aand promoti ng more frequent

bowel movem ents. If the patient experie ncediarr hea, it indicate

s over dosage and the nurse must reduce the amount of medi

cation given t o the p atient. The sto ol will be mas hy or s oft.Lact

ulose is also very sweet and may cause crampin g and bloating.

63. Answer : (B) Sev ere low er back pain, d ecrease d blood

pressur e,decrea sed RBC count, increase d WBC count.

Rationa le: Severe lower b ack pai n indica tes an a neurys m ruptu

re,secon dary to pressure being applied within the abdomi nal

cavity. Whenru ptured occurs, the pain is constant because it cant

s due to be alleviate the loss d until of blood the aneurys m is repaired. Blood pressure decrease

. After the aneurys m ruptures, the vasculat

ure is interrupt ed andbloo d volume is lost, so blood pressure wouldnt

increase. For the samerea son, the RBC count is decrease d not increase d. The

WBC countinc reases as cell migrate to the site of injury. 64. Answer:

(D) Apply gloves and assess the groin site Rational e:

Observi ng stand ard prec autions i s the firs t priorit y whend ealing with any blood

fluid. Assessm ent of the groin site is the secondpr iority. This establish

es where the blood is coming from and determin eshow much blood has been

lost. The goal in this situation is to stop thebleed ing. The nurse would

call for help if it were warrante d after theasses sment of the situation. After

determin ing the extent of the bleeding, vital signs assessm ent is importa

nt. The nurse should never move theclient , in case a clot has formed.

Moving can disturb the clot and causereb leeding. 65. Answer:

(D) Percutan eous translumi nal coronary angiopla sty (PTCA)

Rational e: PTCA can alleviate the blockage and restore blood

flow andoxyg enation. An ech ocardio gram is a nonin vasive d iagnosis test.Nit

roglyceri n is an oral sublingu al medicati on. Cardiac catheteri zation is

adiagnos tic tool not a treatment . 66. Answer: (B) Cardioge nic shock

Rational e: Cardioge nic shock is shock related to ineffecti ve

pumping of the heart. Anaphyl actic shock results from an allergic reaction.

Distribut iveshock results from changes in the intravasc ular volume distributi

on and isusually associate d with increase d cardiac output. MI isnt a shock state,tho

ugh a severe MI can lead to shock. 67. Answer: ( C) Kidneys

excretion of sodium and water Rational e: The kidneys respond

to rise in blood pressure by excretin gsodium and excess water. This

response ultimatel y affects sysmolic bloodpre ssure by regulatin g blood volume. Sodium

or water retention wouldon ly further increase blood pressure. Sodium and

water travel together across the membran e in the kidneys; one cant travel

without the other. 68. Answer : (D) It inhibits reabsorp tion of sodium

and water in the loop of Henle. Rational e: Furosem ide is a loop diuretic

that inhibits sodium and water re absorpti on in th e loop H enle, the reby cau

sing a d ecrease i n bloodp ressure. Vasodila tors cause dilation of peripher

al blood vessels, directlyr elaxing vascular smooth muscle and decr easing b lood pre

ssure.A drenergi c blocke rs decre ase sym pathetic cardioac celeratio n andde crease b

lood pre ssure. A ngiotens inconverti ng enzy me inhi bitorsde crease blood

pressure due to their action on angioten sin. 69. Answer :

(C) Pancytop enia, elevated antinucle ar antibody (ANA) titer

Rational e: Laborat ory find ings for clients with SL E usuall y showp ancytop

enia, ele vated A NA titer, and dec reased s erum co mpleme ntlevels. Clients may hav

e elevat ed BUN and cre atinine l evels fr omnephr itis, but the increase does

not indicate SLE. 70. Answer : (C) Narcotic s are avoided after a

head injury because they mayhide a worsenin g condition .

Rational e: Narcotic s may mask changes in the level of consciou snessthat

indicate increased ICP and shouldnt acetamin ophen is strong enoughig nores the

mothers question and therefor e isnt appropri ate. Aspirin iscontrai ndicated

in condition s that may have bleeding, such as trauma, andfor children

or young adults with viral illnesses due to the danger of Reyessy ndrome.

Stronger medicati ons may not nece ssarily lead to vomiting butwill sedate t he clien

t, there by mask ing cha nges in his leve l of cons ciousnes s. 71. Answer

: (A) Appropr iate; low ering ca rbon dio xide (C O2) red ucesintra cranial

pressure (ICP) Rational e: A norm al Paco 2 value is 35 t o 45 m m Hg C

O2 has vasodilat ing propertie s; therefore , lowering Paco2 through

hyperven tilationw ill lower ICP ca used by dilated cerebral vessels. Oxygen ation ise

valuated through Pao2 and oxygen saturatio n. Alveolar hypoven tilationw ould be

reflected in an increased Paco2. 72. Answer : (B) A 33-yearold client

with a recent diagnosi s of GuillainBarresyn drome Rational e:

Guillain Barre sy ndrome is chara cterized by ascen dingpara lysis and potential

respirato ry failure. The order of client assessme ntshould follow client

priorities , with disorder of airways, breathin g, and thencircu lation. Theres

no informati on to suggest the postmyo cardial infarctio nclient has an

arrhyth mia or other complic ation. Theres no evidence tosugges t

hemorrh age or perforati on for the remainin g clients as a priority of care.

73. Answer : (C) Decrease s inflamm ation Rational e:

Then act ion of co lchicines is to de crease inflamm ation byr educing the migratio

n of leukocyt es to synovial fluid. Colchici ne doesntre place estrogen,

decrease infection, or decrease bone deminera lization. 74. Answer

: (C) Osteoart hritis is the most common form of arthritis Rational e:

Osteoart hritis is the most common form of arthritis and can beextre mely debilitati

ng. It can afflict people of any age, although most areelderl y.

75. Answer : (C) Myxede ma coma Rational e: Myxede ma coma , severe

hypothyr oidism, i s a lifethreateni ngcondit ion that may develop if thyroid

replacem ent medicati on isn't taken.Ex ophthal mos, protrusio n of the eyeballs,

is seen with hyperthy roidism. Thyroid storm is lifethreateni ng but is caused

by severe hyperthy roidism. Tibial myxede ma, peripher al mucinou

s edema involvin g the lower leg, isassocia ted with hypothyr oidism but isn't

lifethreateni ng. 76. Answer: (B) An irregular apical pulse

Rational e: Becaus e Cushi ng's syn drome c auses al dostero neoverpr oduction

, which increases urinary potassiu m loss, the disor der maylead to hypokale

mia. Therefor e, the nurse should immediat ely report signsand sympto

ms of hypokale mia, such as an irregular apical pulse, to thephysi cian. Ed

ema is a n expec ted find ing bec ause ald osteron eoverpr oductio n cause s sodiu

m and f luid ret ention. Dry mu cousme mbranes and fre quent ur ination signal d

ehydrati on, whi ch isn'ta ssociated with Cushing' s syndrom e. 77.

Answer: (D) Belo wnormal u rine osm olality le vel, abo venormal s erumos

molality level Rational e: In diabetes insipidus , excessiv e

polyuria causes dilute urine,res ulting in a below normal urine os molality

level. A t the sa me time, polyuria depletes the body of water, causing dehydrat ion that

leads to anabove normal s erum os molality level. Fo r the sa me reaso ns, diabe

tesinsipi dus doesn't cause abovenormal urine osmolali ty or below-

normalse rum osmolalit y levels. 78. Answer: (A) "I can avoid getting

sick by not becomin g dehydrat ed and bypaying attention to my need to

urinate, drink, or eat more than usual." Rational e: Inadequa te fluid intake

during hypergly cemic episodes oftenlea ds to H HNS. B y recogn izing the signs of

hypergl ycemia ( polyuria, polydips ia, and p olyphagi a) and in creasing fluid int ake, the

client m aypreven t HHNS. Drinking a glass of nondiet soda would be appropri

ate for hypo glycemia . A client whose diabetes is controlle d with oral

antidiabe ticagents usually doesn't n eed to m onitor blood glucose levels. A high-

carbohy drate diet would exacerba te the client's conditio n, particula

rly if fluid intake is low. 79. Answer: (D) Hyperpar athyroidi sm

Rational e: Hyperpa rathyroid ism is most common in older women and

ischarac terized b y bone p ain and weaknes s from e xcess pa rathyroi dhormon e (PTH).

Clients also exhibit hypercal iuriacausing polyuria. Whilecli ents with diabetes

mellitus and diabetes insipidus also have polyuria, they don't have

bone pain and increase d sleeping. Hypopar athyroidi sm ischaract erized by

urinary frequenc y rather than polyuria 80. Answer: (C) "I'll take two-

thirds of the dose when I wake up and onethirdin the late afternoo n."

Rational e: Hydroco rtisone, a glucoc orticoid, should be admi nistered accordin

g to a schedule that closely reflects the body's own secretion of this

hormone ; therefore , twothirds of the dose of hydrocor tisone shouldbe

taken in the morning and onethird in the late afternoo n. This dosagesc hedule

reduces adverse effects. 81. Answer: (C) High corticotr opin and high

cortisol levels Rational e: A cortic otropinsecretin g pituita ry tumor would c

ause hig hcorticot ropin and high cortisol levels. A high corticotr opin level

with a lowcortis ol level and a low corticotr opin level with a low

cortisol level would beassoci ated with hyp ocortisol ism. Low corticotr

opin and high cort isol levelswo uld be seen if there was a primary defect in

the adrenal glands. 82. Answer: (D) Performi ng capillary glucose

testing every 4 hours Rational e: The nurse should perform capillary

glucose testing every 4hours because excess cortisol may cause insulin

resistanc e, placing theclient at risk f or hyper glycemi a. Urine ketone t esting is

n't indic atedbeca use the client does secrete insulin and, therefor e, isn't at

risk for ketos is. Urine specific gravity isn't indi cated be cause alt hough fl uidbalan

ce can be compro mised, it usually isn't dangero usly imbalan ced.Tem

perature regulatio n may be affected by excess cortisol and isn't anaccura te

indicator of infection. 83. Answer: (C) onset to be at 2:30 p.m. and its peak to

be at 4 p.m. Rational e: Regular insulin, which is a shortacting insulin,

has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because

the nurse gave theinsuli n 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 thyroidstimulati ng hormone (TSH) levelafte r 30 minutes during

the TSH stimulati on test Rational e: In the TSH test, failure of the

TSH level to rise after 30minut es confir ms hype rthyroidi sm. A de creased

TSH lev el indica tes apitui tary deficienc y of this hormone . Belownormal levels of

T3 and T4, asdetecte d by radioim munoass ay, signal hypothyr oidism.

A belownormal T4level also occurs in malnutri tion and liver disease

and may result fromadm inistratio n of phenytoi n and certain other drugs.

85. Answer: (B) "Rotate injection sites within the same anatomic region,

notamon g different regions." Rational e: The nurse should instruct

the client to rotate injection siteswith in the same anatomic region. Rotating

sites among different regions may cause excessiv e day-today variation

s in the blood glucose level;als o, insulin absorpti on differs from one

region to the next. Insulin should

tissue lacking large blood be vessels, injected nerves, only or scar into hea tissue or lthy other

deviatio ns. Injectin g insulin into areas of hypertro phymay

delay a bsorptio n. The clie nt shoul dn't inject insulin into are

as of lip odystro phy (such as hypertro phy or atrophy) ; to prevent

lipodyst rophy,th e client should r otate inj ection s ites syst ematica lly. Exe

rcise sp eedsdru g absorpti on, so t he client s houldn't inject i

nsulin i nto sites ab ovemus cles that will be exercise d heavily.

86. Answer : (D) Belownormal serum potassiu m level

Rationa le: A client with HHNS has an overall body deficit

of potassiu mresulti ng from diuresi s, which occurs seconda ry to th

e hyper osmolar ,hypergl ycemic state caused by the relat ive

insulin deficien cy. An elevated serum a cetone l evel an d serum ketone

bodies are char acteristi c of dia betic ketoacid osis. Metabol ic

acidosis , not serum alkalosi s, may occur in HHNS. 87.

Answer : (D) Maintai ning room temperat ure in the low-

normal range Rationa le: Graves ' disea se cau ses sig ns and

sympt oms of hyperm etabolis m, such as heat intolera nce, diaphor

esis, excessiv e thirstan d appet ite, and weight loss. T o reduc

e heat i ntolera nce and diaphor esis, the nurse should keep the client's

room tempera ture in thelownormal range. To replace fluids

lost via diaphor esis, the nurse shoulde ncourag e, not restrict, intake

of oral fluids. Placing extra blankets on thebed of a client

with heat intolera nce would cause discomf ort. To provide

needed energy and calories, the nurse should encoura ge the

client to eathighcarbohy drate foods. 88. Answer :

(A) Fracture of the distal radius Rationa le: Colles' fracture

is a fracture of the distal radius, such as froma f all on a n outstr

etched hand. It 's most commo n in wo men. C olles'fra cture doesn't

refer to a fracture of the olecran on, humeru s, or

carpalsc aphoid. 89. Answer : (B) Calcium and

phospho rous Rationa le: In osteo porosis, bones l ose calc ium and

phosph ate salts ,becomi ng porous, brittle, and abnorm ally

vulnera ble to fracture. Sodium and potassiu m aren't involved in the

develop ment of osteopor osis. 90. Answer : (A)

Adult respirato ry distress syndrom e (ARDS) Rationa le:

Severe hypoxia after smoke inhalati on is typicall y related

toARD S. The other conditio ns listed arent typicall y associat

ed with smokein halation and severe hypoxia. 91. Answer :

(D) Fat embolis m Rationa le: Long bone fra ctures a re

correlat ed with fat emb oli, whichc ause sh ortness of breat h and h

without a previo us histor y. He co ulddevel op develop atelectasi ed asth s but it ma or br typically onchitis doesnt

ypoxia. Its un likely t he clien t has

produce progressi ve hypoxia. 92. Answer: (D) Spontane ous

pneumot horax Rational e: A spontane ous pneumot horax occurs

when the clients lungcoll apses, causing an acute decrease d in the amount of

function al lungused in oxygenat ion. The sudden collapse was the cause of

his chest painand shortnes s of breath. An asthma attack would show

wheezin g breathso unds, an d bronc hitis wo uld have rhonchi . Pneum onia wo

uld have bronchial breath sounds over the area of consolid ation. 93. Answer:

(C) Pneumot horax Rational e: From the trauma the client

experien ced, its unlikely he hasbron chitis, p neumoni a, or TB; rhonchi with bro

nchitis, bronchia l breaths ounds with TB would be heard. 94. Answer

: (C) Serous fluids fills the space and consolid ates the region

Rational e: Serous f luid fills the spa ce and e ventuall y consol idates,pr eventing

extensiv e mediasti nal shift of the heart and remainin g lung. Air cant

be left in the space. Theres no gel that can be placed in the pleurals

pace. Th e tissue from the other lu ng cant cross th e media stinum,a lthough a temporar

y mediasti nal shift exits until the space is filled. 95. Answer

: (A) Alveolar damage in the infracted area Rational e: The infracted

area produces alveolar damage that can lead tothe producti on of bloody

sputum, sometim es in massive amounts . Clotfor mation usually occurs in

the legs. Theres a loss of lung parenchy maand subseque nt scar tissue

formatio n. 96. Answer : (D) Respirat ory alkalosis Rational e:

A client with massive pulmona ry embolis m will have a largeregi on and

blow off large amount of carbon dioxide, which crosses theunaff ected

alveolarcapillary membra ne more readily than does oxygena nd results in

respirato ry alkalosis. 97. Answer : (A) Air leak Rational e:

Bubbling in the water seal chamber of a chest drainage systemst ems

from an air leak. In pneumot horax an air leak can occur as air ispulled

from the pleural space. Bubblin g doesnt normally occur with either ad equate or

inadequa te suction or any preexisti ng bubbling in the water se

al chamber. 98. Answer : (B) 21 Rational e: 3000 x 10 divided

by 24 x 60. 99. Answer: (B) 2.4 ml Rational e: .05 mg/ 1 ml =

.12mg/ x ml, .05x = .12, x = 2.4 ml. 100. Answer: (D) I should put on the

stocking s before getting out of bed inthe morning. Rational e: Promote venous

return by applying external pressure on veins. TEST VAnswe rs and Rati onale

Care of Clients with Ph ysiologic andPsyc hosocial Alterati ons 1. Answer

: (D) Focusing Rational e : The nurse is using focusing by suggestin

g that the clientdis cuss a specific issue. The nurse didnt restate the

question, makeobs ervation, or ask further question (explorin g). 2. Answer

: (D) Remove all other clients from the dayroom . Rational e

: The nurses first priority is to consider the safety of the clientsin

the therapeut ic setting. The other actions are appropri ate

response safter ensuring the safety of other clients. 3. Answer

: (A) The client is disruptiv e. Rational e : Group activity provides too much

stimulati on, which the clientwill not be able to handle (harmful to self)

and as a result will be disruptiv eto others. 4. Answer : (C) Agree to

talk with the mother and the father together. Rational e : By agreeing

to talk with both parents, the nurse can providee motional support and further

assess and validate the familys needs. 5. Answer : (A) Perceptu

al disorders . Rational e : Frighteni ng visual hallucina tions are

especiall y common inclients experien cing alcohol withdraw al. 6.

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

Rational e : The client needs a specific response; that it takes 2 to 3

weeks(a delayed effect) until the therapeut ic blood level is reached. 7. Answer

: (C) Superego Rational e : This behavior shows a weak sense of moral

consciou sness.Ac cording to Freudian theory, personali ty disorders stem

from a weaksup erego. 8. Answer : (C) Skeletal muscle paralysis.

Rational e : Anectine is a depolariz ing muscle relaxant causing

paralysis. Itis used to reduce the intensity of muscle contracti ons during

theconvu lsive stage, thereby reducing the risk of bone fractures or disloc ation.

9. Answer : (D) Increase calories, carbohyd rates, and protein.

Rational e : This client increased protein for tissue building and increased

calories to replace what is burned up (usually via carbohyd rates)

10. Answer : (C) Acting overly solicitou s toward the child. Rational e

: This behavior is an example of reaction formatio n, a copingm

echanism . 11. Answer : (A) By designati ng times during which the client

can focus on thebehav ior. Rational e : The nurse should d esignate

times during which the client canfocus on the compulsi ve behavior or

obsessiv e thoughts. The nursesho uld urge the client to reduce the frequenc

y of the compulsi ve behavior gradually , not rapidly. She shouldn't call

attention to or try to prevent thebehav ior. Trying to prevent the behavior

may cause pain and terror in theclient. The nurse should encourag e the

client to verbalize anxieties to helpdistr act attention from the compulsi

ve behavior. 12. Answer : (D) Explorin g the meaning of the traumatic

event with the client. Rational e : The client with PTSD needs

encourag ement to examine andunder stand the meaning of the traumatic event and

conseque nt losses.Ot herwise, symptom s may worsen and the client may

become depresse dor engage in selfdestructi ve behavior such as substanc

e abuse. Theclient must explore the meaning of the event and won't

heal without this,no matter how much time passes. Behavior al

techniqu es, such asrelaxat ion therapy, may help decrease the client's anxiety

and inducesle ep. The physicia n may prescribe antianxie ty agents or antidepre

ssantscau tiously to avoid depende nce; sleep medicati on is rarely appropri

ate. Aspecial diet isn't indicated unless the client also has an eating disorder or a

nutrition al 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 happene d." Rational e : The nurse must be honest with the

client by telling her that theparaly sis has no physiolo gic cause while also

conveyin g empathy andackn owledgin g that her symptom s are real. The client

will benefit frompsyc hiatric treatment , which will help her understa nd the

underlyi ng causeof her symptom s. After the psycholo gical conflict

is resolved, her symp toms will disappea r. Saying that it must be awful not to be

able tomove her legs wouldn't answer the client's question; knowing that

thecause is psycholo gical wouldn't necessari ly make her feel better. Tellingh

er that she has develope d paralysis to avoid leaving her parents or

thather personali ty caused her disorder wouldn't help her understa nd andresol

ve the underlyi ng conflict. 14. Answer : (C) fluvoxa mine (Luvox)

and clomipra mine (Anafran il) Rational e : The antidepre ssants flu

voxamin e and clom ipramine 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 medicati ons mentione d aren't effective

in the treatment of OCD. 15. Answer : (A) A warning about the drugs delayed

therapeut ic effect, whichis from 14 to 30 days. Rational e : The client

should b e informed that the drug's therapeut ic effectmi ght not be

reached for 14 to 30 days. The client must be instructe d tocontinu e taking

the drug as directed. Blood level checks aren't necessar y.NMS hasn't

been reported with this drug, but tachycar dia is frequentl yreporte d. 16.

