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JUNE, 2007 NLE NP4

Situation 1- Patrick works as an ER nurse and at times attends to ambulance calls. 1. During an external disaster many patients were injure. Using principles of triage, Patrick initiates immediate care for a client with which of the following injuries? A. Bright red bleeding from a neck wound B. Penetrating abdominal injury C. Fractured tibia D. Open massive head injury in deep coma Answer: B Rationale: ER: Option A: The client with arterial bleeding from a neck wound is in immediate need of treatment to save the clients life. This client is classified as such and would wear a color tag of red from the triage process. Option B: A client with a penetrating abdominal injury would be tagged yellow and classified as delayed, requiring interventions within 30 to 60 minutes. Option C: A green or minimal designation would be given to the client with fractured tibia who requires intervention but who can provide self-care if needed. Option D: a designation of expectant would be applied to the client with massive injuries and minimal chance of survival. This client would be coded black in the triage process. He is given supportive care and pain management but is given definitive treatment last. Source: Saunders 2nd ed. by Silvestri Field: Red- emergent Yellow- immediate Green- urgent Blue- fast track, psychological Black-dead 2. One Sunday, one of the churchgoers fainted. The skin looks very pale. Which of the following measures should Patrick initiate? A. Reassure casually and encourage to stay lying until fully recovered B. Loosen tight clothing at the neck and waist C. Raise the legs casually, use a bench or ask the onlookers to give support D. Gradually help the person casually to stand up Answer: B Rationale: If someone else faints: 1. Position the person on his or her back. Make sure the legs are elevated, if possible above the heart level. 2. Check the person's airway to be sure it's clear. Watch for vomiting. 3. Check for signs of circulation (breathing, coughing or movement). If absent, begin CPR. Call 911 or your local emergency number. Continue CPR until help arrives or the person responds and begins to breathe. 4. Help restore blood flow. If the person is breathing, restore blood flow to the brain by raising the person's legs above the level of the head. Loosen belts, collars or other constrictive clothing. The person should revive quickly. If the person doesn't regain consciousness within one minute, dial 911 or call for emergency medical assistance. Since the main problem is that the skin looks very pale, it is important to restore blood flow. Option A: This does not address the problem which is the skin looks pale. Staying in a lying position until recovered without loosening the tight clothing and raising the legs may took a long time for the patient to recover or the skin to turn pink again. Option C and D: the person should be positioned on his back with legs elevated above the heart level. Source: http://www.mayoclinic.com/health/first-aid-fainting/FA00052 3. He responded to a vehicular accident along the highway. The following are the principles for safety lifting to be observed in this situation, EXCEPT: A. Bend on his knees B. Ensure a good grip, using the whole hands C. Keep his back bend D. Keep his feet apart with one foot slightly in front of another Answer: C Rationale:

When standing: Wear shoes. They protect your feet from injury, give you a firm foundation, and keep you from slipping. Keep your feet flat on the floor separated about 12 inches (30 cm). Keep your back straight. When walking: Keep your back straight as you walk. If helping a person to walk you may need one arm around the back of the person. Put the other arm at the side or ready to help the person if needed. When lifting an object: Your feet should be apart, in a standing position. Keep your back straight. Lower your body to get close to the object. Bend from your hips and knees. DO NOT bend at the waist. When turning, rotate your whole body, not just your back. Hold the object by putting your hands around it. Keeping your knees bent and your back straight, lift the object using your arm and leg muscles. Do not use your back muscles. If the object is too heavy ask another person to help you. Many devices are available to help move or lift heavy objects. If you need help from a device, ask caregivers how to get one. When carrying an object: Hold the object close to your body. DO NOT carry things that are too heavy for you. Always ask for help to move heavy objects. There are many devices available to help carry heavy objects. If you need help from a device, ask caregivers how to get one. Pushing or pulling: Use the weight of your body to help push or pull an object. Your feet should be apart as in the standing position. Keep your back straight. Lower your body to get close to the object. Bend from your hips and knees. DO NOT bend at the waist. If the object or person you are pulling or pushing is too heavy ask someone to help you. There are many devices available to help you move, push or pull heavy objects. If you need help from a device, ask caregivers how to get one. Source:http://www.healthtouch.com/bin/EContent_HT/cnoteShowLfts.asp? fname=02555&title=USING+GOOD+BODY+MECHANICS+&cid=hthlth 4. A client is brought to the emergency room following a burn injury. In assessment the nurse notes that the clients eyebrow and nasal hairs are singed. The nurse would identify this type of burn as: A. thermal B. electrical C. radiation D. chemical Answer: A Rationale: Exposure to or contact with flames, hot liquids, or hot objects causes thermal burns. Thermal burns are those sustained in residential fires, explosive accidents, scald injuries, or ignition of clothing or liquids. If the nurse notes facial burns or singed eyebrow or nasal hairs, the victim likely experienced the burn in an enclosed smoke filled space such as in a residential fire. Option B: Electrical burns are caused by heat that is generated by the electrical energy as it passes through the body. Option C: Radiation burns are caused by exposure to a radioactive source. Option D: Chemical burns are caused by tissue contact with strong acids, alkalis, or organic compounds. Source: Saunders Q&A NCLEX Review 3rd edition Situation 2- Nurse JC is on duty when a mother came to the clinic asking for an injection for her son was bitten by a dog. 5. A. B. C. D. Which of the following should be done by nurse JC? Refer to the municipal health office Ask about the history of the incident Wash the wound with soap and water Immediately inject anti rabies medicine

Answer: B Rationale: The nurse should be able to follow the nursing process. Assessment should always be a priority. This is to establish a database about the clients response to health concerns or illness and the ability to manage health care needs. The activities included in assessment are: obtain a nursing health history, conduct physical assessment, review clients record, consult support persons, and consult health professionals. Option A: Nurses should not pass the back. It is important to obtain history and implement Nursing intervention to the patient. Options C: This is under implementation. Implementing is to assist the client to meet desired goals/outcomes; promote wellness, prevent illness and disease; restore health; and facilitate coping with altered functioning. Option D: Immediately injecting anti rabies medicine without the doctors order can place the nurse to be liable of malpractice. 6. A. B. C. D. When assessment has been completed and nurse JC saw the wound, he should: Wash the wound with soap and water Ask prescription from the doctor Apply ointment and dress the wound Ask for immunoglobulin