Answer : (B) Severe anxiety and fear. Rational e : Phobias cause severe an

xiety (such as a panic attack) th at isout of proportio n to the threat of

the feared object or situation. Physicals igns and symptom s of phobias include

profuse sweating, poor motor co ntrol, tachycar dia, and elevated blood pressure.

Insomnia , an inability toconcen trate, and weight loss are common in depressio

n. Withdra wal andfailur e to distingui sh reality from fantasy occur in

schizoph renia. 17. Answer : (A) Antidepr essants Rational e

: Tricycli c and mon oamine oxidase ( MAO) inhibitor antidepre ssants have

been found to be effective in treating clients withpani c attacks. Why

these drugs help control panic attacks isn't clearlyun derstood. Anticholi

nergic agents, which are smoothmuscle relaxants ,relieve physical symptom

s of anxiety but don't relieve the anxiety itself.Ant ipsychoti c drugs are

inapprop riate because clients who experien cepanic attacks aren't psychoti

c. Mood stabilizer s aren't indicated becausep anic attacks are rarely associate d with

mood changes. 18. Answer : (B) 3 to 5 days Rational e : Monoa mine

oxidase i nhibitors, such as tranylcyp romine, havean onset of action of approxi mately 3

to 5 days. A full clinical response may be delayed for 3 to 4 weeks. The

therapeut ic effects may continue for 1 to 2 weeks after discontin uation. 19.

Answer : (B) Providin g emotiona l support and individua l

counseli ng. Rational e : Clients in the first stage of Alzhei mer's

disease are aware th atsometh ing is happenin g to them and may become overwhel

med andfright ened. Therefor e, nursing care typically focuses on

providin gemotion al support and individua l counseli ng. The other

options areappro priate during the second stage of Alzheim er's disease,

when theclient needs continuo us monitori ng to prevent minor illnesses

fromprog ressing into major problems and when maintaini ng adequate

nutrition may become a challeng e. During this stage, offering nourishin

g finger fo ods helps clients to feed themselv es and maintain adequate nutrition

20. Answer : (C) Emotion al lability, euphoria, and impaired memory

Rational e : Signs of antian xiety agent overdose include emotiona l

lability,e uphoria, and impaired memory. Phencycl idine overdose can causeco

mbativen ess, sweating, and confusio n. Ampheta mine overdose canresult

in agitation, hyperacti vity, and grandios e ideation. Hallucin ogenover dose can

produce suspiciou sness, dilated pupils, and increased bloodpre ssure. 21.

Answer : (D) A low tolerance for frustratio n Rational e

: Clients with an antiso cial personali ty disorder exhibit a lowtole rance for

frustratio n, emotiona l immaturi ty, and a lack of impulsec ontrol. They

commonl y have a history of unemplo yment, miss workrepe atedly, and quit

work without other plans for employm ent. They don'tfeel guilt about their

behavior and commonl y perceive themselv es asvictims . They also

display a lack of responsi bility for the outcome of their acti ons. Because

of a lack of trust in others, clients with antisocia lpersonal ity disorder commonl

y have difficulty developi ng stable, closerela tionships . 22. Answer

: (C) Methado ne Rational e : Methado ne is used to detoxify

opiate users because it bindswit h opioid receptors at many sites in the

central nervous system butdoesn t have the same deterious effects as other opiates,

such ascocain e, heroin, and morphin e. Barbitura tes, ampheta mines,

andbenz odiazepi nes are highly addictive and would require detoxific

ationtreat ment. 23. Answer : (B) Hallucin ations Rational e

: Hallucin ations are visual, auditory, gustatory , tactile, or olfact ory

perceptio ns that have no basis in reality. Delusion s are falsebeli efs, rather

than perceptio ns, that the client accepts as real. Looseass ociations are rapid shifts

among unrelated ideas. Neologis ms arebizarr e words that have meaning only to

the client. 24. Answer : (C) Set up a strict eating plan for

the client. Rational e : Establish ing a consisten t eating plan and

monitori ng theclient s weight are very importan t in this disorder. The family

and friendssh ould be included in the clients care. The client should be

monitore dduring mealsnot given privacy. Exercise must be limited and

supervise d. 25. Answer : (A) Highly importan t or famous.

Rational e :A delusion of grandeur is a false belief that one is

highlyim portant or famous. A delusion of persecuti on is a false

belief that one isbeing persecute d. A delusion of reference is a false belief

that one isconnect ed to events unrelated to oneself or a belief that one

is responsi blefor the evil in the world 26. Answer : (D) Listening

attentivel y with a neutral attitude and avoiding power struggles .

Rational e : The nurse should listen to the clients requests, expressw

illingnes s to seriously consider the request, and respond later. The

nursesho uld encourag e the client to take short daytime naps because

heexpen ds so much energy. The nurse shouldnt try to restrain the

clientwh en he feels the need to move around as long as his activity isnthar

mful. High calorie finger foods should be offered to supplem

ent theclient s 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 selfconfident

toneof voice. 27. Answer : (D) Denial Rational e : Denial is

unconsci ous defense mechanis m in which emotiona lconflict and anxiety

is avoided by refusing to acknowl edge feelings, desires, impulses,

or external facts that are consciou sly intolerab le.Withdr awal is a common

response to stress, character ized by apathy.L ogical thinking is the ability to think

rationall y and make responsi bledecisi ons, which would lead the client

admittin g the problem and seekingh elp. Repressi on is suppressi ng past

events from the consciou snessbec ause of guilty associati on. 28. Answer

: (B) Paranoid thoughts Rational e : Clients with schizoty pal personali

ty disorder experien ceexcessi ve social anxiety that can lead to paranoid thoughts.

Aggressi vebehavi or is uncomm on, although these clients may experien

ce agitation with anxiety. Their behavior is emotiona lly cold with a

flattened affect,reg ardless of the situation. These clients demonstr ate a reduced

capacityf or close or depende nt relations hips. 29. Answer

: (C) Identify anxietycausing situation s Rational e : Bulimic behavior

is generally a maladapt ive coping response tostress and underlyi

ng issues. The client must identify anxietycausingsi tuations that

stimulate the bulimic behavior and then learn new ways of coping

with the anxiety. 30. Answer : (A) Tension and irritabilit y

Rational e : An ampheta mine is a nervous system stimulant that is subjectto

abuse because of its ability to produce wakefuln ess and euphoria. Anoverd ose

increases tension and irritabilit y. Options B and C are incorrect because

ampheta mines stimulate norepine phrine, 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 the m. Rational e : The nurse, demonstr ating knowled ge and

understa nding,ac cepts the clients perceptio ns even though they are hallucina tory.

32. Answer : (C) Confusio n for a time after treatment Rational e

: The electrical energy passing through the cerebral cortexdu ring ECT results in

a temporar y state of confusio n after treatment . 33. Answer

: (D) Acceptan ce stage Rational e : Commun ication and intervent

ion during this stage are mainlyno nverbal, as when the client gestures to hold

the nurses hand. 34. Answer : (D) A higher level of anxiety continuin

g for more than 3 months. Rational e : This is not an expected outcome

of a crisis because bydefinit ion a crisis would be resolved in 6 weeks.

35. Answer : (B) Staying in the sun Rational e : Haldol causes

photosen sitivity. Severe sunburn can occur onexpos ure to the sun. 36.

Answer : (D) Moderat e-level anxiety Rational e :A moderate ly

anxious person can ignore periphera l events andfocus es on central concerns.

37. Answer : (C) Diverse interest Rational e : Before onset of depressi

on, these clients usually have verynarr ow, limited interest. 38. Answer

: (A) As their depressio n begins to improve Rational e : At this point the

client may have enough energy to plan andexec ute an attempt. 39.

Answer : (D) Disturba nce in recalling recent events related to

cerebral hypoxia. Rational e : Cell damage seems to interfere with registeri

ng input stimuli, which af fects the abilit y to regi ster and recall recent events; v

ascular d ementia is related to multiple vascular lesions of the cerebral cortex

andsubc ortical structure. 40. Answer : (D) Encoura ging the client to have

blood levels checked asordere d. Rational e : Blood levels must be

checked monthly or bimonthl y when theclient is on mainten ance therapy

because there is only a small rangebet ween therapeut ic and toxic levels

1. Answer : (B) Fine hand tremors or slurred speech

Rational e : These are common side effects of lithium carbonat e.

42. Answer : (D) Presence Rational e : The constant presence of a

nurse provides emotion al supportb ecause the client knows that someone

is attentive and available in caseof an emergen cy. 43. Answer

: (A) Clients perceptio n of the presentin g problem. Rational e

: The nurse can be most therapeu tic by starting where the clientis,

because it is the clients concept of the problem that serves as thestartin g point

of the relations hip. 44. Answer : (B) Chocolat e milk, aged cheese,

and yogurt Rational e : These hightyramine foods, when ingested

in the presence of an MAO inhibitor, cause a severe hyperten sive response.

45. Answer : (B) 4 to 6 weeks Rational e : Crisis is selflimiting and lasts

from 4 to 6 weeks. 46. Answer : (D) Males are more likely to use lethal methods

than are females Rational e : This finding is supporte d by research; females

account for 90%of suicide attempts but males ar e three times mo re

successf ul because of metho ds used. 47. Answer : (C) "Your cursing

is interrupti ng the activity. Take time out in your roo m for 10

minutes. " Rational e : The nurse should set limit s on client

behavior to ensur e acomfort able environ ment for all client s. The nurse

should accept hostile o r quarrel some cli ent outb ursts wit hin limit s withou t becomi

ng perso nallyoffe nded, 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 ownmise ry. Judgmen tal remarks, such as option D, may decrease

the client'sse lfesteem. 48. Answer : (C) lithium carbonat

e (Lithane) Rational e : Lithiu m carbonat e, an antimani a drug, is

used to treat clientswi th cyclical schizoaff ective disorder, a psychoti

c disorder once classifie dunder schizoph renia that causes affective

sympto ms, includin g maniclik eactivity . Lithiu m helps control t he affect

ive com ponent o f this disorder. Phenelzi ne is a monoam ine oxidase inhibitor

prescribe d for clients whodon' t respon d to oth er antid epressa nt drugs such as

imipra mine.Ch lordiaze poxide, an antia nxiety a gent, ge nerally i s contrai ndicated

inpsych otic clie nts. Imip ramine, primaril y consid ered an antidepr essantag ent, is

also used to treat clients with agoraph obia and that undergoi ngcocain e

detoxific ation. 49.

Answer : (B) Report a sore throat or

fever to the physicia n immedia tely. Rationa le

:A sore thro at and fever are indicatio ns of an infect ion causedb

y agranulo cytosis, a potential ly lifethreateni ng complic

ation of clozapin e.Becau se of the risk of agranulo cytosis, white blood

cell (WBC) counts areneces sary weekly, not monthly . If the

WBC count drops below 3,000/l ,the medicati on must be

stopped. Hypoten sion may occur in clients takingth is medicati

on. Warn the client to stand up slowly to avoid dizzines s

fromort hostatic hypoten sion. The medicati on should be

continue d, even whensy mptoms have been controll ed. If the

medicati on must be stopped, itshould be slowly tapered over 1

to 2 weeks and only under thesuper vision of a physicia n.

50. syndrom ms sugg Answer e. est Rationa neurolep : (C) le ticmalig Neurole : The nant ptic client's syndrom maligna signs an e, a lifent d threateni sympto ng

reaction to neurolep tic medicati onthat requires immedia te

treatmen t. Tardive dyskines ia causes involunt arymove ments of

the tongue, mouth, facial muscles, and arm and legmusc les.

Dystoni a is characte rized by cramps and rigidity of the tongue,f

ace, neck, and back muscles. Akathisi a causes restlessn ess,

anxiety, and jitte riness. 51. Answer

client to sit up for 1 minute before getting : (B) out Advisin of bed. g the

Rationa le : To minimiz e the effec ts of amitri ptyline-

induced orthostat ichypote nsion, the nurse should advise the

client to sit up for 1 minuteb efore getting out of bed. Orthosta

tic hypoten sion common ly occurs withtric yclic antidepr

essant therapy. In these cases, the dosage may bereduc ed or the

physicia n may prescrib e nortripty line, another tricyclic antidepr

essant. Orthosta tic hypoten sion disappea rs only when the drug

isdiscon tinued. 52. Answer

Rationa le : Dysthy mic disorder : (D) is marke Dysthy d mic by feelin disorder. gs

of depre ssion lastingat least 2 years, accomp anied by at least two of

the followin g sympto ms:sleep disturba nce, appetite disturba

nce, low energy or fatigue, low selfesteem, poor concentr ation,

difficult y making decision s, andhope lessness. These sympto

ms may be relativel y continuo us or separ ated by interven

ing periods of normal mood that last a few days to afew

weeks. Cycloth ymic disorder is a chronic mood disturba nce of at

least2 years' duration marked by numero us periods of

depressi on andhypo mania. Atypical affective disorder is characte

rized by manic signs andsym ptoms. Major depressi on is a recurrin

g, persiste nt sadness or loss of intere st or pleasure in

almost all activitie s, with signs and sympto msrecur ring for

at least 2 weeks. 53. Answer : (C) 30 g mixed in 250

ml of water

of activa ted charcoal Rationa is 5 to 10 le timesthe : The estimate usual d weight adult dosage of the

drug or chemica l ingested , or a minimu m doseof 30 g,

mixed in 250 ml of water. Doses less than this will be ineffecti

ve;doses greater than this can increase the risk of adverse reaction

s,althou gh toxicity doesn't occur with activate d charcoal

, even at themaxi mum dose. 54. Answer

: (C) St. John's wort Rationa le : St. John's wort has been

found to have ser otoninelevatin gpropert ies, similar to prescript

ion antidepr essants. Ginkgo biloba isprescri bed to enhance mental

acuity. Echinac ea has immune stimulati ngprope rties. Ephedra

is a naturall y occurrin g stimulan t that is similar

toephedr ine. 55. Answer

: Lithiu m is chemica lly similar : (B) to sodiu Sodium m. If Rationa sodium l le evels

arereduc ed, such as from sweatin g or diuresis, lithium will be reabsorb

ed bythe kidneys, increasi ng the risk of toxicity. Clients taking lithium

shouldn' trestrict their intake of sodium and should drink adequat

e amounts of fluideac h day. The other electroly tes are

importa nt for normal body function sbut sodium is most importa

nt to the absorpti on of lithium. 56. Answer : (D) It's characte

rized by an acute onset and lasts hours to anumber of days Rationa le

: Deliriu m has an acute onset and typi cally can last fromsev eral

hours to several days. 57. Answer

commun ication. Rationa le : Initiall y, : (B) memory Impaire impairm d ent may

be the only cog nitive deficitin a client with Alzheim er's disease.

During the early stage of this disease,s ubtle personal ity changes

may also be present. Howeve r, other thanocc asional irritable outburst

s and lack of spontan eity, the client is usuallyc ooperati ve and exhibits

socially appropri ate behavior . Signs of advan cement to the middle

stage of Alzheim er's disease includee xacerbat ed cognitiv e

impairm ent with obvious personal ity changes andimpa ired commun

ication, such as inappro priate convers ation, actions, andresp onses.

During the late stage, the client can't perform selfcareacti

vities and may become mute. 58. Answer : (D) This

medicati on may initially cause tirednes s, which shouldb ecome less

botherso me over time. Rationa le : Sedatio n is a comm on early

adverse effect of imipram ine, atricycli c antidepr essant, and

usually decrease s as toleranc e develop s.Antide pressant s aren't

habit forming and don't cause physical or psych ological depende

nce. Howeve r, after a long course of highdosether apy, the dosage

should be decrease d graduall y to avoid mild

withdraw al symptom s. Serious adverse effects, although rare, includem

yocardial infarctio n, heart failure, and tachycar dia. Dietary restrictio ns,such

as avoiding aged cheeses, yogurt, and chicken livers, are necessar

yfor a client taking a monoami ne oxidase inhibitor, not a tricyclica

ntidepres sant. 59. Answer : (C) Monitor vital signs, serum electrolyt

e levels, and acidbasebala nce. Rational e : An anorexic client who requ

ires hospitali zation is in poor p hysical condition from starvatio n and may die

as a result of arrhythm ias,hypot hermia, malnutrit ion, infection, or cardiac

abnormal ities secondar y toelectrol yte imbalanc es. Therefor e,

monitori ng the client's vital signs, serumele ctrolyte level, and acid base

balance is crucial. Option A may worsena nxiety. Option B is incorrect

because a weight obtained after breakfast ismore accurate than one obtained after the

evening meal. Option D wouldre ward the client with attention for not eating

and reinforce the controlis sues that are central to the underlyi ng

psycholo gical problem; also, theclient may record food and fluid intake

inaccurat ely. 60. Answer : (D) Opioid withdraw al Rational e

: The symptom s listed are speci fic to opioid withdraw al. Alcohol withdraw

al would show elevated vital signs. There is no real withdraw alfrom cannibis.

Sympto ms of cocaine withdraw al include depressio n,anxiety , and agitation.

61. Answer : (A) Regressi on Rational e : An adult who

throws te mper tantrums, such as this one, isdisplay ing regressiv e behavior,

or behavior that is appropri ate at ayounger age. In projectio n, the client

blames someone or somethin g other tha n the source. In reaction

formatio n, the client acts in oppositio n to hisfeelin gs. In intellectu alization,

the client overuses rational explanati ons or abstra ct thinking to decrease

the significa nce of a feeling or event. 62. Answer : (A) Abnorma l

moveme nts and involunta ry moveme nts of themouth , tongue, and face.

Rational e : Tardive dyskinesi a is a severe reaction associate d with longterm

use of antipsyc hotic medicati on. The clinical manifest ations includea bnormal

moveme nts (dyskine sia) and involunta ry moveme nts of themouth , tongue

(fly catcher tongue), and face. 63. Answer : (C) Blurred vision

Rational e : At lithium levels of 2 to 2.5 mEq/L the client will experien

cedblurre d vision, muscle twitching , severe hypotens ion, and persisten tnausea and

vomiting . With levels between 1.5 and 2 mEq/L the clientexp eriencing vomiting

, diarrhea, muscle weaknes s, ataxia, dizziness ,slurred speech, and confusio

n. At lithium levels of 2.5 to 3 mEq/L or higher, urinary and fecal incontine

nce occurs, as well as seizures, cardiacd ysrythmi as, periphera l

vascular collapse, and death. 64. Answer : (C) No acts of aggressio n have

been observed within 1 hour afte r the release of two of the extremit y

restraints . Rational e : The best indicator that the behavior is

controlle d, if the clientexh ibits no signs of aggressio n after partial release of

restraints . Options A, B, and D do not ensure that the client has controlle

d the behavior. 65. Answer: (A) increased attention span and concentr ation

Rational e : The medicati on has a paradoxi c effect that decrease hyperacti

vity and impulsivi ty among children with ADHD. B, C, D. Sideeffec ts of Ritalin

include anorexia, insomnia , diarrhea and irritabilit y. 66. Answer:

(C) Moderat e Rational e : The child with moderate mental

retardati on has an I.Q. of 35-50 Profound Mental retardati on has an I.Q. of below

20; Mild mentalret ardation 50-70 and Severe mental retardati on has an

I.Q. of 20-35. 67. Answer: (D) Rearrang e the environ ment to

activate the child Rational e : The child with autistic disorder does not

want change. Maintain ing a consisten t environ ment is therapeut ic. A.

Angry outburst canbe rechanneli ng through safe activities . B. Acceptan

ce enhances atrusting relations hip. C. Ensure safety from selfdestructi

ve behavior s likehead banging and hair pulling. 68. Answer:

(B) cocaine Rational e : The manifest ations indicate intoxicati on with

cocaine, a CNSstim ulant. A. Intoxicat ion with heroine is manifest ed by

euphoria thenimpa irment in judgment , attention and the presence of papillary

constricti on. C. Intoxicat ion with hallucino gen like LSD is manifest ed bygrandi

osity, hallucina tions, synesthe sia and increase in vital signs D.Intoxic ation

with Marijuan a, a cannabin oid is manifest ed by sensation of slowe d time,

conjuncti val redness, social withdraw al, impaired judgment and

hallucina tions. 69. Answer : (B) insidious onset Rational e

: Dementi a has a gradual onset and progressi ve deteriora tion. Itcauses

pronounc ed memory and cognitive disturban ces. A,C and D are allcharac

teristics of delirium. 70. Answer: (C) Claustro phobia Rational e

: Claustro phobia is fear of closed space. A. Agoraph obia is fear of open

space or being a situation where escape is difficult. B. Socialph obia is fear of

performi ng in the presence of others in a way that will behumili ating or embarras sing. D.

Xenopho bia is fear of strangers 71. Answer: (A) Revealin g personal

informati on to the client Rational e : Counter transfere nce is an emoti

onal reaction of the nurse ont he client based on her unconsci ous needs

and conflicts. B and C. Theseare therapeut ic approach es. D. This is transfere

nce reaction where aclient has an emotiona l reaction towards the nurse

based on her past. 72. Answer: (D) Hold the next dose and obtain an order for a stat

serumlith ium level Rational e : Diarrhea and vomiting are manifest

ations of Lithium toxicity. The next dose of lithium should be withheld and test

is done to validatet he observati on. A. The manifest ations are not

due to drug interactio n. B.Cogen tin is used to manage the extra pyramida

l symptom side effects of antips ychotics. C. The common side effects of

Lithium are fine handtrem ors, nausea, polyuria and polydipsi a. 73.

Answer: (C) A living, learning or working environ ment. Rational e

:A therapeut ic milieu refers to a broad conceptu al approach inwhich all

aspects of the environ ment are channele d to provide atherape utic environ

ment for the client. The six environ mental elements include structure, safety,

norms; limit setting, balance and unitmodi fication. A. Behavior al

approach in psychiatr ic care is based on thepremi se that behavior can be learned

or unlearne d through the use of rewar d and punishm ent. B. Cognitiv

e approach to change behavior isdone by correctin g distorted

perceptio ns and irrational beliefs to correctm aladaptiv e behavior s. D. This is

not congruen t with therapeut ic milieu. 74. Answer: (B) Transfer ence

Rational e : Transfer ence is a positive or negative feeling associate

d with asignific ant person in the clients past that are unconsci ously

assigned toanother A. Splitting is a defense mechanis m commonl y seen in

a clientwit h personali ty disorder in which the world is perceive

d as all good or allbad C. Countert transfere nce is a phenome non where

the nurse shiftsfeel ings assigned to someone in her past to the patient

D. Resistan ce isthe clients refusal to submit himself to the care of the nurse

75. Answer: (B) Adventiti ous Rational e : Adventiti ous crisis

is a crisis involvin ga traumatic event. It isnot part of everyday life. A. Situation

al crisis is from an external sourceth at upset ones psycholo gical equilibri

um C and D. Are the same. Theyare transition al or develop mental

periods in life 76. Answer : (C) Major depressio n Rational e

: The DSMIV-TR classifies major depressio n as an Axis Idisorder .

Borderli ne personali ty disorder as an Axis II; obesity andhyper

tension, Axis III. 77. Answer : (B) Transfer ence Rational e

: Transfer ence is the unconsci ous assignme nt of negative or positiv

e feelings evoked by a significa nt person in the clients past toanother

person. Intellectu alization is a defense mechanis m in which theclient avoids

dealing with emotions by focusing on facts. Triangul ationrefe rs to conflicts

involvin g three family members . Splitting is a defense mechanis m

commonl y seen in clients with personali ty disorder in whichthe world is

perceive d as all good or all bad. 78. Answer : (B) Hypocho ndriasis

Rational have no e apparent : medical causes Complai are ns of character vague istic of physical clients symptom with s that hypocho

ndriasis. In manycas es, the GI system is affected. Conversi on disorders

are character izedby one or more neurolog ic symptom s. The clients

symptom s dontsug gest severe anxiety. A client experien cing sublimati

on channels maladapt ive feelings or impulses into socially acceptabl

e behavior 79. Answer : (C) Hypocho ndriasis Rational e

: Hypocho driasis in this case is shown by the clients belief thatshe has a

serious illness, although pathologi c causes have beenelim inated. The disturban

ce usually lasts at lease 6 with identifia ble lifestress or such as, in this

case, course examinat ions. Conversi on disorder sare character ized by

one or more neurolog ic symptom s.Depers onalizati on refers to persisten

t recurrent episodes of feelingde tached from ones self or body.

Somatof orm disorders generally have achronic course with few remissio ns.

80. Answer : (A) Triazola m (Halcion ) Rational e

: Triazola m is one of a group of sedative hypnotic medicati onthat can be

used for a limited time because of the risk of depende nce.Paro xetine is a

scrotonin -specific reutake inhibitor used for treatment of depres sion panic disorder,

and obsessiv ecompulsi ve disorder. Fluoxeti neis a scrotonin -specific

reuptake inhibitor used for depressiv e disorders andobses sivecompulsi ve

disorders . Risperid ome is indicated for psychoti cdisorder s. 81.

Answer : (D) It promotes emotiona l support or attention for the client

Rational e : Secondar y gain refers to the benefits of the illness

that allowthe client to receive emotiona l support or attention. Primary gain

enablesth e client to avoid some unpleasa nt activity. A dysfuncti onal

family maydisre gard the real issue, although some conflict is relieved.

Somatof ormpain disorder is a preoccup ation with pain in the absence of

physical disease. 82. Answer : (A) I went to the mall with my friends last

Saturday be socially

Rationa le : Clients with panic disorder tent to

withdra wn. Goingto the mall is a sign of working

on avoidan ce behavior s. Hyperve ntilating isa key sympto

m of panic disorder. Teachin g breathin g control is a

major in terventi on for clients with panic disorder. The client

taking medicati onsfor panic disorder ; such as tricylic antidepr essants

and benzodi azepines ,must be weaned off these drugs. Most clients

with panic disorder withago raphobia dont have nutrition al

problem s. 83. Answer

and dont have nightma res : (A) Rationa Im le sleeping :MAO better inhibitor

s are used to treat sleep problem s, nightma res,and intrusive

daytime thoughts in individu al with posttrau matic stressdis order.

MAO inhibitor s arent used to help control flashbac ks or phobias

or to decrease the craving for alcohol. 84. Answer

: (D) Stoppin g the drug can cause withdra wal sympto ms

Rationa benzodi ms. le: azepines Stoppin cancaus g a Stoppin e the benzodi g client to azepine antianxi have doesnt ety withdra tend to drugs wal cause such as sympto depressi

on, increase cognitiv e abilities, or decrease sleeping

difficulti es. 85. Answer

difficulti es Rationa le : : (B) Adolesc Behavio ents ral tend to demonst

rate severe irritabilit y andbeha vioral problem s rather than

simply a depresse d mood. Anxiety disorder is more common ly associat

ed with small children rather than withadol escents. Cognitiv e

impairm ent is typically associat ed with delirium or deme ntia. Labile

mood is more characte ristic of a client with cognitiv eimpair ment or

bipolar disorder. 86. Answer

to major depressi on but of mild tomoder : (D) Its ate a mood severity disorder Rationa similar le

: Dysthy mic disorder is a mood disorder similar to

major de pression but it remains mild to moderat e in severity. Cycloth

ymicdis order is a mood disorder characte rized by a mood range from

moderat edepress ion to hypoma nia. Bipolar I disorder is

characte rized by a singlem anic episode with no past major

depressi ve episodes . Seasona laffective disorder is a

form of depressi on occurrin g in the fall and winter. 87.

Answer abrupt onset : (A) Rationa Vascula le r : dementi Vascula a has r more dementi a differs

from Alzheim ers disease in that ithas a more abrupt onset

and runs a highly variable course. Personal lychang e is common in

Alzheim ers disease. The duration of delirium isusuall y brief.

The inability to carry out motor activitie s is common inAlzhei

mers disease. 88. Answer : (C) Drug intoxicat ion

Rational e : This client was taking several medicati ons that have

apropens ity for producin g delirium; digoxin (a digitalis glycoxid e),furose

mide (a thiazide diuretic), and diazepa m (a benzodia zepine).S ufficient supportin

g data dont exist to suspect the other options ascauses. 89. Answer

: (D) The client is experien cing visual hallucina tion Rational e

: The presence of a sensory stimulus correlate s with thedefini tion of a hallucina

tion, which is a false sensory perceptio n. Aphasiar efers to a communi cation

problem. Dysarthri a is difficulty in speechpr oduction. 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 frighteni ng faces on the wall.

Rational e : Minor memory problems are distingui shed from dementia

bytheir minor severity and their lack of significa nt interfere nce with theclient

s social or occupati onal lifestyle. Other options would be included inthe

history data but dont directly correlate with the clients lifestyle. 91. Answer

: (D) Loose associati on Rational e : Loose associati ons are conversa

tions that constantl y shift intopic. Concrete thinking implies highly definitiv e thought

processe s. Flightof ideas is character ized by conversa tion thats disorgani

zed from theonset. Loose associati ons dont necessari ly start in a cogently, thenbeco

mes loose. 92. Answer : (C) Paranoid Rational e : Because

of their suspiciou sness, paranoid personali tiesascrib e malevole nt activities

to others and tent to be defensiv e, becomin gquarrels ome and argument ative.

Clients with antisocia l personali tydisorde r can also be antagoni stic and

argument ative but are lesssuspi cious than paranoid personali ties. Clients

with histrionic personali tydisorde r are dramatic, not suspiciou s and argument

ative. Clients withschi zoid personali ty 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 Rational e

: Olanzapi ne (Zyprexa ) is less effective for clients who smokeci

garettes. Serotoni n syndrom e occurs with clients who take acombin ation of

antidepre ssant medicati ons. Olanzapi ne doesnt causeeup horia, and

extrapyra midal adverse reactions arent a problem. However , the client should

be aware of adverse effects such as tardivedy skinesia. 94. Answer

: (A) Lack of honesty Rational e :

l personali ty disorder tent to engage inacts of Clients dishonest y, shown with antisocia by lying.

Clients with schizoty pal personali tydisorde r tend to be superstiti ous.

Clients with histrionic personali tydisorde rs tend to overreact to frustratio ns and

disappoi ntments, havetem per tantrums, and seek attention. 95. Answer

: (A) Im not going to look just at the negative things about myself

Rational e : As the clients makes progress on improvin g selfesteem,

selfblame and negative self evaluatio n will decrease. Clients with

depende ntperson ality disorder tend to feel fragile and inadequa te and

would beextrem ely unlikely to discuss their level of compete nce and

progress. These clients focus on self and arent envious or jealous. Individu

als withdepe ndent personali ty disorders dont take over situation s because

theysee themselv es as inept and inadequa te. 96. Answer : (C) Assess

for possible physical problems such as rash Rational e : Clients with

schizoph renia generally have poor visceralr ecognitio n because they live

so fully in their fantasy world. They need tohave as in-depth assessme nt of

physical complain ts that may spill over into their delusion al symptom s.

Talking with the client wont provide asassess ment of his itching, and

itching isnt as adverse reaction of antips ychotic drugs, calling the physicia

n to get the clients medicati onincrea sed doesnt address his physical

complain ts. 97. Answer : (B) Echopra xia Rational e

: Echopra xia is the copying of anothers behavior s and is theresult of the

loss of ego boundari es. Modelin g is the consciou s copying of someo

nes behavior s. Egosyntonici ty refers to behavior s that correspo ndwith

the individua ls sense of self. Ritualis m behavior s are repetitive

andcomp ulsive. 98. Answer : (C) Hallucin ation Rational e

: Hallucin ations are sensory experien ces that aremisre presentat ions of

reality or have no basis in reality. Delusion s arebelief s not based in reality.

Disorgan ized speech is character ized by jumpi ng from one topic to the next or

using unrelated words. An idea of refere nce is a belief that an unrelated situation

holds special meaning for the client. 99. Answer : (C) Regressi on

Rational e : Regressi on, a return to earlier behavior to reduce anxiety,

isthe basic defense mechanis m in schizoph renia. Projectio n is a defense

mechanis m in which one blames others and attempts to justify actions;

itsused primarily by people with paranoid schizoph renia and delusion aldisorde

r. Rationali zation is a defense mechanis m used to justify onesacti on. Repressi

on is the basic defense mechanis m in the neuroses; its an involunta ry

exclusio n of painful thoughts, feelings, or experien ces fromawa

reness.10 0. Answer : (A) Should report feelings of restlessn ess or

agitation at once Rational e : Agitatio n and restlessn ess are adverse

effect of haloperi doland can be treated with antochol inergic drugs. Haloperi

dol isnt likely tocause photose nsitivity or contr ol essent ial hyper tension. Althoug

h theclie nt may experien ce increase d concentr ation and activity, these

effectsar e due to a decrease d in symptom s, not the drug itself.

NUR SING 1.Whi FOU ch ele NDA ment i TION n OF the cir

cular ed chain bypres of infe erving ction skin can integri be eli ty?a . minat H o s t

b.Res ervoi r c.M ode of trans missi

ond.P ortal of ent ry2.W hich of the follow

ing will proba bly result in a brea

k in sterile techni que for res pirator y

isolati on?a. Openi ng the patien ts windo

w to the outsid e enviro nment b.Tur

ning on the pa tients room ventil ator c.

Openi ng the door of the patien ts roo m lea

ding i nto the hospit alcorri dor d. Failin

g to wear glove s when admin isterin

ga bed bath3. Whic h of the fol lowin

g patien ts is at gre ater ri sk for co

ntracti ng aninfe ction? a.A patien t with

leuko penia b.A patien t receiv ing

broad posto perati spectr ve um patien antibi t who oticsc. has un A dergo

ne orthop edic s urgery d.A newly diagn

osed d diabet washi ic pati ngreq ent uires 4. the Effecti use vehan of:a.S

oap or deterg ent to prom ote emuls ificati

onb.H ot wat er to destro y bacter iac.A

disinf ectant to increa se surfac e

tensio nd.Al l of the a bove 5.

After routin e patient contac t,hand washi

ngsho uld last at least:a .30 s econ dsb.1

minu tec.2 min uted. 3 mi nutes 6.Whi

ch of the fol lowin g proce dures alway

s requir es surgic al asepsi s?a.V

aginal instill ation of conju gated

estrog en b. Urinar y cathet

erizati on c. Nasog astric tube

inserti on d. Colost omy irrigati on7.St

erile t echni que is used when ever:a .Strict

isolati on is requir edb.T ermin al disi nfecti

on is perfor medc. Invasi ve proce dures

are pe rform edd.P rotecti ve iso lation is nec

essary 8.Whi ch of the fol lowin g consti

tutes a brea k in ster ile techni que w

hilepr eparin ga sterile field for a dressi

ng chang e?a.U sing sterile forcep s, rath

er sterile than item sterile b.Touchi ng the gloves outside , wrapper of sterili to han zed mate dle a rial with

out steril eglovesc. Placing a sterile object on the edge of the sterile fieldd.Po

uring out a small amount of soluti on (15 to 30 ml) befo re pouringt he

solution into a sterile container 9.A natural body defense that plays an

active role in preventi ng infection is:a.Ya wningb .Body h air c.Hi ccuppin

gd.Rapi d eye moveme nts 10. All of the followin g statemen

t are true aboutdon ning sterile glovesex cept:a.Th e first glove should b e picked

up by grasping the insid e of thecuff.b .The second glove should be picke

d up by insert ing the glovedfi ngers under the cuff outside the glove.c.

The gloves should be adjust ed by sliding the gloved fingers under th

e sterile cuff and pulling the glove over the wristd.T he inside of the glove is

consider ed sterile11 .When removin ga contamin ated gown, the nurse

should be careful thatthe first thing she touches is the:a.Wa ist tie

and neck tie at the back of the gownb. Waist ti e in front of the gownc.

Cuffs of the go wnd.Ins ide of th e gown12. Which of the followin g nursing

intervent ions is consider ed the mosteffe ctive form or universal precautio ns?a.Cap

all used needles before removin g them from their syringes b.Discar d all

used uncappe d needles and syringes in animpen etrable protectiv

e container c.Wear gloves when administ ering IM injection sd.Follo w

enteric precauti ons13.Al l of the followin g measures are recomme nded to

prevent pressure ulcersexc ept:a.Ma ssaging the redd ened are with lotionb. Using a

water or air mattress c.Adheri ng to a schedule for positioni ng and turningd

.Providi ng metic ulous ski n care14. Which of the followin g blood tests

should be performe d before a bloodtra nsfusion ?a.Proth rombin a nd coag

ulation t imeb.Bl ood typing a nd cross matchin gc.Blee ding and

clotting time d. Complet e blood count (CBC)an d electrolyt e

levels.15 .The primary purpose of a platelet count is to evaluate the:a.Pot

ential for clot formatio nb.Pote ntial for blee ding c.Presen ce of an antig

enantibody response d.Presen ce of cardiac enzymes 16.Whic h of the followin

g white blood cell (WBC) counts clearly indicates leukocyt osis?a.4, 500/mm

b.7,00 0/mmc .10,000 /mmd. 25,000/ mm 17. After 5 days of diuretic

therapy with 20mg of furose mide(Las ix) daily, apatient begins to exhibit fatigue,

muscle cramping and muscle weaknes s.These symptom s probably indicate

that the patient is experien cing:a.H ypokale miab.H yperkal emiac. Anorex iad.Dys

phagia1 8.Which of the followin g statemen ts about chest Xray is false?a.

No contradi ctions exist for this testb.Bef ore the procedur e, the patient s

hould re move all jewelry, metallic objects, and buttons above the waistc.A

signed consent is not required d.Eating, drinking , and medicati ons are allow

ed befor e this test19.Th e most appropri ate time for the nurse to obtain a sputum

specimen for cultur e is:a.Earl y in the morning b.After the patient eats a

light breakfas tc.After aerosol therapy d.After chest physioth erapy20. A patient

with no known allergies is to receive penicillin every 6 hours.W hen administ

ering the medicati on, the nurse observes a fine rash on thepatien ts skin. The most

appropri ate nursing action would be to:a.Wit hhold the moderati on and

notify the physicia nb.Admi nister the medicati on and notify the

physicia nc.Admi nister the medicati on with an antihista mined.A pply

corn starch soaks to the rash21.A ll of the followin g nursing intervent ions are

correct when using the Z-track method of drug injection except:a. Prepare the

injection site with alcoholb .Use a needle t hats a least 1 longc .Aspirat e for

blood be fore inje ctiond.R ub the site vigorous ly after the injection to promo

te absorp tion22.T he correct method for determin ing the vastus lateralis

site for I.M.injec tion is to:a.Loc ate the upper aspect of the upper outer qu

adrant of the butto ckabout 5 to 8 cm below the iliac crestb.Pa lpate the lower edge of

the acro mion pro cess and the midp ointlater al aspect of the arm c.Palpat e a 1

circular area anterior to the umbilicu sd.Divid e the area bet ween the greater

femoral t rochante r and thela teral femoral condyle into thirds, and

select the middle third on theanteri or of the thigh23. The middeltoid injection site is

seldom used for I.M. inje ctions because it:a.Can accomm odate only 1 ml or

less of medicati onb.Bru ises too easil yc.Can be used only wh en the patient

is lying downd. Does not readily parenter al medicati on24.Th e appropri

ate needle size for insulin injection is:a.18G , 1 lo ngb.22 G, 1

longc.2 2G, 1 longd.2 5G, 5/8 long25. The appropri ate

needle gauge for intrader mal injection is:a . 2 0 Gb.22 Gc.25 Gd.26 G 26.Par

enteral penicilli n can be administ ered as an:a.IM injectio n or an IV solution

b.IV or a n intrade rmal injection c.Intrade rmal or subcutan eous injection d.IM or

a subcuta neous injectio n27.The physicia n orders gr 10 of aspirin for a

patient. The equivale nt dose inmilligr ams is:a . 0 . 6 mgb.1 0 mgc. 60 mg

d.600 m g 28.T he physicia n 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 tt/minut eb.13 gt t/minut ec.25 gt t/minut ed.50 gt t/minut e29.Whi

ch of the followin g is a sign or symptom of a hemolyti c reaction toblood

transfusi on?a.He moglobi nuriab. Chest p ainc.Ur ticariad .Distend ed neck veins30.