Answer: A Rationale: Before anything else, it is important that the wound must be washed with soap and water immediately and thoroughly. Antiseptics such as povidone iodine or alcohol may be done. Option B: This may be done after wound care. The patient may be given antibiotics and anti-tetanus treatment. Option C: There is usually no ointment applied and the wound may be left open Option D: The post-exposure treatment is given to persons who are exposed to rabies. Passive immunizationthe process of giving an antibody to the persons (with head and neck bites, multiple single deep bites, contamination of mucous membranes) in order to provide immediate protection against rabies which should be administered within the first seven days of active immunization. The effect of immunoglobulin is short term. Source: Public Health Nursing in the Philippines page 290. 7. A. B. C. D. In the nurse health teaching, which of the following is included? Observe the dog for 14 days Report to authorities Kill the dog immediately Give the dog immunization immediately

Answer: A Rationale: The maximum infectious stage of rabies in dogs and cats is ten days. If a dog or cat remains healthy for 10 days after biting a person, it is safe to assume that rabies was not transmitted. This quarantine/observation period is extended to 14 days for dogs and cats when the bite occurs in a country with endemic canine rabies. Option B: Although it is important to report to authorities, it is much more important to quarantine or observe the dog for 14 days. Option C: Killing the dog immediately is not advisable because it should be observed for 14 days for signs and symptoms of rabies. Option D: Dogs and cats should be initially immunized at 3 months of age, re-immunized at 12 months after the first vaccination, with booster needed every three years if they are vaccinated with a licensed rabies vaccine and the label indicates 3 years duration of immunity. If an animal is vaccinated with a one-year rabies vaccine (label indicates 1 year duration of immunity), then a booster is needed annually. In order to improve rabies vaccination coverage, use of 3-year rabies vaccines is encouraged for dogs and cats. However, there are no laboratory or epidemiologic data to support the annual or biennial administration of 3-year vaccines following the initial series. Three months is considered to be minimum age for primary vaccination. Source: http://www.azdhs.gov/phs/oids/vector/pdf/manual06.pdf 8. A. B. C. D. In the assessment, nurse JC must observe which of the following signs and symptoms affecting deglutition? Sensory changes Muscle spasms Headache Fever

Answer: A Rationale:

It is characterized by spasmodic contraction of the larynx on attempts at swallowing. The sight of water produces great fear, and often precipitates a spasm which is attended with great suffering; the dyspnea is great, and the convulsive action of the larynx and muscles of the mouth causes the patient to emit guttural sounds, which, to the excited Other options: Sensory changes, Headache and Fever does not affect swallowing. Source; http://www.henriettesherbal.com/eclectic/thomas/rabies.html 9. A. B. C. D. Nursing care of clients diagnosed with rabies is provisions of this comfortable environment which is: Adequately supplied with food and water Quiet and dark Provided with soft music Accessible to medications

Answer: B Rationale: The first clinical symptoms are generally non-specific and may be flu-like (i.e. malaise, fever and headache). Pain and abnormal feelings (paresthesia) at the wound site are also common. Clinical disease quickly progresses to an acute neurologic phase with symptoms including one or more of the following: anxiety, confusion, hallucinations, hydrophobia, aerophobia, photophobia and insomnia. Since the patient develops photophobia, the environment should be dimmed as well as quiet to decrease stimuli. http://www.rabies.net/cont_36.faq.php#19 Option A: People with rabies experiences spasms of the muscles of deglutition making it difficult for them to swallow food and water. They also experiences hydrophobia. Option C: The environment should be quiet as much as possible to decrease the stimuli because the patient is usually hyperactive and there is hyper excitability. Option D: Once symptoms appear in humans, rabies can not be cured therefore, accessibility to medications is not a priority. There have been only a few human rabies survivors, and almost all suffered permanent neurological damage. Therefore, efforts are focused on preventing exposure or providing immunity that will prevent disease in those exposed. http://www.in.gov/isdh/programs/rabies/rabies.htm#Can%20rabies%20be%20cured? Situation 3- Endemic malaria occurs in the tropical and subtropical areas where socio-economic conditions are very poor. 10. A. B. C. D. The nurse explains that the best way to prevent malaria is to avoid: mosquito bites untreated water undercooked food overpopulated areas

Answer: A Rationale: A person can become infected with malaria if he/she was bitten by an infective Anopheles mosquito. In the country, it is the adult female Anopheles mosquito that can become infective and therefore carries the malaria parasite after she bites a person infected with malaria. The malaria parasite undergoes several developmental stages inside the adult female mosquito until such time that the mosquito becomes infective with malaria parasites. This anopheles mosquito bites from dusk to dawn and it breeds in clear, slow flowing streams that are found in mountainous/forested areas or in brackish water where salt and fresh water meet. This is usually found in coastal areas. http://www.doh.gov.ph/search/node/malaria Option B, C, D: malaria cannot be transmitted through this medium because The malaria parasite has to undergo development inside the adult female mosquito. http://www.doh.gov.ph/node/1331 11. A. B. C. D. When caring for a client with malaria, the nurse should know that: Seizure precautions must be followed Blood transfusion are usually indicated Isolation is necessary to prevent cross-infection Nutrition should be provided between paroxysms.