Which of the followin g condition s may require fluid restrictio n?a . F e v

e r b.Chr onic Obs tructive Pulmona ry Disease c. Renal Failure

d.Dehy dration3 1.All of the followin g are common signs and symptom s of

phlebitis except:a. Pain or discomf ort at the IV insertion siteb.Ed ema and war

mth at the IV insertion sitec.A red streak ex iting the IV insertion sited.Fra

nk bleeding at the in sertion site32.T he best way of determin ing whether

a patient has learned to instill ear medi cation properly is for the nurse to:a.Ask

the patient if he/she has used ear drops beforeb. Have the patient repeat

the nurse s instruc tions using her own wordsc. Demonst rate the procedur e to

the patie nt and encourag e to askquesti onsd.As k the patient to demonst

rate the procedur e33.Whi ch of the followin g types of medicati ons can be

administ ered viagastro stomy tube?a.A ny oral medicati onsb.Ca psules whole

contents are dissolve in water c. Entericcoated ta blets that are thor oughly

dissolve d in water d. Most tablets designed for oral use, exce pt for extended

duration compoun ds34.A patient who develops hives after receiving

an antibiotic is exhibitin gdrug:a. Toleran ceb.Idio syncras yc.Syne rgismd.

Allergy 35.A patient has returned to his room after femoral arteriogr

aphy. All of thefollo wing are appropri ate nursing intervent ions except:a.

Assess f emoral, popliteal , and pedal pulses every 15 minut es for 2hoursb.

Check the pressure dressing for sanguine ous drainage c.Assess a vital

signs every 15 minutes for 2 hoursd. Order a hemoglo bin and hematoc rit count

1 hour after thearteri ography3 6.The nurse explains to a patient that a

cough:a. Is a protectiv e respon se to clear the respi ratory tract of irritantsb

.Is primaril ya voluntar y action c.Is induced by the administ ration of

an antitussi ve drugd.C an be inhibited by splintin g the abdome

n37.An infected patient has chills and begins shivering . The best nursingin

terventio n is to:a.App ly iced alcohol sponges b.Provid e increas ed cool l iquidsc.

Provide addition al bedcloth esd.Prov ide incre ased ven tilation

38.A clinical

nurse specialis t is a nurse who has:a.Be en certifie d by the

Nationa l League for Nursing b.Recei ved credenti als from

the Phil ippine Nurses Associa tionc.Gr aduated from an associat e degree

progra m and is a registe redprofe ssional nursed. Comple ted a masters

degree in the pres cribed clinical area and isa registere d

professi onal nurse.39 .The purpose of increasi ng urine acidity

through dietary means is to:a.De crease burning sensatio nsb.Cha nge the

urines color c. Change the urin es conc entratio nd.Inhi bit the growth

of microor ganisms 40.Clay colored stools indicate :a.Uppe r GI

bleedin gb.Imp ending constip ationc. An effe ct of medicat iond.Bi

le obstr uction4 1.In which step of the nursing process would

the nurse ask a patient if themedi cation she administ

ered relieved his pain? a. Assessm ent b.A nalysis c.

Plannin g d. Evaluati on42.Al l of the followin g are good

sources of vitamin A except:a .White potatoe sb.Car rotsc.

Aprico tsd.Eg g yolks4 3.Which of the followin g is a primary

nursing interven tion necessar y for allpatien ts with a Foley Catheter

in place?a. Maintai n the drainag e tubing and collecti on bag

level with thepatie nts bladder b.Irrigat e the patient with 1%

Neospor in soluti on three times a dailyc. Clamp the catheter for 1

hour every 4 hours to maintai n thebladd ers elasticit yd.Main

tain the drainag e tubing and collecti on bag below b ladder l evelto

facilitate drainage by gravity4 4.The ELISA test is used to: a.

Screen blood donors for antibodi es to human immuno deficien

cyvirus( HIV)b. Test blood to be used for transfus ion for HIV

antibodi es c. Aid in diagnosi ng a patient withAI DSd.Al

l of the abo ve45.Th e two blood vessels most common ly used

for TPN infusion are the:a.Su bclavia n and jugular veinsb. Brachia

l and su femoral includes bclavia veins46. which n veins Effective of the

skin c.Femor disinfecti al and on before subclavi a an surgical veinsd. procedur Brachial e and

followin g methods ?a.Shavi ng the site on the day

before surgeryb .Applyin ga topical antisepti c to the skin on the eveni ng befor

esurgery c.Havin g the patient take a tub bath on the morning of surgeryd

.Having the patient shower with an antisepti c soap on the eveningv =before

and the morning of surgery4 7.When transferri ng a patient from a bed to a

chair, the nurse should usewhich muscles to avoid back injury?a. Abdomi nal

muscles b.Back muscles c.Leg m usclesd. Upper arm mu scles48. Thrombo phlebitis

typically develops in patients with which of the followin gconditio ns?a.Incr

eases partial thrombo plastin timeb.A cute pul sus paradox usc.An impaired

or traumati zed blood vessel walld.C hronic Obstruct ive Pulmona

ry Disease (COPD) 49.In a recumbe nt, immobili zed patient, lung

ventilatio n can become altered,le ading to such respirato ry complica tions

as:a.Res piratory acidosis, ateclect asis, and hypostati c pneumo niab.App neustic

breathin g, atypic al pneum onia and respirato ry alkalo sisc.Che yneStrokes r espiratio

ns and s pontaneo us pneu mothora xd.Kuss mails respirati ons and hypoven tilation5

0.Immob ility impairs bladder eliminati on, resulting in such disorders asa.Incre

ased urine aci dity and relaxatio n of the perineal muscles, causing incontine nceb.Uri

ne retention , bladder distentio n, and infection c.Diures is, natriures is, and

decrease d urine specific gravityd. Decreas ed calcium and phospha te levels

in the urine

DATIO N OF ANSW NURSI ERS NG AND 1. RATIO D NALE . In the circular FOUN chain of

infectio n, pathoge ns must be able to leave their res ervoir and be

transmit ted to a suscepti ble host through a portal of entry, such as

broken skin. 2. C . Respirat ory isolation , like

strict isolation , requires that the door to thedoor patients room

remain closed. Howeve r, the patients room should bewell ventilate

d, so opening the window or turning on the ventricu lar

isdesira ble. The nurse does not need to wear gloves for respirato

ryisolati on, but good hand washing is importa nt for all types of

isolation . 3. A . Leukope nia is a decrease d

number of leukocyt es (white blood cells),w hich are importa

nt in resisting infectio n. None of the other situation swould put the

patient at risk for contracti ng an infectio n; taking broadspectru

m antibioti cs might actually reduce the infectio n risk. 4.

A . Soaps and detergen ts are used to help remove bacteria

because of their ability to lower the surface tension of water and act

as emulsify ingagent s. Hot water may lead to skin irritation

or burns. 5. A . Dependi ng on the degree

of exposur e to pathoge ns, hand washing may last from 10 seconds

to 4 minutes. After routine patient contact, handwas hing for 30

seconds effective ly minimiz es the risk of pathoge ntransmi ssion.

6. B . The urinary system is normall y free of microor

ganisms except at theurina ry meatus. Any procedu re that

involves entering this system mustuse surgicall y aseptic measure s to

maintain a bacteriafree state. 7. C . All invasive

procedu res, includin g surgery, catheter insertion , andadmi

nistratio n of parenter al therapy, require sterile techniqu e to

maintain asterile environ ment. All equipme nt must be sterile,

and the nurse and thephysi cian must wear sterile gloves

and maintain surgical asepsis. In theopera ting room, the

nurse and physicia n are required to wear sterilego wns, gloves,

masks, hair covers, and shoe covers for all invasive procedu res.

Strict isolation requires the use of clean gloves, masks,g owns and

equipme nt to prevent the transmis sion of highly commun icabledi

seases by contact or by airborne routes. Termina l disinfect

ion is thedisinf ection of all contami nated supplies and equipme

nt after a patient hasbeen discharg ed to prepare them for reuse by another

patient. Thepurp ose of protecti ve (reverse ) isolation is to

prevent a person withseri ously impaire d resistanc e from coming

into contact who potential lypathog enic organis ms. 8.

C . The edges of a sterile field are consider ed contami nated.

When sterileite ms are allowed to come in contact with the edges of

the field, the sterileite ms also become contami nated. 9. B

. Hair on or within body areas, such as the nose, traps

and holdspar ticles that contain microor ganisms. Yawnin g and

hiccuppi ng do notpreve nt microor ganisms from entering or

leaving the body. Rapid eyemov ement marks the stage of sleep

during which dreamin g occurs. 10. D . The inside of

the glove is always consider ed to be clean, but not sterile

11.

A . The back of the gown is consider ed clean, the front is contamin

ated.So, after removin g gloves and washing hands, the nurse should untie

theback of the gown; slowly move backwar d 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 contamin ated linen container ; then

washher hands again. 12. B . Accordin g to the Centers for

Disease Control (CDC), blood-tobloodcon tact occurs most commonl y when a

health care worker attempts to capa used needle. Therefor e, used needles

should never be recapped ;instead they should be inserted in a specially

designed puncture resistant, labeled container . Wearing gloves is not always

necessar y whenad ministeri ng an I.M. injection. Enteric precautio ns

prevent the transfer of pathog ens via feces. 13. A . Nurses and other

health care professio nals previousl y believed thatmass aging a reddened

area with lotion would promote venous return andreduc e edema to the area.

However , research has shown that massage only increases the

likelihoo d of cellular ischemia and necrosis to the area. 14. B

. Before a blood transfusi on is performe d, the blood of the donor andrecipi ent must

be checked for compatib ility. This is done by blood typing (atest

that determin es a persons blood type) and crossmatching (aproced ure that

determin es the compatib ility of the donors and recipient sblood after the

blood types has been matched) . If the blood specimen s areincom patible,

hemolysi s and antigenantibody reactions will occur. 15. A

. Platelets are diskshaped cells that are essential for blood coagulati on.A

platelet count determin es the number of thrombo cytes in blood available

for promotin g hemostas is and assisting with blood coagulati on 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

to350,00 0/mm
3

. A count of 100,000/ mm
3

or less indicates a

potential for bleed ing; count of less than 20,000/ mm

d with spontane ousbleed ing. 16. D . 3 Leukocyt is osis is associate any

transient increase in the number of white bloodcell s (leukocyt es) in the blood.

Normal WBC counts range from 5,000 to100,00 0/mm

3

. Thus, a count of 25,000/ mm

. Fatigue, muscle cramping , and 3 muscle indicates weaknes leukocyt ses are osis. symptom 17. s A of hypok

alemia (an inadequa te potassiu m level), which is a potential sideeffec

t of diuretic therapy. The physicia n usually orders supplem entalpota ssium to

prevent hypokale mia in patients receiving diuretics. Anorexia is another symptom

of hypokale mia. Dysphag ia means difficulty swallowi ng. 18. A

. Pregnanc y or suspecte d pregnanc y is the only contraind ication

for achest Xray. However , if a chest Xray is necessar y, the patient

can wear a lead apron to protect the pelvic region from radiation.

Jewelry, metallico bjects, 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 examinat ion. Eating, drinking and

medicati ons areallow ed because the X-ray is of the chest, not the

abdomin al region. 19. A . Obtainin ga sputum specimen early in

this morning ensures anadequa te supply of bacteria for culturing and

decrease s the risk of conta mination from food or medicati on. 20. A

. Initial sensitivit y to penicillin is commonl y manifest ed by a skin

rash,even in individua ls who have not been allergic to it previousl y.

Because of the danger of anaphyla ctic shock, he nurse should withhold the drug

andnotif y the physicia n, who may choose to substitut e another drug.Ad ministeri

ng an antihista mine is a depende nt nursing intervent ion thatrequi res a

written physicia ns order. Although applying corn starch to therash may

relieve discomfo rt, it is not the nurses top priority in such apotentia lly life-

threateni ng situation. 21. D . The Ztrack method is an I.M.

injection techniqu e in which the patients skin is pulled in such a way that

the needle track is sealed off after theinjecti on. This procedur e seals medicati

on deep into the muscle, therebym inimizin g skin staining and irritation. Rubbing

the injection site iscontrai ndicated because it may cause the medicati on to

extravasa te intothe skin. 22. D . The vastus lateralis, a long, thick

muscle that extends the full length of the thigh, is viewed by many clinician

s as the site of choice for I.M.injec tions because it has relatively few

major nerves and blood vessels.T he middle third of the muscle is

recomme nded as the injection site. Thepatie nt can be in a supine or sitting

position for an injection into this site. 23. A . The middeltoid

injection site can accomm odate only 1 ml or less of medic ation 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 recomme nded size for insulin injection because insulin is administ ered by

the subcutan eous route. An 18G, 1 needl e is usually used for I.M.

injection s in children, typically in the vastuslat eralis. A 22G, 1 needle is

usually used for adult I.M. injection s, whichare typically administ ered in

the vastus lateralis or ventrogl uteal site. 25. D . Because

an intrader mal injection does not penetrate deeply into theskin, a small-

bore 25G needle is recomme nded. This type of injection isused primarily to

administ er antigens to evaluate reactions for allergy or sensiti vity

studies. A 20G needle is usually used for I.M. injection s of oilbased medicati

ons; a 22G needle for I.M. injection s; and a 25G needle, for I.M. injection

s; and a 25G needle, for subcutan eous insulin injection s. 26.

A . Parentera l penicillin can be administ ered I.M. or added to a

solutiona nd given I.V. It cannot be administ ered subcutan eously or

intrader mally. 27. D . gr 10 x 60mg/gr 1 = 600 mg 28. C

. 100ml/6 0 min X 15 gtt/ 1 ml = 25 gtt/minut e 29. A

. Hemoglo binuria, the abnormal presence of hemoglo bin in the urine,ind

icates a hemolyti c reaction (incompa tibility of the donors andrecipi ents

blood). In this reaction, antibodie s in the recipient s plasmaco mbine rapidly

with donor RBCs; the cells are hemolyz ed in either

circulato ry or

reticuloe ndotheli al system. Hemoly sis occurs more rapidly

inABO incompa tibilities than in Rh incompa tibilities. Chest pain and

urticaria may be sympto ms of impendi ng anaphyl axis. Distend

ed neck veins are anindica tion of hypervo lemia. 30. C

. In real failure, the kidney loses their ability to effective

ly eliminat ewastes and fluids. Because of this, limiting the

patients intake of oral andI.V. fluids may be necessar y. Fever, chronic

obstructi ve pulmona rydiseas e, and dehydrat ion are conditio ns for

which fluids should beencou raged. 31. D . Phlebitis

, the inflamm ation of a vein, can be caused by chemica lirritants

(I.V. solution s or medicati ons), mechani cal irritants (the

needle or cathet er used during venipun cture or cannulat ion), or a

localize d allergicr eaction to the needle or catheter. Signs

and sympto ms of phlebitis include pain or discomf ort, 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 demonst

ration provides the most certain evidenc e for evaluati ngthe effective

ness of patient teaching . 33. D . Capsule s,

entericcoated tablets, and most extende d duration or sustai

ned release products should not be dissolve d for use in agastros

tomy tube. They are pharmac eutically manufac tured in these formsfor

valid reasons, and altering them destroys their purpose. The

nursesh ould seek an alternate physicia ns order when an ordered

medicati on isinappr opriate for delivery by tube. 34. D

.A drugallergy is an adverse reaction resulting from an immuno

logicres ponse followin ga previous sensitizi ng exposur e to the

drug. Thereact ion can range from a rash or hives to anaphyl

actic shock. Toleran ce to a drug means that the patient

experien ces a decreasi ng physiolo gicrespo nse to repeated administ

ration of the drug in the same dosage. Idiosync rasy is an individu

als unique hyperse nsitivity to a drug, food, or other substanc

e; it appears to be genetica lly determi ned. Synergis m

, is adrug interacti on in which the sum of the drugs combine

d effects is greater t han that of their separate effects. 35. D

.A hemoglo bin and hematoc rit count would be ordered by the

physicia nif bleeding were suspecte d. The other answers are

appropri ate nursingi ntervent ions for a patient who has undergo ne

femoral arteriogr aphy. 36. A . Coughin g, a protecti

ve response that clears the respirato ry tract of irritan ts,

usually is involunt ary; however it can be voluntar y, as when

apatient is taught to perform coughin g exercise s. An antitussi

ve druginhi bits coughin g. Splintin g the abdome n

supports the abdomin al muscles when a patient coughs. 37.

C . In an infected patient, shiverin g results from the bodys attempt

toincrea se heat producti on and the producti on of neutrop hils

andphag ocytotic action through increase d skeletal muscle tension

andcontr actions. Initial vasocon striction may cause skin to feel cold

to thetouch . Applyin g addition al bed clothes helps to

masters degree in . A increased aclinical temperat clinical metabloi specialty ure and nurse sm, and and be a stop the specialist thus registere chills. must increased d Attempts have heat professio to cool complete producti nal the body d a on. nurse. result in

equalize further s 38. the body hivering, D

The National League of Nursing accredits educatio nal programs in

nursing and provides a testing service to evaluate student nursing compete

nce but it does notcertif y nurses. The America n Nurses Associati on identifies

requirem entsfor certificati on and offers examinat ions for certificati on in many

areas of nursin g., such as medical surgical nursing. These certificati on(crede

ntialing) demonstr ates that the nurse has the knowled ge and theability to provide

high quality nursing care in the area of her certificati on. Agraduat e of an

associate degree program is not a clinical nurse specialist :however , she is prepared

to provide bed side nursing with a high degreeof knowled ge and skill. She

must successf ully complete the licensing examinat ion to become a

registere d professio nal nurse. 39. D . Microorg anisms

usually do not grow in an acidic environ ment. 40. D . Bile colors

the stool brown. Any inflamm ation or obstructi on that impairsbi le flow will

affect the stool pigment, yielding light, claycolored stool.Up per GI bleeding

results in black or tarry stool. Constipa tion ischaract erized by small, hard

masses. Many medicati ons and foods willdisco lor stool for example, drugs

containin g iron turn stool black.; beetsturn stool red. 41. D . In the evaluatio

n step of the nursing process, the nurse must decidew hether the patient

has achieved the expected outcome that wasident ified in the

planning phase. 42. A . The main sources of vitamin A are

yellow and green vegetabl es (suchas carrots, sweet potatoes, squash,

spinach, collard greens, broccoli, andcabba ge) and yellow fruits (such as apricots,

and cantalou pe). Animals ources include liver, kidneys, cream, butter,

and egg yolks. 43. D . Maintain g the drainage tubing and

collectio n bag level with the patients bladder could result in reflux of urine

into the kidney. Irrigating the bladder with Neospori n and clamping the

catheter for 1 hour every 4 hours mustbe prescribe d by a physicia n.

44. D . The ELISA test of venous blood is used to assess blood

and potential blood donors to human immuno deficienc y virus (HIV). A positive

ELISAte st combine d with various signs and symptom s helps to diagnose acquired

immuno deficienc y syndrom e (AIDS) 45. D . Tachypn ea (an

abnormal ly rapid rate of breathing ) would indicate thatthe patient was still hypoxic

(deficien t in oxygen). The partial pressures of arteria l oxygen and carbon

dioxide listed are within the normal range.Eu pnea refers to normal

respiratio n. 46. D . Studies have shown that showerin g with an

antisepti c soap beforesur gery is the most effective method of removin g

microorg anisms from theskin. Shaving the site of the intended surgery might

cause breaks in theskin, thereby increasin g the risk of infection ; however,

if indicated ,shaving, should be done immediat ely before surgery, not the

day before. A topical antisepti c would not remove microorg anisms and

would bebenefi cial only after proper cleaning and rinsing. Tub bathing

mighttra nsfer organism s 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 ar ms may be easily injured. 48. C . The factors,

known as Virchow s triad, collectiv ely predispo se a patientto thrombo

plebitis; impaired venous return to the heart, bloodhyp ercoagul ability, and injury to

a blood vessel wall. Increase d partialthr ombopla stin time indicates a

prolonge d bleeding time during fibrin clotform ation, commonl y the

result of anticoag ulant (heparin) therapy. Arterialb lood disorders (such as pulsus

paradoxu s) and lung diseases (such asCOPD ) do not necessari ly impede

venous return of injure vessel walls. 49. A . Because of

restricted respirato ry moveme nt, a recumbe nt, immobili zepatient is at

particula r risk for respirato ry acidosis from poor gasexcha nge; atelectasi

s from reduced surfactan t and accumul ated mucus inthe bronchio les, and

hypostati c pneumon ia from bacterial growth causedby stasis of mucus

secretion s. 50. B . The immobili zed patient commonl y suffers

from urine retention causedby decrease d muscle tone in the perineum . This

leads to bladder d istention and urine stagnatio n, which provide an excellent medium

for bacte rial growth leading to infection. Immobili ty also results in morealka

line urine with excessiv e amounts of calcium, sodium and phosphat

e,a gradual decrease in urine producti on, and an increased specific gravity.

MATER NAL AND CHILD HEALT H 1.For the client who is using ora

l contrace ptives, the nurse informs the clientabo ut the need to take the

pill at the same time each day to accompli shwhich of the followin g?a.Decr

ease the incidenc e of nause ab.Main tain hormon al levelsc. Reduce

side eff ectsd.Pr event drug interacti ons2.Wh en teaching a client about

contrace ption. W hich of the followin g wouldthe nurse include as the

most effective method for preventin g sexuallyt ransmitte d infection

s?a.Sper micides b.Diaph ragmc. Condo msd.Va sectom y3.When preparin ga

woman who is 2 days postpart um for disch arge,reco mmendat ions for which of

the followin g contrace ptive methods wouldbe avoided? a.Diaph ragmb.

Female condom c.Oral contrace ptivesd. Rhythm method 4. For which of

the followin g clients would the nurse expect that anintraut erine

device would not be recomme nded?a. Woman over age 35b. Nullipar

ous womanc .Promis cuous young adultd.P ostpartu m client5. A

client in her third trimester tells the nurse, I m constipat ed all the time!W hich of

the followin g should the nurse recomme nd?a.Da ily ene masb.L axative sc.Incre

ased fib er intake d.Decre ased flui d intake6. Which of the followin g

would th e nurse use as the basis for the teaching plan when caring

for a pregnant teenager concerne d about gaining toomuch weight during pregnanc

y?a.10 p ounds per trim ester b.1 pound per week for 40 weeksc. pound

per week for 40 weeksd. A total gain of 25 to 30 pounds7 .The client

tells the nurse that her last menstrua l period st arted on January1 4 and

ended on January 20. Using Nageles rule, the nurse determin esher EDD to

be which of the followin g?a.Sept ember 27 b.Octob er 21c. Novem ber

7d.Dec ember 2 78.When taking an obstetric al history on a pregnant client wh

o states, I hada son born at 38 weeks gestation ,a daughter born at 30 weeks

gestation and I lost a baby at about 8 weeks, the nurse should record her obste trical

history as which of the followin g?a.G2 T2 P0 A0 L2b.G3 T1 P1 A0

L2c.G3 T2 P0 A0 L2d.G4 T1 P1 A1 L29.Wh en preparin g to

listen to the fetal hea rt rate at 12 weeks gestation , thenurse would

use which of the followin g?a.Stet hoscope placed midline at the umbilicu

sb.Dopp ler placed midline at the suprapu bic regionc. Fetoscop e placed

midway between the umbi licus and the xiphoidp rocessd. External electroni c fetal m

onitor pl aced at the umbilicu s10.Whe n developi ng a plan of care for a

client newly diagnose d withgest ational diabetes, which of the followin

g instructio ns would be thepriorit y?a.Diet ary intakeb. Medicat ionc.Ex

ercised. Glucose monitor ing11.A client at 24 weeks gestation has gained 6 pounds

in 4 weeks. Which of the followin g would be the priority when assessing

the client?a. Glucos uriab.D epressi onc.Han d/face e demad. Dietary intake1

2.A client 12 weeks pregnant come to the emergen cy departme nt

withabdo minal cramping and moderate vaginal bleeding. Speculu mexamin ation

reveals 2 to 3 cms cervical dilation. The nurse woulddo cument these findings

as which of the followin g?a.Thre atened a bortionb .Immine nt abortion c.Compl

ete abortion d.Misse d aborti on13.W hich of the followin g would be the

priority nursing diagnosis for a clientwit h an ectopic pregnanc y?a.Risk for

infectio nb . P a i n c.Kno wledge Deficitd .Anticip atory Gr ieving 14.Befor e

assessing the postpartu m clients uterus for firmness and positioni

n relation to the umbilicu s and midline, which of the followin g should thenurse

do first?a.A ssess the vital signsb. Adminis ter analg esiac.A mbulate her in th

e halld. Assist her to ur inate15. Which of the followin g should the nurse do when

a primipar a who islactatin g tells the nurse that she has sore nipples?a .Tell her

to breast fe ed more frequent lyb.Adm inister a narcotic before breast feedingc

.Encoura ge her to wear a nursing brassiere d.Use soap and water to clean the nipples1

6.The nurse assesses the vital signs of a client, 4 hours postpartu m that areas

follows: BP 90/60; temperat ure 100.4F; pulse 100 weak, thready;

R 20per minute. Which of the followin g should the nurse do first?a.R eport the

temperat ure to the physicia nb.Rech eck the blood pressure with another

cuff c.A ssess the uterus fo r firmness and position d.Deter mine the amount

of lochia17 .The nurse assesses the postpartu m vaginal discharg

e (lochia) on four clie nts. Which of the followin g assessme nts

would warrant notificati on of the physicia n?a.A dark red discharg e on a 2day

postpart um clientb. A pink to brownis h discharg e on a client

who is 5 days postpart umc.Al most col orless to creamy discharg e on a client 2

weeks after deli veryd.A bright red discharg e 5 days after delivery 18.A

postpartu m client has a temperat ure of 101.4F, with a uterus that istender

when palpated, remains unusuall y large, and not descendi ng asnormal ly

expected. Which of the followin g should the nurse assess next?a.L ochiab. Breasts

c.Incisi ond . U r i n e 19.W hich of the followin g is the priority focus of nursing

practice with thecurren t early postpartu m discharg e?a.Pro moting comfort

and restorati on of healthb. Explorin g the emotion al status of the familyc.

Facilitati ng safe and effective self-and newborn cared.Te aching about the

importa nce of family planning 20. Which of the followin g actions

would be l east effective in maintaini ng aneutral thermal environ

ment for the newborn ?a.Placi ng infant under radiant warmer after bathingb

.Coverin g the scale with a warme d blanket prior to weighin gc.Placi ng crib

close to nursery window for family viewing d.Coveri ng the infants head

with a knit stockine tte21.A newborn who has an asymmet rical Moro

reflex response should befurther assessed for which of the followin g?a.Tali

pes equi novarus b.Fractu red clavicle c.Conge nital hypothy roidism d.Increa

sed intra cranial p ressure2 2.During the first 4 hours after a male circumci sion,

assessing for which of the followin g is the priority? a.Infect ionb.He morrha

gec.Dis comfort d.Dehy dration2 3.The mother asks the nurse. Whats wrong

with my sons breasts? Whyare they so enlarged ? Whish of the followin g would

be the best response by the nurse?a. The breast tissue is inflam ed from

the trauma experien ced with birthb. A decrease in material hormone

s present before bi rth causesen largemen t,c.Yo u should discuss this with you

r doctor. It could be a maligna ncyd.T he tissue has hype rtrophied while the baby

was in the uterus2 4.Immed iately after birth the nurse notes the followin

g on a male newborn: respiratio ns 78; apical hearth rate 160 BPM, nostril

flaring; mild intercost alretracti ons; and grunting at the end of expiratio n. Which

of the followin gshould the nurse do?a.Cal l the assessm ent data to the physicia

ns attention b.Start oxygen per nasal cannula at 2 L/min. c.Suctio n the inf

ants mo uth and naresd.R ecognize this as normal first period of reactivit

y25.The nurse hears a mother telling a friend on the telephon e about umbilical

cord care. Which of the followin g statemen ts by the mother indicates

effective teaching ?a.Dail y soap and water cleansin g is bestb. Alcohol

helps it dry and kills ger msc.A n antibioti c ointment applied

daily prevents infection d.He c an have a tub bath eac h day26. A

newborn weighing 3000 grams and feeding every 4 hours needs 120calori

es/kg of body weight every 24 hours for proper growth anddevel opment. How

many ounces of 20 cal/oz formula should this newborn receive at each

feeding to meet nutrition al needs?a. 2 ounces b.3 ounces c.4 oun

cesd.6 amniotic which of roblems ounces fluid the c.Integ

27.The postterm neonate with meconiu mstained

needs caredesi gned to especiall y monitor for

followin g?a.Res piratory proble msb.Ga strointe stinal p

umenta ry probl emsd.El iminati on prob lems28. When

measuri ng a clients fundal height, which of the followin g

techniqu esdenote s the correct method of measure ment used by

the nurse?a. From th e xiphoid process to the umbilic usb.Fro

m the symphy sis pubis to the xiphoid process c.From the

symphy sis pubis to the fund usd.Fro m the fu ndus to the umbilic

us29.A client with severe preecla mpsia is admitted with of BP

160/110, proteinu ria, and severe pitting edema. Which of the followin

g would bemost importa nt to include in the clients plan of care?a.

Daily weight sb.Seiz ure pre caution sc.Righ t lateral position ingd.St

ress red uction3 0.A postpart um primipar a asks the nurse,

When can we have sexualin tercours e again? Which of the

followin g would be the nurses bestresp onse?a. Anytim e you both

want to.b. As soon as choo se a contrac eptive method. c.Wh

en the dischar ge has stopped and the incision is healed. d.After

your 6 weeks examin ation.3 1.When preparin g to administ er the

vitamin K injection to a neonate, thenurse would select which of

the followin g sites as appropri ate for theinject ion?a.D eltoid

muscle b.Anter ior fem oris mu sclec.V astus lateralis muscle d.Glute

us maxi mus muscle 32.Whe n performi ng a pelvic examina

tion, the nurse observes a red swollen area on the right side of the

vaginal orifice. The nurse would docume ntthis as enlarge ment of

which of the followin g?a.Cli torisb. Parotid glandc. Skene s gland

d.Barth olins gland33 .To different iate as a female, the hormon

al stimulati on of the embryo thatmust occur involves which of

the followin g?a.Incr ease in materna l estroge n secret ionb.De

crease in materna l androge n secretio nc.Secr etion of

androge n by the fetal gonadd. Secretio n of estroge n by the

fetal gonad
34.A client at 8 weeks gestation calls complain ing of slight

nausea in themorni ng hours. Which of the followin g client intervent ions should

the nurseque stion?a.T aking 1 teaspoon of bicarb onate of soda in an 8ounce

glass of water b.Eating a few lowsodium crackers before g etting ou t

of bedc. Avoidin g the intake of liquids in the morning hoursd.E ating six small

meals a day instead of thee large meals35. The nurse documen ts

positive ballottem ent in the clients prenatal record.T he nurse understa nds that this

indicates which of the followin g?a.Palp able con tractions on the a bdomen b.Passiv

e moveme nt of the unen gaged fetusc.F etal kicking felt by the

clientd. Enlarge ment and softenin g of the uterus36 .During a pelvic exam the

nurse notes a purpleblue tinge of the cervix.T he nurse documen ts this as

which of the followin g?a.Bra xtonHicks signb.C hadwick s signc. Goodell

s signd .McDon alds sig n37.Duri ng a prenatal class, the nurse explains the

rationale for breathing techniqu es during preparati on for labor based on the

understa nding thatbreat hing techniqu es are most importan t in achievin

g which of thefollo wing?a.E liminate pain and give the expectan t parents

somethin g to dob.Red uce the risk of fetal distress by increasin g uteropl

acentalp erfusionc .Facilitat e relaxatio n, possib ly reduci ng the percepti on of

paind.Eli minate p ain so that less analgesi a and anesthesi a are needed3

8.After 4 hours of active labor, the nurse notes that the contracti ons of aprimigr

avida client are not strong enough to dilate the cervix. Which of thefollo

wing would the nurse anticipat e doing?a. Obtainin g an order to begin IV

oxytocin infusion b.Admin istering a light sedative to allow the patient to rest

for sever alhour c. Preparin g for a cesarean section for failure to progress

d.Increas ing the encourag ement to the patient when pushing begins39 .A

multigra vida at 38 weeks gestation is admitted with painless, bright

redbleedi ng and mild contracti ons every 7 to 10 minutes. Which of thefollo

wing assessme nts should be avoided? a.Mater nal vital signb.F etal

heart rat ec.Contr action m onitorin gd.Cerv ical dilation 40.Whic h of the followin

g would be the nurses most appropri ate response toa client who asks why she

must have a cesarean delivery if she has acomplet e placenta previa?a. You

will have to ask your physicia n when he returns. b.You need a cesarean

to prevent hemorrh age.c. The plac enta is covering most of your cervix.

d.The placenta is covering the openi ng of the uteru s and blocking your

baby.41 .The nurse understa nds that the fetal head is in which of the followin

gposition s with a face presentat ion?a.Co mpletel y flexedb. Complet ely exte

ndedc.P artially extende dd.Parti ally flexed42 .With a fetus in the leftanterior

breech presentat ion, the nurse wouldex pect the fetal heart rate would be most

audible in which of the followin gareas?a. Above the maternal umbilicu s and to

the right of midlineb .In the lowerleft maternal abdomin al quadrant

c.In the lowerright maternal abdomin al quadrant d.Above the maternal

umbilicu s and to the left of midline4 3.The amniotic fluid of a client has a

greenish tint. The nurse interprets thisto be the result of which of the followin g?a.Lan

ugob.H ydramn ioc.Me conium d.Verni x44.A patient is in labor and has just been

told she has a breech presentat ion.The nurse should be particula rly alert

for which of the followin g?a.Qui ckening b.Ophth almia ne onatoru mc . P i c

a d.Prola psed umbilica l cord45. When describin g dizygotic twins to

a couple, on which of the followin gwould the nurse base the explanati on?a.Tw o ova fer

tilized by separ ate sper mb.Shar ing of a common placenta c.Each ova with the

same genotyp ed.Shari ng of a common chorion 46.Whic h of the followin g refers

to the single cell that reproduc es itself after con ception? a.Chro mosom eb.Blas

tocystc. Zygote d.Troph oblast

health care professi onals 47.In beganch the late allengin 1950s, g the consum routine ers and use of

analgesi cs and anesthet ics during childbirt h.Which of the followin

g was an outgrow th of this concept ?a.Labo r, delivery , recover

y, postpart um (LDRP) b.Nurse midwif eryc.Cli nical

nurse s pecialis td.Prep ared chi ldbirth4 8.A client has a midpelv

ic contract ure from a previous pelvic injury due to amotor

vehicle accident as a teenager . The nurse is aware that this couldpre

vent a fetus from passing through or around which structure

duringc hildbirth ?a.Sym physis pubisb. Sacral promon toryc.Is chial

spinesd .Pubic arch49. When teaching a group of adolesce nts

about variatio ns in the length of themens trual cycle, the

nurse understa nds that the underlyi ng mechani sm isdue to

variatio ns in which of the followin g phases? a.Mens trual ph

aseb.Pr oliferati ve phas ec.Secr etory phased. Ischemi c phase 50.Whe

n teaching a group of adolesce nts about male hormon

e producti on,whic h of the followin g would the nurse include

as being produce d by theLeyd ig cells?a. Follicle stimulat

ing hor moneb. Testost eronec. Leutein izing h ormone d.Gona dotropi

n releasin g horm one

ANSWE RS AND RATIO NALE MATER

NAL AND CHILD HEALT H 1. B . Regular timely ingestion

of oral contrace ptives is necessar y to maintain hormona l levels of the drugs to

suppress the action of the hypothal amusand anterior pituitary leading to

inapprop riate secretion of FSH and LH.Ther efore, follicles do not mature,

ovulation is inhibited, and pregnanc y isprevent ed. The estrogen content

of the oral site contrace ptive may causethe nausea, regardles s of when the

pill is taken. Side effects and druginter actions may occur with oral

contrace ptives regardles s of the time thepill is taken. 2. C

. Condom s, when used correctly and consisten tly, are the most effective

contrace ptive method or barrier against bacterial and viral sexuallyt ransmitte d

infection s. Although spermici des kill sperm, they do notprovi de reliable

protectio n against the spread of sexually transmitt edinfecti ons, especiall y

intracellu lar organism s such as HIV. Insertion andremo val of the diaphrag m along

with the use of the spermici des maycaus e vaginal irritation s, which could

place the client at risk for infection transmiss ion. Male sterilizati on eliminate

s spermato zoa from the ejaculate, but it does not eliminate bacterial and/or

viral microorg anisms that cancause sexually transmitt ed infection s.

3. A . The diaphrag m must be fitted individua lly to ensure effective

ness.Bec ause of the changes to the reproduc tive structure s during pregnanc

yand followin g delivery, the diaphrag m must be refitted, usually

at the 6weeks examinat ion followin g childbirt h or after a weight loss of

15 lbs or more. In addition, for maximu m effective ness, spermici

dal jelly should beplaced in the dome and around the rim. However ,

spermici dal jelly shouldno t be inserted into the vagina until involutio n is

complete d atapproxi mately 6 weeks. Use of a female condom protects the

reproduc tivesyste m from the introduct ion of semen or spermici des into the

vagina andmay be used after childbirt h. Oral contrace ptives may be started

within thefirst postpartu m week to ensure suppressi on of ovulation . For the couplew

ho has determin ed the females fertile period, using the rhythm method,a voidance

of intercour se during this period, is safe and effective. 4. C

. An IUD may increase the risk of pelvic inflamm atory disease, especiall yin

women with more than one sexual partner, because of the increased risk of

sexually transmitt ed infection s. An UID should not be used if thewoma

n has an active or chronic pelvic infection, postpartu m infection, endometr ial

hyperpla sia or carcinom a, or uterine abnormal ities. Age is nota factor in

determin ing the risks associate d with IUD use. Most IUD usersare over the

age of 30. Although there is a slightly higher risk for infertility in women

who have never been pregnant, the IUD is an acceptabl e optionas

long as the riskbenefit ratio is discusse d. IUDs may be insertedi mmediat ely after

delivery, but this is not recomme nded because of theincrea sed risk and rate

of expulsio n at this time 5.

r, the enlargin g uterus places pressure C on . During theintest the third ines. trimeste This

coupled with the effect of hormon es on smooth muscler elaxatio n causes

decrease d intestina l motility (peristal sis). Increasi ngfiber

in the diet will help fecal matter pass more quickly through

theintest inal tract, thus decreasi ng the amount of water that is

absorbe d. As aresult, stool is softer and easier to pass. Enemas

could precipita te preterml abor and/or electroly te loss and

should be avoided. Laxative s may causepre term labor by stimulati

ng peristals is and may interfere with theabsor ption of nutrients

. Use for more than 1 week can also lead to laxative depende ncy.

Liquid in the diet helps provide a semisoli d, soft consiste

ncyto the stool. Eight to ten glasses of fluid per day are

essential to maintain hydratio n and promote stool evacuati on.

6. D . To ensure adequat e fetal growth and develop

ment during the 40 weeksof a pregnan cy, a total weight

gain 25 to 30 pounds is recomm ended: 1.5poun ds 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 andseco nd

trimeste r than in the third. During the first trimeste r, the clientsh

ould 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 totalpre gnancy, less than the recomm ended amount.