Answer: D Rationale: Maintaining adequate nutritional and fluid balance is essential to life and must be accomplished during periods when intestinal motility is not too excessive so that absorption can occur. Option A: Although shaking chills may occur, seizures do not generally occur Option B: This s not used in the treatment of malaria Option C: Infection may occur only through direct serum contact or a bite from the infected anopheles Mosquito. Source: Mosby comprehensive Review for Nursing 8th ed. page 340 12. In giving health teachings to family in malaria endemic place, all are preventive measure against malaria except:

A. B. C. D.

using mosquito repellants planting of Neem tree in the backyard wearing clothes that cover arms and legs in the evening none of the above

Answer: D Rationale: For those living in a malarious area Sleep inside an insecticide-treated mosquito net every night. Screen windows and doors (if a family can afford to do so) or in the sleeping area. Wear long sleeves and long pants during night time activities. Use insect repellant during night time activities. Consult immediately to the nearest health facility when experiencing symptoms of malaria and complete the medications as instructed. Do not self-medicate. Source: http://www.doh.gov.ph/node/1336 Neem oil has been found to be an effective mosquito repellent. Studies have shown that one Neem compound is a more effective insect repellent than DEET, a chemical widely used in commercial mosquito repellents. Also Neem oil treated mosquito nets are becoming popular. Apart from mosquitoes Neem also repels a great variety of other insects which are main storage pests. Neem has been used in the treatment of malaria for centuries. It has been taken as an infusion of bark, leaves or roots boiled in water or as dispersion of Neem seed powder. Recent experiment have shown that several of Neem's components are effective against malaria parasites. Irodin A, a substance found in Neem leaves, is toxic for resistant strains of malaria. Studies showed a 100 percent mortality in 72 hours at a ratio of 1:20,000 in vitro. Gedunin and quercentin, to other compounds found in neem leaves, are at least as effective against malaria as quinine and chloroquine. http://www.gigers.com/matthias/engmala/neemtree.htm#Use%20of%20Neem%20in%20Malaria 13. A. B. C. D. What drug of choice is ordered for Malaria taken for 4-6 weeks? Chloroquine Primaquine Phosphate Sulfates

Answer: A Rationale: Chloroquine phosphate is the drug of choice to prevent and treat malaria Chloroquine phosphate prevents the development of malaria parasites in the blood. Doctors use it to both prevent and treat malaria. Chloroquine phosphate does not destroy the Plasmodium (P.)vivax and P. ovale parasites that may remain in the liver. To prevent some strains of malaria, you take chloroquine phosphate once, 1 to 2 weeks prior to travel to an area where malaria is present, and then weekly while you are in the area, and weekly for 4 weeks after you depart from the area. http://www.webmd.com/a-to-z-guides/chloroquine-for-malaria Option B: People take primaquine phosphate to kill malaria parasites that may persist in the liver . It is generally only used for people with exposure to or known infection with Plasmodium (P.) vivax and P. ovale. To prevent relapses of malaria due to parasites that persist in the liver, you take this medication daily for 14 to 21 days. Source: http://www.webmd.com/a-to-z-guides/chloroquine-for-malaria Options C and D: Phosphates and Sulfates are merely distractors and are not rugs which are included in the treatment of malaria. Situation 4- A 65 year old male client is examined by a private physician and diagnosed as possible pulmonary tuberculosis. 14. A. B. C. D. What is the infectious agent of PTB? Mycobacterium Tubercle Corynebacterium Diptheriae Hansens bacillus Wuchereria bancrofti

Answer: A Rationale: TB is a communicable disease caused by mycobacterium tuberculosis or mycobacterium tubercle/ tubercle bacilli. Option B: This is the causative organism for Diphtheria. Option C: Mycobacterium leprae, the agent of leprosy (Hansen disease). http://www.medterms.com/script/main/art.asp?articlekey=25708 Option D: Wuchereria bancrofti is a parasitic filarial nematode worm spread by a mosquito vector. It is one of the three parasites that cause lymphatic filariasis. Elephantiasis can result if the infection is left untreated. Limited treatment modalities exist and no vaccines have been developed. (http://en.wikipedia.org/wiki/Wuchereria_bancrofti)

15. The client asks the nurse how he got infected with pulmonary tuberculosis. The nurse explains that the mode of transmission is one of the following: A. Exposure to tuberculosis cattle by ingestion of unpasteurized milk B. Airborne droplet method through coughing, singing and sneezing C. Contaminated food and water D. Prolong skin to skin contact Answer: B Rationale: The mode of transmission is airborne droplet method through coughing, singing or sneezing. There is direct invasion through mucous membranes or breaks in the skin mat occur, but is extremely rare. Option A: Bovine tuberculosis results from exposure to tuberculosis cattle, usually by ingestion of unpasteurized milk or dairy products. Option C: Contaminated food and water can be the cause of typhoid fever and hepatitis B but it cannot transmit tuberculosis. Option D: This is one of the modes of transmission of Hansens disease or leprosy. Source: Public Health Nursing in the Philippines page 240 16. When teaching a client with tuberculosis about recovery after discharge from the hospital, the nurse should reinforce that the treatment measure with the highest priority is: A. Having sufficient rest B. Getting plenty of fresh air C. Changing the current lifestyle D. Consistently taking the prescribed medications. Answer: D Rationale: Treatment of TB is a long term process that should be initiated immediately upon suspicion of infection. client with the diagnosis of active TB are usually started at a minimum of four medications to ensure elimination of resistant organisms. The dose of some drug may initially be large because the bacilli are difficult to kill. Treatment continues long enough to eliminate or substantially reduce the number or dormant or semidormant bacilli. The other options: These options can help boost the immune system but it cannot eradicate the causative organism which can only be done through the use of drug therapy. SOURCE: Black.Medical-Surgical Nursing.7th Ed.Vol. 2.pp. 1847 17. The client asks the nurse why the physician thinks he has tuberculosis. The nurse explains that the diagnosis of tuberculosis may take some weeks to confirm. Which of the following statement support the answer of the nurse? A. A client with a positive smear will have to have a positive culture to confirm the diagnosis B. A positive reaction to a tuberculosis skin test indicates that the client has active tuberculosis even if one negative sputum is obtained C. A positive sputum culture would take at least 3 weeks because of a slow reproduction of the TB bacillus D. Chest x-ray needs to be repeated during several consecutive weeks because the small lesions are difficult to detect. Answer: C Rationale: A more reliable indicator is a positive culture for M. tuberculosis, which is one to confirm active TB; however, final culture may not be available for 2 to 12 weeks. Although newer detection tests can generate faster results and show clinical promise, the prevalence of MDR TB still mandates the use of traditional culture methods for diagnosis. Option A: Three different sputum specimens should be collected on three consecutive mornings. Sputum AFB smears are not extremely sensitive, but the positive result of a sputum AFB smears confirms active disease. Option C: Tuberculin test or Mantoux test is performed on a routine basis in high-risk groups when active TB is suspected. For anyone who has positive skin test reaction, AFB sputum smear examination and chest radiograph are used to identify active disease. Option D: chest x-ray should not be repeated during several consecutive weeks. SOURCE: Black.Medical-Surgical Nursing.7th Ed.Vol. 2.pp. 1847 18. The physician prescribes an anti-tuberculosis drug to the client. The nurse is aware that one of the drugs listed can cause damage to the VIII cranial nerve. This drug is known as: A. Rifampicin B. Streptomycin Sulfate C. Isoniazid D. Ethambutol Hydrochloride (Myambutol) Answer: B Rationale: These are the most common effects of streptomycin and chek with the physician immediately if these happen. Any loss of hearing; clumsiness or unsteadiness; dizziness; greatly increased or decreased frequency of urination or amount of urine; increased thirst; loss of appetite; nausea or vomiting; numbness, tingling, or burning of face or

mouth (streptomycin only); muscle twitching, or convulsions (seizures); ringing or buzzing or a feeling of fullness in the ears (http://www.drugs.com/cons/Streptomycin.html) Option A: Taking rifampicin can cause certain bodily fluids, such as urine and tears, to become orange-red in color, a benign but sometimes frightening side-effect. This may permanently stain soft contact lenses. http://en.wikipedia.org/wiki/Rifampicin Option C: Isoniazid can interfere with the activity of vitamin B6.Vitamin B6 supplementation is recommended, especially in people with poor nutritional status, to prevent development of Isoniazid-induced peripheral neuritis (inflamed nerves). One case is reported in which injectable vitamin B6 reversed Isoniazid-induced coma. In another case, however, 10 mg per day of vitamin B6 failed to reverse Isoniazid-induced psychosis. http://www.svcmc.org/113361.cfm Option D: The side effect the is commonly connected to Ethambutol is optic neuritis. Source: http://www.medicinenet.com/ethambutol-oral/article.htm Situation 5 - A two year old has been admitted with a suspected diagnosis of meningitis. 19. A lumbar puncture is done to confirm the diagnosis of meningitis. The nurse correctly interprets that bacterial meningitis is present when the report of the spinal fluid indicates: A. increased protein B. increased glucose C. decreased cell count D. clear cerebrospinal fluid Answer: A Rationale: Understanding the Results Fluid collected from a lumbar puncture is immediately sent to the laboratory and analyzed for evidence of an infection. Some of the results are available within 30 to 60 minutes. However, bacterial culture is necessary to watch for an organism growing in the sample. Culture results are usually available in 48 hours. If the doctor determines that the child has an infection, he or she will start antibiotic treatment while waiting for the results of the culture and then make any necessary adjustments once the final results come in. The lab technicians look for a number of things when examining the spinal fluid sample, including: General appearance: CSF is usually clear and colorless and looks like water. Cloudy spinal fluid may indicate infection because of increased cells and proteins suspended in the fluid. Cell count: This includes the number and type of white blood cells and the number of red blood cells present. CSF normally does not contain either of these types of cells. The presence of too many white cells indicates an infection. Protein: Large amounts of protein in the spinal fluid also suggest an infection or other disease. Glucose: In bacterial infections of the spinal fluid, the glucose level of the fluid is often low. Gram's stain and culture: CSF is also stained and examined under the microscope to look for bacteria. The staining technique used, called the Gram's stain, detects bacteria in the CSF. To confirm an infection, it is also cultured to see if any organisms grow from the fluid. CSF may also be processed for other tests for which results are not available immediately. A lumbar puncture (LP), sometimes called a spinal tap, is a procedure in which a small amount of the fluid that surrounds the brain and spinal cord, called the cerebrospinal fluid (CSF), is removed and examined. Source: http://kidshealth.org/parent/general/sick/lumbar_puncture.html 20. A. B. C. D. The nurse should maintain isolation of a child: For 12 hours after admission until the cultures are negative until antibiotic therapy is completed For 48 hours after antibiotic therapy begins

Answer: D Rationale: This is the closest answer; the patient should be placed in respiratory precaution for 24 hours after the start of antibiotic therapy. Antibiotic therapy as indicated by sensitivity studies is the primary treatment measure. In addition to standard precautions, children with meningitis are placed on respiratory precaution for 24 hours after the start of antibiotic therapy to prevent the transmission of the infection. Antibiotics also may be prescribed prophylactically for the immediate family members of the ill child or others who have been in close contact with the child or for others who have been in close contact with the child. Option B and C: This may take a long time. In some children, it takes a month before the CSF cell count returns to normal. Why should a person wait this long if for 24 hours after antibiotic therapy, the child can no longer be place on respiratory isolation/precaution. Option D: For 12 hours after admission, at this point the child can spread the infection to other people because antibiotics and proper treatment was not implemented. SOURCE: Pilliterri. Maternal and child Nursing. .5th Edition. pp. 1559

21. During the acute stage of meningitis, the child is restless and irritable. Which of the following is the most appropriate to institute? A. Limiting conversation with the child B. Keeping extraneous noise to a minimum C. Allowing the child to play in the bathtub D. Performing treatments quickly

Answer: B Rationale: A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. Option A: There is no need to limit conversations with the child. However, the nurse should speak in a calm, gentle, reassuring voice. Option C: The child needs gentle and calm bathing. Because of the acuteness of infection, sponge baths would be more appropriate than tub baths. Option D: Although treatments need to be completed as quickly as possible to prevent overstressing the child, any treatments should be performed carefully and at a pace that avoids sudden movements to prevent startling the child and subsequently increasing intracranial pressure. Source: Diane M. Billings Lippincotts review for NCLEX-RN Examination 8 th ed. page 206 22. A. B. C. D. To identify the possible increasing intracranial pressure in a two year old child, the nurse should monitor: restlessness, anorexia, rapid respirations vomiting, seizures, complaints of head pain anorexia, irritability, subnormal temperature bulging fontanels, decreased blood pressure, increased temperature