7. B . To calculat e the EDD by Nagele s rule, add 7

days to the first day of thelast menstru al period and count back 3

months, changin g the year app ropriatel y. To obtain a date of Septemb

er 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 Nove mber 7, 7 days

have been subtract ed (instead of added) from thefirst

day of LMP plus Novemb er indicate s counting back 2

months (instead of 3 months) from January. To obtain the date

of Decemb er 27, 7 dayswer e added to the last day of the LMP

(rather than the first day of theLMP ) and Decemb er indicate

s counting back only 1 month (instead of 3months

) from January. 8. D. The client has been pregnant four

times, includin g current pregnan cy(G). Birth at 38 weeks

gestatio n is consider ed full term (T), while birthfor m 20

weeks to 38 weeks is consider ed preterm (P). A spontan eousabo

rtion occurred at 8 weeks (A). She has two living children (L).

9. B. At 12 weeks gestatio n, the uterus rises out of the

pelvis and is palpable above the symphy sis pubis. The

Doppler intensifi es the sound of the fetalpuls e rate so it is audible.

The uterus has merely risen out of the pelvisint o the abdomin

al cavity and is not at the level of the umbilic us. The fetalhear t rate at

this age is not audible with a stethosc ope. The uterus at 12weeks is just

above the symphy sis pubis in the abdomin al cavity, notmid

way between the umbilic us and the xiphoid process. At 12

weeks theFHR would be difficult to ausculta te with a fetoscop

e. Althoug h theexter nal electroni c fetal monitor would

project the FHR, the uterus has notrisen to the umbilic

us at 12 weeks. 10. A. Althoug h all of the choices are

importa nt in the manage ment of diabet es, diet therapy is the mainsta

y of the treatmen t plan and shouldal ways be the priority. Women

diagnos ed with gestatio nal diabetes generall y need only diet therapy

without medicati on to control their bloodsu gar levels. Exercise

, is importa nt for all pregnant women and especiall yfor diabetic

women, because it burns up glucose, thus decreasi ng bloodsu

gar. Howeve r, dietary intake, not exercise, is the priority.

All pregnant women with diabetes should have periodic monitori

ng of serum glucose. Howeve r, those with gestatio nal diabetes

generall y do not need dailyglu cose monitori ng. The standard of care

recomm ends a fasting and 2hour postpran dial blood sugar

level every 2 weeks. 11. C. After 20 weeks gestatio n, when

there is a rapid weight gain,pre eclamps ia should be suspecte

d, which may be caused by fluidrete ntion manifest ed by edema,

especiall y of the hands and face. Thethre e classic signs of preecla

mpsia are hyperten sion, edema, andprote inuria. Althoug h urine

is checked for glucose at each clinic visit, thisis not the

priority. Depressi on may cause either anorexia or excessiv efood

intake, leading to excessiv e weight gain or loss. This is not,

however ,the priority consider ation at this time. Weight gain

thought to be caused byexces sive food intake would require a

24-hour diet recall. Howeve r,excessi ve intake would not be

the primary consider ation for this client atthis time. 12.

B. Crampin g and vaginal bleeding coupled with cervical dilation

signifies that terminat ion of the pregnan cy is inevitabl e and

cannot be prevente d.Thus, the nurse would docume nt an

immine nt abortion . In a threaten edaborti on, crampin g and

vaginal bleeding are present, but there is nocervic al dilation.

The sympto ms may subside or progress to abortion . In

acomple te abortion all the products of concepti on are expelled

.A misseda bortion is early fetal intrauter ine death without

expulsio n of the products of concepti on. 13. B.

For the client with an ectopic pregnan cy, lower abdomin al pain,

usuallyu nilateral, is the primary sympto m. Thus, pain is the priority.

Althoug h thepoten tial for infectio n is always present, the risk

is low in ectopicp regnanc y because pathoge nic microor ganisms

have not been introduc edfrom external sources. The client may

have a limited knowled ge of thepatho logy and treatmen t of the conditio

n and will most likely experien cegrievi ng, but this is not the

priority at this time. 14. D. Before uterine assessm ent is

perform ed, it is essential that the womane mpty her bladder. A full

bladder will interfere with the accurac y of theasses sment by

elevatin g the uterus and displaci ng to the side of themidli ne. Vital

sign assessm ent is not necessar y unless an abnorma lity

inuterin e assessm ent is identifie d. Uterine assessm ent

should not causeac ute pain that requires administ ration of analgesi

a. Ambulat ing the clientis an essential compon ent of postpart

um care, but is not necessar y prior to assessm ent of

the uterus. 15. A. Feeding more frequent ly, about every 2

hours, will decrease the infantsf rantic, vigorous sucking from

hunger and will decrease breasten gorgeme nt, soften the breast,

and promote ease of correct latching -onfor feeding. Narcotic s

administ ered prior to breast feeding are passedth rough the

breast milk to the infant, causing excessiv e sleepine ss.

Nipples oreness is not severe enough to warrant narcotic analgesi

a. Allpostp artum clients, especiall y lactating mothers, should

wear a supporti vebrassi ere with wide cotton straps. This does

not, however , prevent or reduc e nipple soreness . Soaps are drying

to the skin of the nipples andshou ld not be used on the breasts

of lactating mothers. Dry nipple skinpred isposes to cracks

and fissures, which can become sore and painful. 16. D.

A weak, thready pulse elevated to 100 BPM may indicate impendi

nghemo rrhagic shock. An increase d pulse is a compen satory

mechani sm of the body in response to decrease d fluid volume.

Thus, the nurse shouldc heck the amount of lochia present. Temper

atures up to 100.48F in thefirst 24 hours after birth are related

to the dehydrat ing effects of labor andare consider ed normal.

Althoug h rechecki ng the blood pressure may be acorrect choice

of action, it is not the first action that should beimple mented

in light of the other data. The data indicate a potential impendi

ng hemorrh age. Assessin g the uterus for firmness and

position inrelatio n to the umbilic us and midline is importa nt, but

the nurse shouldc heck the extent of vaginal bleeding first. Then it

would be appropri ate tocheck the uterus, which may be

a possible cause of the hemorrh age. 17. D.

Any bright red vaginal discharg e would be consider ed

abnorma l, butespec ially 5 days after delivery, when the

lochia is typically pink tobrown ish. Lochia rubra, a dark red discharg

e, is present for 2 to 3 daysafte r delivery. Bright red

vaginal bleeding at this time suggests latepost partum hemorrh age,

which occurs after the first 24 hours followin gdeliver y and is generall

y caused by retained placenta l fragmen ts or bleedi ng

disorder s. Lochia rubra is the normal dark red discharg eoccurri

ng in the first 2 to 3 days after delivery, containi ng epithelia l

cells,ery throcyes , leukocyt es and decidua. Lochia serosa is a pink to

brownis hserosan guineou s discharg e occurrin g from 3 to 10

days after delivery thatcont ains decidua, erythroc ytes, leukocyt

es, cervical mucus, andmicr oorganis ms. Lochia alba is an

almost colorles s to yellowis h discharg eoccurri ng from 10 days

to 3 weeks after delivery and containi ngleuko cytes, decidua,

epithelia l cells, fat, cervical mucus, choleste rolcrysta ls, and bacteria.

18. A. The data suggests an infectio n of the endomet rial

lining of the uterus.T he lochia may be decrease d or copious,

dark brown in appeara nce, andfoul smelling , providin

g further evidenc e of a possible infectio n. All theclient s data indicate

a uterine problem , not a breast problem . Typicall y,transie nt fever,

usually 101F, may be present with breast engorge ment.Sy mptoms

of mastitis include influenz a-like manifest ations. Localize dinfecti

on of an episioto my or Csection incision rarely causes systemic

sympto ms, and uterine involuti on would not be affected. The

client data do not include dysuria, frequenc y, or urgency, sympto

ms of urinary tractinfe ctions, which would necessit ate assessin

g the clients urine. 19. C. Because of early postpart um

discharg e and limited time for teaching ,the nurses priority is to

facilitate the safe and effective care of the clientan d newborn

. Althoug h promoti ng comfort and restorati on of

health,e xploring the familys emotion al status, and teaching about

family planning are importa nt in postpart um/new born nursing

care, they are not the priorityf ocus in the limited time presente

d by early postpartum discharg e. 20. C.

Heat loss by radiatio n occurs when the infants crib is placed

too near col d walls or window s. Thus placing the newborn

s crib close to theviewi ng window would be least effective . Body

heat is lost through evaporat ion during bathing. Placing the

infant under the radiant warmer after bathing will assist

the infant to be rewarme d. Coverin g the scale witha

warmed blanket prior to weighin g prevents heat loss through conducti

on.A knit cap prevents heat loss from the head a large head, a large

bodysur face area of the newborn s body. 21. B.

A fracture d clavicle would prevent the normal Moro

response of sym metrical sequenti al extensio n and abductio n of the

arms followe d byflexio n and adductio n. In talipes equinov

arus (clubfoo t) the foot is turnedm edially, and in plantar flexion,

with the heel elevated . The feet are notinvol ved with the Moro

reflex. Hypothy roiddis m has no effect on theprimi tive reflexes.

Absence of the Moror reflex is the most significa ntsingle indicato r of

central nervous system status, but it is not a sign of increa sed

intracra nial pressure . 22. B. Hemorr hage is a potential

risk followin g any surgical procedu re.Altho ugh the infant has been

given vitamin K to facilitate clotting, theprop hylactic dose is often

not sufficien t to prevent bleeding . Althoug hinfecti on is a

possibili ty, signs will not appear within 4 hours after thesurgi cal

procedu re. The primary discomf ort of circumci sion occurs duringth

e surgical procedu re, not afterwar d. Althoug h feedings

are withheld prior to the circumci sion, the chances of dehydrat

ion are minimal . 23. B. The presence of excessiv

e estrogen and progeste rone in the maternal -fetal blood

followe d by prompt withdra wal at birth precipita tes breasten

gorgeme nt, which will spontan eously resolve in 4 to 5 days

after birth.Th e trauma of the birth process does not cause inflamm

ation of thenewb orns breast tissue. Newbor ns do not have breast

maligna ncy. Thisrepl y by the nurse would cause the mother

to have undue anxiety. Breasttis sue does not hypertro phy in the fetus

or newborn s. 24. D. The first 15 minutes to 1

hour after birth is the first period of reactivit yinvolvi ng

respirato ry and circulato ry adaptati on to extraute rine life. Thedata

given reflect the normal changes during this time period. The

infantsa ssessme nt data reflect normal adaptati on. Thus, the

physicia n does notneed to be notified and oxygen is not needed.

The data do not indicate theprese nce of choking, gagging or coughin

g, which are signs of excessiv esecreti ons. Suctioni ng is not

necessar y 25. B. Applicat ion of 70% isopropy l alcohol

to the cord minimiz esmicro organis ms (germici dal) and promote

s drying. The cord should bekept dry until it falls off and the

stump has healed. Antibiot ic ointmen tshould only be used to

treat an infectio n, not as a prophyl axis. Infantss hould not be

submerg ed in a tub of water until the cord falls off and thestum

p has complet ely healed. 26. B. To determi ne the

amount of formula needed, do the followin gmathe matical calculati

on. 3 kg x 120 cal/kg per day = 360 calories/ dayfeedi ng q 4 hours =

6 feedings per day = 60 calories per feeding: 60calori es per

feeding; 60 calori es per feeding with formula 20 cal/oz = 3ounces

per feeding. Based on the calculati on. 2, 4 or 6 ounces

areincor rect. 27. A. Intrauter ine anoxia may cause

relaxatio n of the anal sphincte r andempt ying of meconiu m into

the amniotic fluid. At birth some of themeco nium fluid may be

aspirate d, causing mechani cal obstructi on or chemi cal

pneumo nitis. The infant is not at increase d risk for gastr ointestin

al problem s. Even though the skin is stained with meconiu

m,it is noninfec tious (sterile) and nonirrita ting. The postterm

meconiu mstained infant is not at addition al risk for bowel or

urinary problem s. 28. C. The nurse should use a

nonelast ic, flexible, paper measuri ng tape,pla cing the zero

point on the superior border of the symphy sis pubis andstret ching

the tape across the abdome n at the midline to the top of thefund

us. The xiphoid and umbilic us are not appropri ate landmar

ks to usewhen measuri ng the height of the fundus (McDon alds

measure ment). 29. B. Women hospitali zed with severe preecla

mpsia need decrease d CNSsti mulatio n to prevent a

seizure. Seizure precauti ons providee nvironm ental safety should a

seizure occur. Because of edema, dailywei ght is importa nt but

not the priority. Preclam psia causes vasospa smand therefor e can

reduce uteroplacenta l perfusio n. The client should beplace

d on her left side to maximiz e blood flow, reduce blood pressure

, andpro mote diuresis. Interven tions to reduce stress and

anxiety are veryimp ortant to facilitate coping and a sense of control,

but seizurep recautio ns are the priority. 30. C.

Cessatio n of the lochial discharg e signifies healing of the endomet

rium.Ris k of hemorrh age and infectio n are minimal 3 weeks after a

normalv aginal delivery. Telling the client anytime is inappro

priate because thisresp onse does not provide the client with the

specific informat ion she isreques ting. Choice of a contrace ptive

method is importa nt, but not thespeci fic criteria for safe

resumpti on of sexual activity. Cultural ly, the 6weeks examina

tion has been used as the time frame for resumin g sexualac

tivity, but it may be resumed earlier. 31. C . The middle

third of the vastus lateralis is the preferre d injection site

for vita min K administ ration because it is free of blood vessels and

nervesa nd is large enough to absorb the medicati on. The

deltoid muscle of anewbor n is not large enough for a newborn

IM injection . Injectio ns into thismus cle 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 proximit y of the sciatic nerve, the gluteusm aximus muscle

should not be until the child has been walking 2 years. 32. D

. Bartholin s glands are the glands on either side of the vaginal orifice.T

he clitoris is female erectile tissue found in the perineal area above

theurethr a. 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 differenti

ateas a female. An increase in maternal estrogen secretion does not effectdiff

erentiatio n of the embryo, and maternal estrogen secretion occurs inevery pregnanc

y. Maternal androgen secretion remains the same asbefore pregnanc y and does not

effect differenti ation. Secretion of andro gen by the fetal gonad would produce

a male fetus. 34. A . Using bicarbon ate would increase the

amount of sodium ingested, which can cause complica tions. Eating

lowsodium crackers would beapprop riate. Since liquids can increase

nausea avoiding them in themorni ng hours when nausea is usually the strongest

is appropri ate. Eatingsix small meals a day would keep the stomach

full, which often decrease nausea. 35. B . Ballotte ment

indicates passive moveme nt of the unengag ed fetus.Bal lottement is not a contracti

on. Fetal kicking felt by the client represent squicken ing. Enlarge ment and softening

of the uterus is known asPiskac eks sign. 36. B . Chadwic

ks sign refers to the purpleblue tinge of the cervix. Braxton Hicks

contracti ons are painless contracti ons beginnin g around the 4

th

month. Goodell s sign indicates softening of the cervix. Flexibilit y of theuterus

against the cervix is known as McDonal ds sign. 37. C

. Breathin g techniqu es can raise the pain threshold and reduce

theperce ption of pain. They also promote relaxatio n. Breathin g

techniqu es donot eliminate pain, but they can reduce it. Positioni ng, not breathing ,increase

s uteroplac ental perfusion . 38. A . The clients labor is

hypotoni c. The nurse should call the physical andobtai n an order for an

infusion of oxytocin, which will assist the uterus tocontact more forcefull

y in an attempt to dilate the cervix. Administ eringligh t sedative would be done for

hyperton ic uterine contracti ons. Preparin gfor cesarean section is unnecess ary at

this time. Oxytocin would increaset he uterine contracti ons and hopefull y

progress labor before a cesarean would be necessar y. It is too early to anticipat

e client pushing withcont ractions. 39. D . The signs indicate placenta

previa and vaginal exam to determin ecervical dilation would not be done

because it could cause hemorrh age.Asse ssing maternal vital signs can help

determin e maternal physiolo gicstatus. Fetal heart rate is importan t to

assess fetal wellbeing and shouldbe done. Monitori ng the contracti

ons will help evaluate the progress of labor. 40.

.A complet e placenta previa occurs when the placenta

covers theopeni ng of the uterus, thus blocking the passage

way for the baby. Thisresp onse explains what a complet e previa

is and the reason the babycan not come out except

by cesarean delivery. Telling the client to ask thephysi cian is a

poor response and would increase the patients anxiety. Althoug

ha cesarean would help to prevent hemorrh age, the stateme ntdoes

not explain why the hemorrh age could occur. With a complet

eprevia, the placenta is covering all the cervix, not just

most of it. 41. B . With a face presenta tion, the head is

complet ely extende d. With avertex presenta tion, the head is complet

ely or partially flexed. With a brow(fo rehead) presenta tion, the head

would be partially extende d. 42. D . With this

presenta tion, the fetal upper torso and back face the left

upper m aternal abdomin al wall. The fetal heart rate would

be most audiblea bove the maternal umbilic us and to the left of the

middle. The other po sitions would be incorrec t. 43.

C. The greenish tint is due to the presence of meconiu

m. Lanugo is thesoft, downy hair on the shoulder s and

back of the fetus. Hydram niosrepr esents excessiv e amniotic

fluid. Vernix is the white, cheesy substanc ecoverin g the fetus.

44. D. In a breech position, because of the space between

the presenti ng partand the cervix, prolapse of the umbilica

l cord is common . Quicken ing isthe woman s first percepti on of

fetal moveme nt. Ophthal mia neonator umusual ly results

from maternal gonorrh ea and is conjunct ivitis. Pica refers tothe

oral intake of nonfood substanc es. 45. A. Dizygoti c

(fraterna l) twins involve two ova fertilize d by separate sperm. Monozy

gotic (identica l) twins involve a common placenta , same genotyp

e,and common chorion. 46. C. The zygote is the single

cell that reprodu ces itself after concepti on. Thechro mosome is the

material that makes up the cell and is gained fromeac h parent.

Blastocy st and trophobl ast are later terms for the embryoa

fter zygote. 47. D. Prepare d childbirt h was the

direct result of the 1950s challeng ing of therouti ne use of

analgesi c and anesthet ics during childbirt h. The LDRP wasa

much later concept and was not a direct result of the challeng

ing of routin e use of analgesi cs and anesthet ics during childbirt

h. Roles for nurs e midwive s and clinical nurse specialis ts did

not develop from thischall enge. 48. C. The ischial

spines are located in the midpelvic region and could

benarro wed due to the previous pelvic injury. The symphy sis

pubis, sacralpr omontor y, and pubic arch are not part of the

midpelvis. 49. B. Variatio ns in the length of the menstru

al cycle are due to variatio ns inthe prolifera tive phase. The

menstru al, secretor y and ischemi c phases donot contribu te to this

variatio n. 50. B . Testoste rone is produce d by the

Leyding cells in the seminife roustubu les. Folliclestimulati ng

hormon e and leuteinzi ng hormon e are released by the anterior

pituitary gland. The hypothal amus is responsi blefor releasin g

gonadot ropinreleasin g hormon e

MEDIC AL SURGI

CAL NURSI NG 1. Marco who was diagnose d with brain tumor

was schedule d for cranioto my. Inpreven ting the develop ment of cerebral

edema after surgery, the nursesho uld expect the use of:a.Diu reticsb.

Antihyp ertensiv ec.Ster oidsd.A nticonv ulsants 2. Halfway through the

administr ation of blood, the female client complain s of lumba r pain.

After stopping the infusion Nurse Hazel should:a. Increase the flow of

normal salineb. Assess the pain further c .Notify the blood bankd.O btain

vital signs. 3. Nurse Maureen knows that the positive diagnosis for HIV i

nfection is madebas ed on which of the followin g:a.A history o f high

risk sexual behavior s.b.Posit ive ELIS A and western blot test sc.Identi fication

of an associat ed opportu nistic infection d.Eviden ce of extreme weight

loss and high fever 4. Nurse Maureen is aware that a client who has

been diagnose d with chronicre nal failure recogniz es an adequate amount

of highbiologicvalue proteinw hen the food the client selected from the menu

was:a.R aw carrots b.Apple juicec. Whole wheat breadd. Cottage cheese

5. Kenneth who has diagnose d with uremic syndrom e has the potential todevelo

p complica tions. Which among the followin g complica tions

should thenurse anticipat es:a.Flap ping han d tremor sb.An elevated hematoc rit

levelc.H ypotens iond.Hy pokale mia 6. A client is admitted to the

hospital with benign prostatic hyperpla sia, the nursemo st relevant assessme

nt would be:a.Fla nk pain radiating in the groinb.D istention of the lowe r

abdome nc.Perin eal ede mad.Ur ethral discharg e 7. A client has

undergon e with penile implant. After 24 hrs of surgery, the clientssc rotum

was edemato us and painful. The nurse should:a. Assist th e client with

sitz bath b.Apply war soaks in the scrot umc.Ele vate the scrotum using a

soft support d.Prepar e for a possible incision and drainage . 8.