Answer: B Rationale: With increased ICP, symptoms are often subtle at first. The child may report a headache, irritability and restlessness. There is presence of nausea, vomiting. double vision and seizures. (http://www.uncc.edu/jmruth/n3202Child%20with%20Cerebral%20Dysfunction2004-joyce.htm) Option A: In increased ICP, there is growing pressure on the brainstem, which control respirations and cardiac activity, causes pulse and respirations to SLOW. Option C: Due to he pressure on the hypothalamus, the temperature regulating center of the body, causes an increase in temperature. Option D: The fontanels of a two year old child are already closed. Bulging fontanels can be present in infants. Due to compression of the cranial nerves SOURCE: Pilliterri. Maternal and child Nursing. .5th Edition. pp. 1549 23. A. B. C. D. Which of the following assessment data indicates meningeal irritation? positive Kernigs sign negative Brudzinskis sign positive Homan sign negative Kernigs sign

Answer: A Rationale: The symptoms of meningitis can occur insidiously or sudden. Children usually have had 2 or 3 days of upper respiratory tract infection. They become increasingly irritable because of headaches. They may have seizures. in some children, seizure or shock is the first noticeable sign of meningitis. As the disease progresses, signs of meningeal irritation occur, as evidenced by positive Brudzinskis and Kernigs sign. Option B: It should be positive Brudzinskis sign. Brudzinskis sign is when the nurse flexes the client neck forward. Positive response: bilateral hip, knee and ankle flexion indicates meningeal irritation. Option C: Homans' sign is said to be present when passive dorsiflexion of the ankle by the examiner elicits sharp pain in the calf. It is caused by a thrombosis of the deep veins of the leg. Source: http://en.wikipedia.org/wiki/Homan's_sign Option D: Kernigs sign. The nurse flexes the childs hip and knee, forming a 90 degrees angle. Positive responses as the leg is extended, pain, resistance, and spasms are noted, indicating meningeal irritation. SOURCE: Pilliterri. Maternal and child Nursing. .5th Edition. pp. 1559 Situation 6 - Leprosy has been a public health problem in the Philippines for several decades. 24. A. B. C. D. What is the initial sign of leprosy? contracture nerve pain loss of eye brows ulceration

Answer: B Rationale: Early signs and symptoms of leprosy includes:

Change in skin color-either reddish or white loss of sensation on the skin lesion decrease/ loss of sweating and hair growth over the lesions Thickened and painful nerves Muscle weakness or paralysis of extremities Pain or redness on the eyes nasal obstruction or bleeding Ulcers that do not heal

Late signs and symptoms: loss of eyebrow- madarosis Inability to close eyelids Clawing of fingers and toes contractures Sinking of nosebridge Gynecomastia Chronic ulcers SOURCE: Community health nursing services in the department of health Philippines pp. 215 25. A. B. C. D. Mode of transmission of leprosy aside from droplet infection is: sharing food sexual contact borrowing utensils prolonged skin to skin contact

Answer: D Rationale: Method of transmission for leprosy is prolonged skin to skin contact and droplet infection. SOURCE: Community health nursing services in the department of health Philippines pp. 216 26. A. B. C. D. A nurse role in the prevention of spread of leprosy is through, EXCEPT: health education Personal hygiene improper hygiene BCG vaccination

Answer: C Rationale: Here are the steps in the prevention of Leprosy: avoidance of prolonged skin-to-skin contact especially with a lepromatous case. children should avoid close contact with active, untreated leprosy case BCG vaccination Good personal Hygiene Adequate Nutrition Health Education SOURCE: Community health nursing services in the department of health Philippines pp. 216 27. A. B. C. D. Late sign and symptoms of leprosy is inability to close eyelids known as: lagophthalmos exophthalmos madarosis clawing

Answer: A Rationale: Lagophthalmos is defined as the inability to close the eyelids completely (http://en.wikipedia.org/wiki/Lagophthalmos) Option B: Exophthalmos is a bulging of the eye anteriorly out of the orbit. This is often associated with Graves disease. (http://en.wikipedia.org/wiki/Exophthalmos) Option C: Madarosis is a late sign of leprosy, it is the loss of eyebrow (Community health nursing services in the department of health Philippines pp. 215) Option D: clawing in leprosy refers to the clawing of fingers and toes. 28. A. B. C. D. Which among the available vaccines is used to prevent Hansens disease? OPV EPI DPT BCG

Answer: D Rationale: Bacillus Calmette-Guerin Vaccine, BCG BCG has a small protective effect against leprosy of around 26%, although it is not used specifically for this purpose. Among the other options, BCG has the closest relation o lprosy, the other vaccines are unrelated (http://en.wikipedia.org/wiki/Bcg_Vaccine) Option A: OPV stands for Oral polio vaccine Oral polio vaccine (OPV) gives protection against the three types of virus that cause polio. It is a liquid that comes in two types of containers: small plastic bottles that work like droppers, and glass vials with droppers in a separate plastic bag. OPV should be stored at a temperature between 0 C and +8 C. (http://www.who.int/vaccines-documents/DoxTrng/IIP-E/www9556-02.pdf) Option B: EPI stands for Expanded Program for Immunization: this includes BCG vaccine, OPV, DPT, Hepa B, Measles vaccine, yellow fever vaccine, and tetanus toxoid. (http://www.who.int/vaccines-documents/DoxTrng/IIP-E/www9556-02.pdf) Option C: DPT, (sometimes DTP) is a mixture of three vaccines, to immunize against diphtheria, pertussis (whooping cough) and tetanus. (http://en.wikipedia.org/wiki/DPT%5Fvaccine) Situation 7- The nurse admits a patient who has diagnosis of AIDS 29. A. B. C. D. During the physical assessment he notices white patches in the buccal cavity. The finding suggests: Kaposi sarcoma Candida albicans Pneumocystis Carinii Shigella