Nurse hazel receives emergen cy laborator y results for a client with

chest painand immediat ely informs the physicia n. An increased myoglob

in levelsug gests which of the followin g?a.Liv er disea seb.My ocardial

damage c.Hyper tension d.Canc er 9. Nurse Maureen would expect

the a client with mitral stenosis wouldde monstrat e symptom s

associate d with congesti on in the:a.Ri ght atri umb.Su perior vena cavac .

Aortad .Pulmo nary 10. A client has been diagnose d with hyperten sion. The

nurse priority nursingdi agnosis would be:a.Inef fective h ealth ma intenanc eb.Impa

ired skin integrity c.Defici ent fluid volume d.Pain 11. Nurse Hazel teaches

the client with angina about common expected sideeffec ts of nitroglyc erin

including :a.high blood pressure b.stoma ch cram psc.hea dached. shortnes

s of breath 12. The followin g are lipid abnormal ities. Which of

the followin g is a risk factor for the develop ment of atheroscl erosis

and PVD?a. High levels of low density lipid (LDL) choleste rolb.Hig

h levels of high density lipid (HDL) choleste rolc.Lo w conce ntration triglycer

idesd.Lo w levels of LDL choleste rol. 13. Which of the followin g

represent sa significa nt risk immediat ely after surgeryf or repair of aortic aneurys

m?a.Pot ential wound infectio nb.Poten tial ineff ective co pingc.Po tential electrol

yte balance d.Potenti al alteratio n in renal perfusio n 14.

Nurse Josie should instruct the client to eat which of the followin g foods

toobtain the best supply of Vitamin B12?a.d airy product sb.vege tablesc. Grains

d.Brocc oli 15. Karen has been diagnose d with aplastic anemia. The

nurse monitors for chang es in which of the followin g physiolo gic

functions tendenc splenect ? iesd.Int omy.

a.Bowe l functi onb.Per ipheral sensatio nc.Blee ding

ake and out put 16. Lydia is schedule d for elective

Before the clients goes tosurger y, the nurse in

charge final assessm ent would be:a.sig ned con sentb.v ital

signsc. name b andd.e mpty bladder

age range in acquirin g acute lymphoc ytic 17. leukemi What is a the peak (ALL)?

a.4 to 12 years.b .20 to 3 0 years c.40 to 50 yearsd.

60 60 7 0 years 18. Marie with acute lymphoc ytic leukemi

a suffers from nausea and headach e.These clinical manifest ations

may indicate all of the followin g excepta. effects of radia tionb.c

hemoth erapy side effectsc .menin geal irr itationd .gastric

distensi on 19. A client has been diagnos ed with Dissemi nated

Intravas cular Coagula tion(DI C). Which of the followin g is

contrain dicated with the client?a. Admini stering Heparin b.Admi nisterin

g Couma dinc.Tr eating the underly ing caused. Replaci

ng deplete d blood p roducts 20. Which of the followin

g findings is the best indicatio n that fluid replace ment

for the client with hypovol emic shock is adequat e?a.Uri ne

output g reater th an 30ml /hr b.Re spirator y rate o f 21 breaths/ minutec

.Diastol ic blood pressure greater than 90 mmhgd. Systolic blood pressure

greater than 110 mmhg 21. Which of the followin g signs

and sympto ms would Nurse Mauree n include inteachi

ng plan as an early manifest ation of laryngea l cancer? a.Stom

atitisb. Airway obstruc tionc.H oarsen essd.D ysphag ia 22.

Karina a client with myasthe nia gravis is to receive immuno

suppress ivethera py. The nurse understa nds that this therapy is

effective because it:a.Pro motes th e removal of antib odies that imp

air the transmis sion of i mpulses b.Stimul ates the prod uction of acety

lcholine at the neur omuscul ar junct ion. c.Decre ases the producti

on of autoanti bodies that attack theacety lcholine receptor s.d.Inhi

bits the breakdo wn of acetylch oline at the neur omuscul ar juncti on.

23. A female client is receivin g IV Mannito l. An assessm

ent specific to safeadm inistratio n of the said drug is:a.Vit

al signs q4hb. Weighi ng dailyc. Urine output hourlyd .Level

of conscio usness q4h 24. Patricia a 20 year old college

student with diabetes mellitus requests addition al informat ion

about the advanta ges of using a pen like insulind elivery devices.

The nurse explains that the advanta ges of these deviceso ver

syringes includes :a.Accu rate dos e deliver yb.Shor ter injectio

n timec. Lower cost with reusable insulin cartridg esd.Use of

smaller gauge needle. 25. A male clients left tibia is fractures

in an automob ile accident , and a cast isapplie d. To assess

for damage to major blood vessels from the fracture tibia,the nurse in

charge should monitor the client for:a.S welling of the left thig

hb.Incre ased skin tempera ture of the footc.Pr olonged reperfus

ion of the toes after blanchi ngd.Inc reased blood pressur e

26. After a long leg cast is removed , the male client should:a

.Cleans e the leg by scrubbi ng with a brisk motionb .Put leg through

full range of moti on twice dailyc. Report any discomf

ort or stiffnes s to the physicia nd.Elev ate the leg when sitting

for long periods of time. 27. While performi ng a physical assessm

ent of a male client with gout of thegreat toe, NurseVi vian

should assess for addition al tophi (urate deposits ) onthe:a.

Buttoc ksb . E a rsc.Fa c e d.A bdome n 28. Nurse Katrina

would recogniz e that the demonst ration of crutch walking withtrip

od gait was understo od when the client places weight on

the:a.Pa lms of the hands and axillary regions b.Palm s of

the han dc.Axil lary reg ionsd.F eet, which are set apart 29.

Mang Jose with rheumat oid arthritis states, the only

time I am without pain iswhen I lie in bed perfectl y still.

During the convales cent stage, the nurse incharge with

Mang Jose should encoura ge:a.Act ive joint fle xion an

d extens ion b.Conti nued immobi lity until pain subside

sc.Rang e of moti on exer cises twice dailyd.F lexion exercise

s three times daily 30. A male client has undergo ne

spinal surgery, the nurse should:a .Observ e the clients bowel

movem ent and voiding patterns b.Logroll the client to prone position

c.Asses s the clients feet for sensatio n and circulati ond.Enc ourage

client to drink plenty o f 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 devel oping:a.

Hypov olemia b.renal failurec .metab olic acidosi sd.hype

rkalemi a 32. Nurse Judith obtains a specime n of

clear nasal drainage from a client with ahead injury. Which

of the followin g tests different iates mucus fromcer ebrospin al fluid

(CSF)?a .Protei nb.Spe cific gr avityc. Glucos ed.Mic roorga nism

33. A 22 year old client suffered from his first tonicclonic

seizure. Uponaw akening the client asks the nurse, What caused

me to have a seizure? Which of the followin g would the nurse

include in the primary cause of tonicclo nic seizures in adults more the

20 years?a. Electrol yte imb alanceb .Head t raumac .Epilep syd.Co

ngenita l defect 34. What is the priority nursing assessm ent in

the first 24 hours after admissi on of the client with thrombo

tic CVA?a. Pupil size and papillar y respons eb.chol esterol

levelc. Echoca rdiogra md.Bo wel sou nds 35. Nurse Linda is

preparin ga client with multiple sclerosis for discharg e from

thehospi tal to home. Which of the followin g instructi on is

most appropri ate?a.P ractice u sing the mechani cal aids that you will

need when futuredi sabilities arise.b. Follow good health habits

to chang e the course of the disease .c.Kee p active, use stress re

duction strategie s, and avoi d fatigu e.d.Yo u will need to accept

the nece ssity for a quiet and inactive lifestyle . 36.

The nurse is aware the early indicato r of hypoxia in the unconsc

ious client is:a.Cy anosis b.Incre ased respirat ions

c.Hyper tension d.Restle ssness 37. A client is experien cing spinal

shock. Nurse Myrna should expect the function of the bladder to be

which of the followin g?a.Nor malb.A tonicc. Spastic d.Unco ntrolled 38.

Which of the followin g stage the carcinog en is irreversi ble?a.Pr ogressio

n stageb.I nitiation stagec. Regress ion stag ed.Prom otion st age 39.

Among the followin g compone nts thorough pain assessme nt, which

is themost significa nt?a.Eff ectb . C a u s e c. Causing factorsd .Intensi ty

40. A 65 year old female is experien cing flare up of pruritus. Which of the

clientsa ction could aggravat e the cause of flare ups?a.Sl eeping in cool

and humidifi ed environ mentb.D aily baths with fragrant soapc.U

sing clothes made from 10 0% cottond. Increasi ng fluid intake 41.

Atropine sulfate (Atropin e) is contraind icated in all but one of the followin

gclient?a .A client with hig h bloodb. A client with bo wel obstructi onc.A

client with glaucom ad.A client with U.T.I 42. Among the

followin g clients, which among them is high risk for potential hazards from the

surgical experien ce?a.67year-old clientb. 49-yearold clientc. 33-yearold

clientd. 15-yearold client 43. Nurse Jon assesses vital signs on

a client undergon e epidural anesthesi a.Which of the followin g would the nurse

assess next?a. Headac heb.Bla dder distensi onc.Diz zinessd. Ability

to move legs 44. Nurse Katrina should anticipat e that all of the followin

g drugs may be used inthe attempt to control the symptom s of

Meniere' s disease except:a. Antiem etics b.Diure ticsc.A ntihista minesd.

Glucoco rticoids 45. Which of the followin g complica tions associate

d with tracheost omy tube?a.I ncreased cardiac outputb. Acute respirato ry

distress syndrom e (ARDS) c.Increa sed blood pressure d.Dama ge to

laryngea l nerves 46. Nurse Faith should recogniz e that fluid shift in

an client with burn injury resultsfro m increase in the:a.Tot al

volume of circulati ng whol e bloodb. Total volume of intravas

cular plasmac. Permeab ility of capillar y wallsd.P ermeabil ity of ki

dney tub ules 47. An 83year-old woman has several ecchymo tic areas

on her right arm. Thebruis es are probably caused by:a.incr eased capillary

fragility and permeab ilityb.in creased blood su pply to the skinc.sel f

inflicted injuryd. elder ab use 48. Nurse Anna is aware that early adaptatio

n of client with renal carcinom a is:a.Nau sea and vomitin gb.flan

k painc. weight gaind.in termitte nt hemat uria 49. A male client with

tuberculo sis asks Nurse Brian how long the chemoth erapymu st be continue

d. Nurse Brians accurate reply would be:a.1 to 3 weeks b.6 to 12

months c.3 to 5 mont hsd.3 years an d more 50. A client has undergon

e laryngect omy. The immediat e nursing priority wouldbe: a.Keep t rachea fr

ee of sec retionsb. Monitor for signs of infectio nc.Provi de emotion al

supportd .Promot e means of comm unicatio n ANSWE RS AND RATIO NALE

MEDIC AL SURGI CAL NURSI NG 1. C . Glucocor

ticoids (steroids) are used for their antiinflamm atory action, whichde creases

the develop ment of edema. 2. A . The blood must be stopped

at once, and then normal saline should beinfuse d to keep the line patent and

maintain blood volume. 3. B . These tests confirm the presence

of HIVa ntibodies that occur in responset o the presence of the human immuno

deficienc y virus (HIV). 4. D . One cup of cottage cheese contains

approxi mately 225 calories, 27 g of protei n, 9 g of fat, 30 mg cholester

ol, and 6 g of carbohyd rate. Proteins of high biologic value (HBV) contain

optimal levels of amino acids essential for life. 5. A . Elevatio

n of uremic waste products causes irritation of the nerves, resultingi n

flapping hand tremors. 6. B . This indicates that the bladder is

distende d with urine, therefore palpable. 7. C . Elevatio n

increases lymphati c drainage, reducing edema and pain. 8. B

. Detectio n of myoglob in is a diagnosti c tool to determin e whether

myocardi al damage has occurred. 9. D . When mitral stenosis i

s present, the left atrium has diffic ulty emptying itsconten ts into the left ventricle

because there is no valve to prevent back wardflo w into the pulmona

ry vein, the pulmona ry circulatio n is under pressure. 10. A

. Managin g hyperten sion is the priority for the client with

hyperten sion.Clie nts with hyperten sion frequentl y do not experien ce pain, deficient

volume,o r impaired skin integrity. It is the asympto matic nature of hyperten

sion thatmake s it so difficult to treat. 11. C . Because of its

widespre ad vasodilat ing effects, nitroglyc erin oftenpro duces side

effects such as headache , hypotens ion and dizziness .12.A. An increased

in LDL cholester ol concentr ation has been documen ted atrisk factor for the

develop ment of atheroscl erosis. LDL cholester ol is notbroke n down into the

liver but is deposite d into the wall of the blood vessels. 13. D

. There is a potential alteration in renal perfusion manifest ed by decrease durine

output. The altered renal perfusion may be related to renal arteryem bolism,

prolonge d hypotens ion, or prolonge d aortic crossclamping duringth

e surgery. 14. A . Good source of vitamin B12 are dairy products

and meats. 15. C . Aplastic anemia decrease s the bone

marrow producti on of RBCs, whiteblo od cells, and platelets. The client is

at risk for bruising and bleedingt endencie s. 16. B.

An elective procedur e is schedule d in advance so that all preparati

ons canbe complete d ahead of time. The vital signs are the final check that must

becompl eted before the client leaves the room so that continuit y of care andasses

sment is provided for. 17. A . The peak incidenc e of Acute

Lympho cytic Leukemi a (ALL) is 4 years of age. It is uncomm on after

15 years of age. 18. D . Acute Lympho cytic Leukemi a (ALL) does not

cause gastric distentio n. Itdoes invade the central nervous system, and

clients experien ce headache sand vomiting from meninge al irritation.

19. B . Dissemin ated Intravasc ular Coagulat ion (DIC)

has not been found torespon d to oral anticoag ulants such as Coumadi n.

20. A . Urine output provides the most sensitive indicatio n of the clients

responset o therapy for hypovole mic shock. Urine output should be

consisten tly greater th an 30 to 35 mL/hr. 21. C . Early warning

signs of laryngeal cancer can vary dependin g on tumor lo cation. Hoarsene ss lasting

2 weeks should be evaluate d because it is oneof the most common

warning signs. 22. C . Steroids decrease the bodys immune response

thus decreasin g theprodu ction of antibodie s that attack the acetylch

oline receptors at theneuro muscular junction 23. C . The osmotic

diuretic mannitol is contraind icated in the presence of inadeq uate renal

function or heart failure because it increases theintrav ascular volume that must

be filtered and excreted by the kidney. 24. A . These devices

are more accurate because they are easily to used andhave improve d adherenc

e in insulin regimens by young people because themedic ation can be administ

ered discreetl y. 25. C . Damage to blood vessels may

decrease the circulato ry perfusion of thetoes, this would indicate

the lack of blood supply to the extremit y. 26. D. Elevatio n will

help control the edema that usually occurs. 27. B.

Uric acid has a low solubility , it tends to precipitat e and form deposits atvarious

sites where blood flow is least active, including cartilagin ous tissuesuc

h as the ears. 28. B . The palms should bear the clients weight to

avoid damage to the nerves inthe axilla. 29. A . Active exercises

, alternatin g extensio n, flexion, abductio n, and adductio n,mobiliz

e exudates in the joints relieves stiffness and pain. 30. C.

Alteratio n in sensation and circulatio n indicates damage to the spinal

cord,if these occurs notify physicia n immediat ely. 31. A

. In the diuretic phase fluid retained during the oliguric phase is excreted

and may reach 3 to 5 liters daily, hypovole mia may occur and fluids should

bereplac ed. 32. C . The constitue nts of CSF are similar to those of

blood plasma. Anexami nation for glucose content is done to determin

e 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

neoplas ms,withd rawal from drugs and alcohol, and vascular disease.

34. A . It is crucial to monitor the pupil size and papillary response to

indicatec hanges around the cranial nerves. 35. C . The nurse

most positive approach is to encourag e the client with multiples clerosis

to stay active, use stress reduction techniqu es and avoid fatiguebe cause it is

importan t to support the immune system while remainin g active. 36.

D . Restless ness is an early indicato r of hypoxia. The

nurse should suspecth ypoxia in unconsc ious client who

suddenl y becomes restless. 37. B . In spinal shock,

the bladder becomes complet ely atonic and will continue to fill

unless the client is catheteri zed. 38. A . Progress

ion stage is the change of tumor from the preneopl astic state

or low degree of maligna ncy to a fast growing tumor that

cannot be reversed . 39. D . Intensity is the

major indicativ e of severity of pain and it is importa nt for theevalu

ation of the treatmen t. 40. B. The use of fragrant

soap is very drying to skin hence causing the pruritus. 41.

C. Atropin e sulfate is contrain dicated with glaucom a

patients because itincreas es intraocu lar pressure . 42.

A . A 67 year old client is greater risk because the older adult

client is morelik ely to have a lesseffective immune system. 43.

B . The last area to return sensatio n is in the perineal area,

and the nurse incharge should monitor the client for distende

d bladder. 44. D . Glucoco rticoids play no significa

nt role in disease treatmen t. 45. D . Tracheo

stomy tube has several potential complic ations includin g bleeding

,infectio n and laryngea l nerve damage. 46. C . In burn,

the capillari es and small vessels dilate, and cell damage cause

therelea se of a histamin e-like substanc e. The substanc e causes the

capillary walls to become more permeab le and significa nt quantitie

s of fluid are lost. 47. A . Aging process involves increase

d capillary fragility and permeab ility. Older ad ults have a

decrease d amount of subcuta neous fat and cause an increase

dinciden ce of bruise like lesions caused by collectio n of

extravas cular blood inloosel y structure d dermis. 48.

D . Intermitt ent pain is the classic sign of renal carcino

ma. It is primaril y due tocapilla ry erosion by the cancero

us growth. 49. B. Tubercl e bacillus is a drug resistant

organis m and takes a long time to beeradic ated. Usually a

combina tion of three drugs is used for minimu m of 6months and at

least six months beyond culture conversi on. 50. A.

Patent airway is the most priority; therefor e removal of

secretio ns isnecess ary.

PSYCH IATRIC NURSI NG

1.Marco approach ed Nurse Trish asking fo r advice on how to deal with hisalcoh

ol addiction . Nurse Trish should tell the client that the only effectivet

reatment for alcoholis m is:a.Psy chother apyb.Al coholics anonym ous

(A.A.)c. Total ab stinence d.Avers ion Ther apy2.Nu rse Hazel is caring for a

male client who exp erience false sen soryperc eptions with no basis in reality.

This perceptio n is known as:a.Hal lucinati onsb.De lusions c.Loose associat

ionsd.N eologis ms3.Nur se Monet is caring for a female client who has suici

dal tende ncy.Whe n accompa nying the client to the restroom, Nurse Monet

should a.Give h er privacy b.Allow her to urinatec .Open the window

and allow her to get some fresh air d.Ob serve her 4.

Nurse Maureen is developi ng a plan of care for a female client withanor

exia nervosa. Which action should the nurse include in the plan?a.P rovide

privacy during mealsb. Set-up a strict eating plan for the clientc.E ncourag

e client to exercise to reduce anxietyd .Restrict visits with the family5.

A client is experien cing anxiety attack. The mos t appropri ate

nursingi nterventi on should include? a.Turnin g on the televisio nb.Leav ing the

client alonec.S taying with the client and speaking in short sentence sd.Ask

the client to play with other clients6. A female cl ient is admitted

with a diagnosi s of delusi ons of GRAND EUR.Thi s diagnosis reflects a

belief that one is:a.Bei ng Kille db.High ly famous and importa ntc.Resp

onsible f or evil worldd. Connect ed to client unrelate d to onesel f 7.A

20 year old client wa s diagnose d with depende nt person ality disorder.

Which behavior is not likely to be evidence of ineffecti ve individua

l coping?a .Recurre nt selfdestructi ve behavior b.Avoid ing relat ionshipc

.Showin g interest in solitary activitie sd.Inabil ity to make choices

and decision without advise8. A male clie nt is diagnose d with schizoty

pal personali ty disord er. Whic hsigns would this client exhibit during

social situation ? a.Paran oid thought sb.Emot ional affectc.I ndepend

ence ne edd.Agg ressive behavior 9.Nurse Claire is caring for a client diagnose

d with bulimia. The mostappr opriate initial goal for a client diagnose d with

bulimia is?a.Enc ourage to avoid foodsb.I dentify a nxiety c ausing si tuations c.Eat

only thr ee meals a dayd.Av oid shoppin g plenty of grocerie s10.

Nurse Tony was caring for a 41 year old female client. Which behavior

bythe client indicates adult cognitive develop ment?a. Generat es new levels

of aware nessb.As sumes re sponsibi lity for her actio nsc.Has maximu m ability to solve

problem s and learn new skillsd.H er perce ption are based on reality11 .A

neuromu scular blocking agent is administ ered to a client before ECTther apy. The

Nurse should carefully observe the client for?a.Re spirator y difficult iesb.Na

usea and vomitin gc.Dizz iness d. Seizures 12.A 75 year old client is

admitted to the hospital with the diagnosis of demen tia of the Alzheim ers type and

depressio n. The symptom that isunrelat ed to depressio n would be?a.Ap athetic

response to the environ mentb.I dont kn ow answer t o question sc.Shall

ow of la bile effectd. Neglect of personal hygiene 13.Nurse Trish is working

in a mental health facility; the nurse priority nursingin terventio n for a newly

admitted client with bulimia nervosa would be to?a.Tea ch client to measure

I& Ob.Invol ve client in planni ng daily mealc.O bserve client du ring mealsd.

Monitor client continuo usly14.N urse Patricia is aware that the major health

complica tion associate d withintra ctable anorexia nervosa would be?a.Car

diac dysrhyth mias resulting to cardiac arrestb. Glucose intoleran ce resulti

ng in pro tracted hypogly cemiac. Endocri ne imbalan ce causing cold

amenorr head.De creased metaboli sm causing cold intoleran ce15.Nu rse Anna

can minimiz e agitation in a disturb ed client by?a.Inc reasing stimulat

ionb.lim iting unn ecessary interacti onc.incr easing appropri ate sensory percepti

ond.ensu ring constant client and staff contact 16.A 39 year old mother

with obsessiv ecompulsi ve disorder has becomei mmobili

zed by her elaborate hand washing and walking rituals. NurseTri

sh recogniz es that the basis of O.C. disorder is often:a.P roblems

with being too conscien tiousb.Pr oblems with anger and

remorse c.Feelin gs of gui lt and in adequac yd.Feeli ng of unworth iness

and hopeless ness17. Mario is complain ing to other clients about not

being allowed by staff tokeep food in his room. Which of the followin

g intervent ions would be mostappr opriate?a .Allowin ga snack to

be kept in his roomb.R epriman ding the clientc.I gnoring the clients

behavior d.Settin g limits on the behavior 18.Conn ey with borderlin e

personali ty disorder who is to be discharg e soonthre atens to

do somethin g to herself if discharg ed. Which of the followin

gactions by the nurse would be most importan t?a.Ask a family member

to stay with the client at home te mporaril yb.Discu ss the meaning

of the clients statemen t with her c.Re quest an immedia te extensio

n for the clientd.I gnore the clients statemen t because i ts a sign

of manip ulation1 9.Joey a client with antisocia l personali ty

disorder belches loudly. A staff member asks Joey, Do you know

why people find you repulsive ? thisstate ment most likely

would elicit which of the followin g client reaction? a.Depen sivenes

sb.Emb arrassm entc . S h a m e d.R emorsef ulness20 .Which of the followin

g approach es would be most appropri ate to use witha client suffering

from narcissist ic personali ty disorder when discrepa nciesexis

t between what the client states and what actually exist?a. Rational

izationb .Support ive confront ationc.L imit sett ingd.Co nsistenc y21.Cely

is experien cing alcohol withdraw al exhibits tremors, diaphore

sis andhyper activity. Blood pressure is 190/87 mmhg and pulse is 92

bpm. Whichof the medicati ons would the nurse expect to administ

er?a.Nal oxone (Narcan )b.Benzl ropine (Cogenti n)c.Lora zepam (Ativan)

d.Halop eridol ( Haldol) 22.Whic h of the followin g foods would the nurse

Trish eliminate from the dietof a client in alcohol withdraw al?a . M i l k b.Ora

nge Juic Nurse Hazel e expect to c.Soda assess d.Regul for a ar Coffe clientwh e23.Whi o is ch of the exhibitin followin g late g would signs of

heroin withdraw al?a.Ya wning & diaphor esisb.Re stlessne ss & Irritabili tyc.Con

stipation & steatorr head.Vo miting a nd Diarrhea 24.To establish open and

trusting relations hip with a female client who hasbeen hospitali zed with severe

anxiety, the nurse in charge should?a .Encoura ge the staff to have frequent interacti

on with the clientb.S hare an activity with the clientc. Give client fe edback

about be havior d. Respect clients need for personal space 25. Nurse Monette

recogniz es that the focus of enviro nmental (MILIE U)therap yis to:a.Man ipulate

the envir onment to bring about positive changes inbehavi or b.Allo w the clients

freedom to deter mine whether or not they will beinvolv ed in activities c.Role p

lay life events to meet i ndividua l needsd. Use natural r emedies rather

than drugs to contro l behavio r 26.Nurs e Trish would expect a child with a

diagnosis of reactive attachme ntdisorde r to:a.Hav e more positive relation

with the father than the mother b .Cling to mothe r& cry on separati onc.Be

able to develop only superfici al relation with the othersd. Have been

physical ly abuse27. When teaching parents about childhoo d depressio

n Nurse Trina shouldsa y?a.It may appear acting out behavior b.Does

not respond to conventi onal treatmen tc.Is short in durati on &

resolves easilyd. Looks almost identical to adult depressi on28.Nu rse Perry is aware

that language develop ment in autistic childrese mbles:a. Scannin g speec hb.Spee

ch lagc. Shutteri ngd.Ec holalia2 9.A 60 year old female client who lives

alone tells the nurse at thecomm unity health center I really dont need

anyone to talk to. The TV ismy best friend. The nurse recogniz es that

the client is using the defense mechanis m known as?a.Dis placeme ntb.Proj ection

c.Subli mation d.Deni al30.W hen working with a male client

sufferin g phobia about black cats, NurseTr ish should anticipat

e that a problem for this client would be?a.An xiety w hen discussi

ng phobiab .Anger toward the feared objectc. Denyin g that

the phobia existd. Distorti on of reality when complet ing

daily routines 31.Lind a is pacing the floor and appears extremel

y anxious. The duty nurseap proache s in an attempt to

alleviate Lindas anxiety. The mostther apeutic question by the nurse

would be?a.W ould you like to watch TV?b. Would you like

me to talk with you?c. Are you feeling upset now?d. Ignore t

he client32 .Nurse Penny is aware that the sympto ms that distingui

sh post traumati cstress disorder from other anxiety disorder would

be:a.Av oidance of situatio n& certain activitie s that rese

mble the stressb. Depress ion and a blunte d affect when di scussing

the trau maticsit uationc. Lack of interest in family & other sd.Re-

experie ncing the trauma in dreams or flashbac k33.Nur

se Benjie is commun icating with a male client with substanc

einduced persistin g dementi a; the client cannot rememb

er facts and fills in the gapswit h imagina ry informat ion.

Nurse Benjie is aware that this is typical of?a.Fli ght of ideasb.

Associa tive loosene ssc.Con fabulat iond.C oncreti sm34.N urse

Joey is aware that the signs & sympto ms that would be mostspe

cific for diagnosi s anorexia are?a.Ex cessive weight l oss, am enorrhe

a & abdo minal distensi onb.Slo w pulse, 10% weight loss &

alopecia c.Comp ulsive behavio r, excessi ve fears & nausead

.Excessi ve activity, memory lapses & an increase d pulse35.

A characte ristic that would suggest to Nurse Anne that an

adolesce nt mayhav e bulimia would be:a.Fre quent regurgit

ation & reswallow ing of foodb.P revious history of gastri tisc.Ba

dly stained teethd. Positiv e body image3 6.Nurse Monette is aware

that extremel y depresse d clients seem to do bestin settings

where they have:a. Multipl e stimu lib.Rou tine Activiti esc.Min

imal decisio n makin g d.Varie d Activiti es37.To further

assess a clients suicidal potential . Nurse Katrina should beespeci ally alert

to the client expressi on of:a.Fru stration & fear of deathb.

Anger & resentm entc.An xiety & lonelin essd.He lplessne ss

& hopel essness 38.A nursing care plan for a male client with

bipolar I disorder should include: a.Provi ding a structur ed envir onment

b.Desig ning activitie s that will require the clien t to maintai

n contact with realityc. Engagin g the client in convers ing

about current affairsd. Touchin g the client provide assuran ce39.W

hen planning care for a female client using ritualisti c behavior

, NurseGi na must recogniz e that the ritual:a. Helps the

client focus on the inabilit y to deal with realityb. Helps

the client c ontrol the anxiety c.Is under th e client s consci

ous controld .Is used by the client primaril y for seconda ry

gains40. A 32 year old male graduate student, who has become increasi

nglywit hdrawn and neglectf ul of his work and personal hygiene,

is brought tothe psychiat ric hospital by his parents. After

detailed assessm ent, adiagno sis of schizop hrenia is made. It is

unlikely that the client willdem onstrate: a.Low self esteem b.Conc

rete thinkin gc.Effe ctive self bounda riesd. Weak ego41.

A 23 year old client has been admitted with a diagnosi s of schizop

hreniasa ys to the nurse Yes, its march, March is little woman . Thats

literal youkno w. These stateme nt illustrate :a.Neol ogisms

b.Echo laliac.F light of ideasd. Looseni ng of asso ciation4 2.A long

term goal for a paranoid male client who has unjustifi ably

accused his wife of having many extrama rital affairs would

be to help the clientde velop:a. Insight into his behavio r b.Bett er self

control c.Feeli ng of self worthd. Faith in his wif e43.A male

client who is experien cing disorder ed thinking about food

beingpoi soned is admitted to the mental health unit. The nurse

uses whichco mmunic ation techniqu e to encoura ge the client to

eat dinner?a .Focusi ng on selfdisclosu re of own food

preferen ce b.Using open ended questio n and silencec .Offerin

g opinion about the need to eatd. Verbali zing reasons

that the client may not choose to eat44.N urse Nina is assigned

to care for a client diagnos ed with Catatoni cStupor. 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 questio ns to encoura ge

talkingb .Rake the client into the dayroo m to be with other

clientsc. Sit beside the client in silence and occasio nally as

k openendedqu estiond. Leave the client alone an d continu

e with providin g care to the other cli ents45. Nurse Tina is caring

for a client with delirium and states that look at thespide

rs on the wall. What should the nurse respond to the client?a.

Youre having hallucin ation, there are no spiders in this room

at allb. I can see the spiders on the wall , but they are

not goin g to hurtyou c.Wo uld you like me to kill the spiders

d.I know y ou are frigh tened, but I do not see spid ers on

the wall46. Nurse Jonel is providin g informat ion to a commun

ity group about violence in the family. Which stateme nt by a

group member would indicate a needto provide addition al informat

ion?a. Abuse occurs more in lowincome families b.Ab user

Are often jealous or selfcentere dc.Ab user use fear an d intimi

dation d.Abus er usually have poor selfesteem 47.Duri

ng electroc onvulsiv e therapy (ECT) the client receives

oxygen bymask via positive pressure ventilati on. The nurse assisting

with thisproc edure knows that positive pressure ventilati on is

necessar y because ?a.Anes thesia is adminis tered during the

procedu reb.Dec rease oxygen to the brain increase s confusi

on anddisor ientation c.Grand mal seizure activity depress es

respirati onsd.M uscle rel axations given to preve nt injury during seizure

activity depress respirati ons.48. When planning the discharg e of a

client with chronic anxiety, Nurse Chrisev aluates achieve ment of

the discharg e mainten ance goals. Which goalwou ld be

most appropri ately having been included in the plan of carerequ

iring evaluati on?a.Th e client eliminat es all anxiety from daily

situatio nsb.The client ignores feelings of anxiety c.The client

identifi es anxiety produci ng situatio nsd.The client maintai

ns contact with a crisis counsel or 49.N urse Tina is caring

for a client with depressi on who has not respond ed toantide

pressant medicati on. The nurse anticipat es that what treatmen tprocedu

re may be prescrib ed a.Neuro leptic medicat ionb.Sh ort term

seclusi onc.Psy chosur geryd.E lectroco nvulsiv e therap y50.Ma rio is a

dmitted to the e mergen cy roo m with druginclude d anxiet yrelated

to over ingestio n of prescrib ed antipsyc hotic medicati on. The

mostim portant piece of infor mation the nurse in charg e should

obtain initially isthe:a. Length of time on the med.b. Name of the

ingested medicat ion & the amount ingested c.Reaso n for the

suicide attempt d.Name of the nearest relative & their phone number

ANSWE RS AND RATIO NALE PSYCH IATRIC NURSI NG 1. C

. Total abstinenc e is the only effective treatment for alcoholis m 2.

A . Halluci nations are visua l, auditory, gustatory , tactile or olfact oryperce

ptions that have no basis in reality. 3. D . The Nurse has a responsi

bility to observe continuo usly the acutely suicidalc lient. The Nurse should

watch for clues, such as communi cating suicidalt houghts, and messages ;

hoarding medicati ons and talking about death. 4. B. Establish ing a

consisten t eating plan and monitori ng clients weight areimpor tant to

this disorder. 5. C . Appropri ate nursing intervent ions for

an anxiety attack include using shortsent ences, staying with the client,

decreasin g stimuli, remainin g calm andmedi cating as needed. 6. B

. Delusion of grandeur is a false belief that one is highly famous

andimpo rtant. 7. D . Individu al with depende nt personali

ty disorder typically showsind ecisivene ss submi ssiveness and cling ing behavior

so that ot hers will make decisions with them. 8. A . Clients with

schizoty pal personali ty disorder experien ce excessiv e socialanx

iety that can lead to paranoid thoughts 9. B . Bulimia disorder generally

is a maladapt ive coping response to stress andunder lying issues. The

client should identify anxiety causing situation thatstimu late the bulimic behavior

and then learn new ways of coping with theanxiet y. 10. A

. An adult age 31 to 45 generates new level of awarenes s. 11. A

. Neuromu scular Blocker, such as SUCCIN YLCHO LINE (Anectin e)produc

es respirato ry depressio n because it inhibits contracti ons of respirato

rymuscle s. 12. C . With depressio n, there is little or no emotiona

l involvem ent therefore littlealter ation in affect. 13. D

. These clients often hide food or force vomiting ; therefore they must

becareful ly monitore d. 14. A . These clients have severely

depleted levels of sodium and potassiu mbecaus e of their starvatio n diet and

energy expendit ure, these electrolyt es areneces sary for cardiac

functioni ng. 15. B . Limiting unnecess ary interactio n will

decrease stimulati on and agitation. 16. C . Ritualisti c behavior

seen in this disorder is aimed at controlli ng guilt andinade quacy by maintaini

ng an absolute set pattern of behavior. 17. D . The nurse

needs to set limits in the clients manipula tive behavior to helpthe client

control dysfuncti onal behavior. A consisten t approach by the staff

isnecessa ry to decrease manipula tion. 18. B . Any suicidal statemen

t must be assessed by the nurse. The nurse shoulddi scuss the clients statemen

t with her to determin e its meaning in terms of suicid e. 19. A

. When the staff member ask the client if he wonders why others find

himrepul sive, the client is likely to feel defensiv e because the question

isbelittlin g. The natural tendency is to counterat tack the threat to self image.

20. B . The nurse would specifica lly use supportiv e confront

ation with the client topoint out discrepa ncies between what the client

states and what actuallye xists to increase responsi bility for self. 21. C

. The nurse would most likely administ er benzodia zepine, such as

lorazepa n(ativan) to the client who is experien cing symptom : The clients

experien cessympt oms of withdraw al because of the rebound phenome non

when thesedati on of the CNS from alcohol begins to decrease. 22. D

. Regular coffee contains caffeine which acts as psychom otor stimulant sand

leads to feelings of anxiety and agitation. Serving coffee top the clientma

y add to tremors or wakefuln ess. 23. D . Vomitin g and

diarrhea are usually the late signs of heroin withdraw al,along with muscle

spasm, fever, nausea, repetitive , abdomin al cramps andbacka che.

24. D . Moving to a clients personal space increases the feeling

of threat, whichinc reases anxiety. 25. A . Environ mental (MILIE

U) therapyai ms at having everythin g in the clientss urroundi ng area toward

helping the client. 26. C . Children who have experien

ced attachme nt difficulti es with primaryc aregiver are not able to trust

others and therefore relate superfici ally 27. A . Children

have difficulty verbally expressin g their feelings, acting outbehav ior, such as

temper tantrums, may indicate underlyi ng depressio n. 28. D

. The autistic child repeat sounds or words spoken by others. 29.

D . The client statemen t is an example of the use of denial, a defense

thatblock s problem by unconsci ous refusing to admit they exist

30. A . Discussi on of the feared object triggers an emotiona

l response to theobject . 31. B . The nurse presence

may provide the client with support & feeling of contro l. 32. D

. Experien cing the actual trauma in dreams or flashbac k is the major sy

mptom that distingui shes post traumatic stress disorder from other

anxietydi sorder. 33. C . Confabul ation or the filling in of

memory gaps with imaginar y facts is adefense mechanis m used by people

experien cing memory deficits. 34. A . These are the major signs of

anorexia nervosa. Weight loss is excessiv e(15% of expected weight) 35. C

. Dental enamel erosion occurs from repeated selfinduced vomiting .

36. B . Depressi on usually is both emotiona l& physical.

A simple daily routine isthe best, least stressful and least anxiety

producin g. 37. D . The expressio n of these feeling may

indicate that this client is unable tocontinu e the struggle of life. 38. A

. Structure tends to decrease agitation and anxiety and to increase theclient

s feeling of security. 39. B . The rituals used by a client with

obsessiv e compulsi ve disorder helpcontr ol the anxiety level by maintaini

ng a set pattern of action. 40. C .A person with this disorder would

not have adequate selfboundari es 41.

ons are thoughts that are presente d without D the . Loose logicalc associati onnectio

ns usually necessar y for the listening to interpret the

message . 42. C . Helping the client to develop

feeling of self worth would reduce the clientsn eed to use

patholog ic defenses . 43. B . Open ended question

s and silence are strategie s used to encoura geclient s to discuss

their problem in descripti ve manner. 44. C

. Clients who are withdra wn may be immobil e and mute, and

requirec onsisten t, repeated interven tions. Commu nication with

withdra wn clientsre quires much patience from the nurse. The

nurse facilitate s commun icationw ith the client by sitting in silence,

asking openended question and pausingt o provide opportu

nities for the client to respond. 45. D . When hallucin ation is

present, the nurse should reinforc e reality with theclient .

46. A . Person al characte ristics of abuser include low self-

esteem, immatur ity,depe ndence, insecurit y and jealousy . 47.

D . A short acting skeletal muscle relaxant such as succinyl choline

(Anectin e)is administ ered during this procedu re to prevent

injuries during seizure. 48. C . Recogni zing situation

s that produce anxiety allows the client to prepare tocope with

anxiety or avoid specific stimulus . 49. D . Electroc

onvulsiv e therapy is an effective treatmen t for depressi on that

hasnot respond ed to medicati on 50. B . In an emergen

cy, lives saving facts are obtained first. The name and theamou

nt of medicati on ingested are of outmost importa nt in treating

thispote ntially life threateni ng situation .