Answer: B Rationale: Candida albicans not only is ubiquitous (in soil and food, on fomites) but is also normally found on the skin and in the mouth, vagina and large intestines. Clinical presentation is related to the site o infection: dysphagia with esophagitis, oral lesions with thrush, and cutaneous lesions with intertrigo, vulvovaginal irritation and discharge with vaginitis. Option A: Kaposi Sarcoma lesions are nodules or blotches that may be red, purple, brown, or black, and are usually papular (ie palpable or raised). They are typically found on the skin, but spread elsewhere is common, especially the mouth, gastrointestinal tract and respiratory tract. Growth can range from very slow to explosively fast, and be associated with significant mortality and morbidity. (http://en.wikipedia.org/wiki/Kaposi's_sarcoma) Option C: P. carinii is a ubiquitous organism that is airborne and can be found in the lungs of humans and animals. With P. carinii pneumonia, coughing is a frequent first manifestation. The pneumonia begins with a nonproductive cough then progress to a productive cough. Eventually the client will have fever and dyspnea on exertion, then dyspnea at rest. Option D; Shigella is a genus of Gram-negative, non-motile, non-spore forming rod-shaped bacteria closely related to Escherichia coli and Salmonella. The causative agent of human shigellosis. Shigellosis, also known as bacillary dysentery in its most severe manifestation is a foodborne illness. (http://en.wikipedia.org/wiki/Shigellosis) SOURCE: Black.Medical-Surgical Nursing.7th Ed.Vol. 2.pp. 2391-2392 30. A. B. C. D. The nurse is aware that HIV is transmitted by: Saliva and droplet infection Sexual contact that involves exchange of body fluids Contaminated food products prolonged exposure to an AIDS victim

Answer: B Rationale: Modes of transmission have remained constant throughout the course of HIV pandemic. the virus is spread through certain sexual practices, through exposure to blood, and through perinatal transmission. The other options are not related to the transmission of HIV. SOURCE: Black.Medical-Surgical Nursing.7th Ed.Vol. 2.pp. 2376 31. A client with acquired immunodeficiency syndrome (AIDS) has raised dark purplish lesions on the trunk of the body. The nurse anticipates that which of the following procedures will be done to confirm whether these lesions are result from Kaposi Sarcoma? A. Enzyme-Linked immunosorbent Assay (ELISA) B. Western Blot C. Skin Biopsy D. Lung Biopsy


Answer: C Rationale: Kaposi's sarcoma is a form of skin cancer that can involve internal organs. It most often is found in patients with acquired immunodeficiency syndrome (AIDS), and can be fatal. Many physicians will diagnose KS based on the appearance of the skin tumors and the patient's medical history. Unexplained cough or chest pain, as well as unexplained stomach or intestinal pain or bleeding, could suggest that the disease has moved beyond the skin. The most certain diagnosis can be achieved by taking a biopsy sample of a suspected KS lesion and examining it under high-power magnification. http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp? requestURI=/healthatoz/Atoz/ency/kaposis_sarcoma.jsp Option A: The abbreviation for enzyme-linked immunosorbent assay is a sensitive immunoassay that uses an enzyme linked to an antibody or antigen as a marker for the detection of a specific protein, especially an antigen or antibody. It is often used as a diagnostic test to determine exposure to a particular infectious agent, such as the AIDS virus, by identifying antibodies present in a blood sample.http://www.answers.com/topic/elisa Option B: The confirmatory HIV test employs a western blot to detect anti-HIV antibody in a human serum sample. Proteins from known HIV-infected cells are separated and blotted on a membrane as above. Then, the serum to be tested is applied in the primary antibody incubation step; free antibody is washed away, and a secondary anti-human antibody linked to an enzyme signal is added. The stained bands then indicate the proteins to which the patient's serum contains antibody. A western blot (alternately, immunoblot) is a method to detect a specific protein in a given sample of tissue homogenate or extract. It uses gel electrophoresis to separate native or denatured proteins by the length of the polypeptide (denaturing conditions) (Figure 1) or by the 3-D structure of the protein (native/ non-denaturing conditions). http://en.wikipedia.org/wiki/Western_blot Option D: For suspected involvement of internal organs, physicians will use a bronchoscope to examine the lungs or an endoscope to view the stomach and intestinal tract http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp? requestURI=/healthatoz/Atoz/ency/kaposis_sarcoma.jsp 32. A. B. C. D. Current medical management for AIDS consists primarily of: palliative treatment since there is no cure early treatment of infections, symptomatic management antiretroviral and protease inhibitors bone marrow transplants

Answer: B Rationale: In advance HIV disease, the goal of nursing care is to diagnose and treat human response to actual or potential health problems related to the development of clinical manifestations and the diagnosis of AIDS. All efforts are directed at controlling manifestations. Option B is more specific and encompassing compared to other options. SOURCE: Black.Medical-Surgical Nursing.7th Ed.Vol. 2.pp. 2394 OPTION A: Palliative care consists of providing pain relief to a person with a serious or life-threatening illness. The focus of palliative care is symptom and pain management, as well as mental and emotional health, and assistance with spiritual needs. Palliative care does not focus on death, but rather, compassionate quality-of-life for the living. (http://www.wisegeek.com/what-is-palliative-care.htm) Option C: Protease inhibitors (PIs) are antiretroviral medications. They prevent HIV from multiplying, reducing the amount of virus in your body. When the amount of virus in the blood is kept at a minimum, the immune system has a chance to recover and grow stronger. Antiretroviral drugs are medications for the treatment of infection by retroviruses, primarily HIV. (http://www.webmd.com/hiv-aids/protease-inhibitors-pis-for-hiv) Option D: A bone marrow transplant is a procedure that transplant healthy bone marrow into a patient whose bone marrow is not working properly. A bone marrow transplant may be done for several conditions including hereditary blood diseases, hereditary metabolic diseases, hereditary immune deficiencies, and various forms of cancer. (http://www.nlm.nih.gov/medlineplus/ency/article/003009.htm#Indications) 33. Being in the terminal stage, an AIDS client needs suctioning. When performing the task you must utilize which of the following protective barrier in order to exercise appropriate universal precaution? A. a mask and eye protector B. A mask and sterile gloves C. sterile gloves an eye protector D. a mask, eye protector and sterile gloves Answer: D Rationale: A mask is worn to reduce the risk of transmission of organisms by the droplet contact and airborne routes, or by splatters of body substances


Protective eyewear (goggles, glasses, or face shields) and masks may be indicated in situations where boy substances may splatter into the face. Gloves are worn for the following reasons: They are likely worn if the nurse is likely to handle any body substances. Second, gloves reduce the likelihood of nurses transmitting their own endogenous microorganisms receiving their care. third, gloves reduce the chance that the nurses hands will transmit microorganisms from one client to another. SOURCE: Kozier. Fundamentals of Nursing.7th Edition.pp. 650-651 34. A client with AIDS is experiencing dysphagia. The nurse would make which of the following dietary alterations for this client to enhance nutritional intake? A. Avoid red meat B. Plan large, nutritious meals C. Add spices to food for added flavor D. Serve food while they are very warm Answer: A Rationale: Minimize Factor related to difficulty in chewing, dysphagia, or odynophagia (painful swallowing) by telling patients to avoid rough food such as raw fruits and vegetables, spicy, acidic and spicy foods. Avoid alcohol and tobacco, also sticky food such as peanut butter. Also discourage to eat slippery food such as gelatin, bologna and elbow macaroni. Encourage the client to do the following: eat food at room temperature choose mild food and drinks, such as apple juice rather than orange juice eat dry grain food 9breads, crackers, cookies) after softening them in milk, tea or other mil beverage Eat non abrasive foods that are easy to swallow, such as ice cream, pudding, well cooked eggs, noodles, baked fish, and soft cheese. eat popsicles (frozen dessert) to numb pain use straw when drinking SOURCE: Black.Medical-Surgical Nursing.7th Ed.Vol. 2.pp. 2396 35. When teaching a client with AIDS on how to avoid food borne illnesses. The nurse instructs client to avoid acquiring infection from food by avoiding which of the following items? A. Raw oysters B. Pasteurized milk C. Products with sorbitol D. Bottled water Answer: A Rationale: The client is taught to avoid raw or undercooked seafood, meat, poultry, and eggs. The client should also avoid unpasteurized milk and dairy products. Fruits that the client peels are safe, as are bottled beverages. The client may be taught to avoid sorbitol, but this is to diminish diarrhea, and has nothing to do with food borne illnesses. Source: Silvestri Saunders Q and A Situation 8- Jade is being treated of pneumonia. She has persistent cough and complains of severe pain on coughing. 36. A. B. C. D. What type of instructions could be given to help the client reduce the discomfort she is having? Hold on you cough as much as possible Place the head of your bed flat to help with coughing Restrict fluids to help decrease the amount of sputum Splint your chest wall with a pillow for comfort

Answer: D Rationale: Coughing uses the abdominal and other accessory respiratory muscles. Splinting the incision may reduce pain while coughing. SOURCE: Kozier. Fundamentals of Nursing.7th Edition.pp. 905 Option A: The clinical manifestations of pneumonia includes: fever, chills, sweat, pleuritic chest pain, cough, sputum production, hemoptysis, dyspnea, headache and fatigue. The cough, an automatic protective reflex used to clear the trachea, occurs most rapidly in the clearing process. In pneumonia, there is sputum production, holding the cough as much as possible is not advisable since the client should be able to have a patent and clear airway. Option B: One of the nursing diagnosis for pneumonia is Ineffective Breathing pattern. Many clients experience compensatory tachypnea because of an inability to meet metabolic demands. The nurse should be able to position the client in a position of comfort and to facilitate breathing. (raise the head of the bed 45 degrees). Option C: fluids should be increased if not contraindicated in order to decrease the viscosity of the sputum as well as to expectorate the phlegm easily. SOURCE: Black.Medical-Surgical Nursing.7th Ed.Vol. 2.pp.1841-1843 37. A diagnosis of pneumonia is typically achieved by which of the following diagnostic test? A. ABG analysis B. Chest x-ray C. Blood cultures


D. Sputum culture and sensitivity Answer; B Rationale: Chest x-ray is nearly always taken to confirm a diagnosis of pneumonia. X-rays are a form of electromagnetic radiation (like light). They are of higher energy, however, and can penetrate the body to form an image on film. Structures that are dense (such as bone) will appear white, air will be black, and other structures will be shades of gray depending on density. X-rays can provide information about obstructions, tumors, and other diseases, especially when coupled with the use of barium and air contrast within the bowel. A chest x-ray may reveal the following: White areas in the lung called infiltrates, which indicate infection Complications of pneumonia, including pleural effusions and abscesses Source: http://www.umm.edu/patiented/articles/how_pneumonia_diagnosed_000064_6.htm Option A: A Blood gas is a test done to measure how much oxygen and carbon dioxide is in your blood. It also looks at the acidity (pH) of the blood. Usually, blood gases look at blood from an artery The test is used to evaluate respiratory diseases and conditions that affect the lungs. It helps determine the effectiveness of oxygen therapy. The acid-base component of the test also gives information about kidney function. Source: http://www.nlm.nih.gov/medlineplus/ency/article/003855.htm Option C: A blood culture is a test to determine if microorganisms such as bacteria, mycobacteria, or fungus are present in the blood. A sample of blood is put in a special laboratory preparation and is incubated in a controlled environment for 1 to 7 days. A blood culture is performed when an infection of the blood (bacteremia or septicemia) is suspected because of symptoms such as fever, chills, or low blood pressure. The blood culture will help identify the origin of the infection and this helps the doctor determine the best course of treatment. (http://www.nlm.nih.gov/medlineplus/ency/article/003744.htm) Option D: The cultures and tests are done on the sputum to help identify the bacteria that are causing an infection in the lungs or the airways (bronchi). The abnormal results will be reported as a positive culture. That means that there is a disease-producing organism found that may help diagnose bronchitis, tuberculosis, a lung abscess, or pneumonia. Sensitivity analysis determines the effectiveness of antibiotics against microorganisms such as bacteria that have been isolated from cultures. (http://www.nlm.nih.gov/medlineplus/ency/article/003741.htm) 38. The nurse auscultates his lung fields and hears abnormal breath sound in the left lower lobe. The nurse determines that the client requires which of the following treatment first? A. antibiotics B. bed rest C. oxygen D. nutritional intake Answer: C Rationale: In Pneumonia, inflammation (irritation, swelling) or infection of the lungs causes fluid and pus to fill a section (Lobar p.) or form patches in both lungs (Bronchial p.), interfering with the uptake of oxygen. Following the ABC, Airway is a priority so it is important to provide oxygen. Option A: This is helpful to eliminate the microorganisms however this may take quite some time to take effect. Option B and D: these is helpful to help boost the immune system however this is not a priority or should be done first. Source: http://www.ecureme.com/emyhealth/data/Bronchial_Pneumonia.asp 39. The client has been treated with antibiotic therapy for left lower lobe pneumonia or 10 days. Which of the following physical findings would lead the nurse to believe it is appropriate to discharge the client? A. Continued dyspnea B. Fever 102 degrees Fahrenheit C. Respiratory rate of 32 breaths/min D. Vesicular breath sounds in the right base Answer: D Rationale: Vesicular breath sounds are normal breath sounds. These are soft intensity, low pitched, gentle-sighing sounds created by air moving through smaller airways (bronchioles and alveoli) . It is best heard on inspiration, which is about 2.5 times longer than the expiratory phase. The other options are still abnormal findings and needs further intervention before discharge. SOURCE: Kozier. Fundamentals of Nursing.7th Edition.pp. 574 40. Which of the following organisms most commonly found in community acquired pneumonia in adults? A. Haemophilus Influenzae B. Klebsiella Pneumonia C. Streptococcus Pnuemoniae


D. Staphylococcus Aureus Answer: C Rationale: Most community-acquired pneumonias are bacterial and the predominant pathogen is Streptococcus pneumonia. Pneumococcal Pneumonia is caused by the said pathogen. There is sudden onset with a hill, high fever, stabbing pleuritic chest pain, malaise, weakness. There is single or multiple lobar consolidation. Cough is productive of rusty brown purulent sputum that turns yellow and mucoid. Option A: Haemophilus influenza which is still the second most common pathogen causing pneumonia. Influenzal pneumonia is caused by the said pathogen. This is similar to pneumococcal pneumonia, the cough is productive of apple or lime green purulent which may be blood tinged. Option C: Klebsiella Pneumoniae causes a gram-negative bacterial pneumonia. There is productive cough of red sputum resembling currant jelly (mucoid, sticky, and difficult to expectorate) Option D: staphylococcus Aureus is a rare cause of community-acquired pneumonia, but must be considered during influenza epidemics or if the patient presents with a history suggesting recent pneumonia. In staphylococcal Pneumoniae, the chest film may show patch infiltrates empyema, abscess, and pneumothorax Source:http://www.bsac.org.uk/pyxis/RTI/Community%20acquired%20pneumonia/Community%20acquired %20pneumonia.htm. SOURCE: Black.Medical-Surgical Nursing.7th Ed.Vol. 2.pp. 1840 Situation 9 - An infant has been admitted to the hospital with gastroenteritis: 41. A. B. C. D. The nursing care plan for this infant will consider which of the following nursing diagnosis first? Acute Pain Diarrhea Deficient Fluid Volume Imbalanced Nutrition: less than body requirements

Answer: C Rationale: Gastroenteritis is the irritation and inflammation of the digestive tract. This condition may cause abdominal pain, vomiting and diarrhea. Severe cases of gastroenteritis can result in dehydration. In such cases, fluid replacement is the primary factor in treatment. Since the patient will have dehydration, the priority nursing diagnosis is Deficient Fluid Volume. Source: http://scsc.essortment.com/whatisgastro_riwd.htm Deficient Fluid Volume is decreased in intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium. Source: NANDA. Option A: unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. Although the patient may experience pain, this is not a priority over fluid volume deficit which can be life threatening Option B: Diarrhea is the passage of loose, unformed stools and is usually present in gastroenteritis, although related to fluid volume deficit, diarrhea can be considered as a secondary problem, fluid volume deficit must be given priority. Option D: Imbalanced Nutrition less than body requirement, this is intake of nutrients insufficient to meet metabolic needs, although there is the presence o vomiting, this is not a priority nursing diagnosis for gastroenteritis. Source: Doenges, Moorhouse Nurses Pocket Guide 10 th edition. 42. A. B. C. D. Voluminous, water stools can deplete fluids and electrolytes. The acid-base imbalance that can occur is: Metabolic Alkalosis Metabolic Acidosis Respiratory acidosis Respiratory alkalosis

Answer: B Rationale: In diarrhea, metabolic acidosis is the acid-base imbalance that occurs while in vomiting, metabolic alkalosis occurs. This is the metabolic disorder therefore Options C and D should be eliminated. Tip: vomiting sound: alk alk alk alosis sound of passage of watery stool (uhh uhh ashidosis) Source: http://pinoybsn.blogspot.com/2006/07/50-item-gastrointestinal-h_115375823133188151.html 43. A. B. C. D. When assessing the fluid and electrolyte balance in an infant, which of the following is important to remember? Infants can concentrate urine at an adult level The metabolic rate of infants is slower than in adults Infants have more intracellular water than adults do Infants have greater body surface areas than adults

Answer D Rationale:


The infants relatively greater body surface area allows greater quantity of fluid to be lost in insensible perspiration through the skin. It is estimated that the BSA of premature neonate is five times as great, and that of a newborn is two to three times as great, as that of an older child or adult. The proportionately longer GI tract in infancy is another source of fluid loss, especially from diarrhea. Option A: of particular importance of fluid balance is the inability of the infants kidneys to concentrate or dilute urine, to conserve or excrete sodium and to acidify urine. Option B: the rate of metabolism in infancy is significantly higher than the adulthood because of the larger BSA in relation to the mass of active tissue. Option C: Fluid losses create compartment deficits that are reflected throughout the duration of dehydration. In general, approximately 60% of fluid is lost from the ECF and the remaining 40% comes from the intracellular fluid. SOURCE: Hokenberry, M. Wongs Essentials of Pediatric Nursing 7th ed. pp 840 44. When planning care for an 8 month old infant with dehydration, which of the following interventions would be the most accurate for monitoring hydration status? A. Measuring fluid intake and output B. monitoring daily weight C. checking electrolyte values D. assessing skin turgor Answer: B Rationale: Accurate measurement of fluid intake and output are vital to the assessment of dehydration. This includes oral and parenteral intake and losses from urine, stools, vomiting, fistulas, nasogastric suction, sweat, and wound drainage: In addition to fluid intake and output, the following observations assist in assessment of dehydration: Vital signs: temperature 9normal, elevated or lowered depending on degree of dehydration), pulse (tachycardia), respirations (tachypnea), and blood pressure (hypotension). Skin: color, temperature, turgor, presence or absence of edema, and capillary refill Mucous membranes: moisture, color, presence and consistency of secretions Body weight: decreased in relation to degree of dehydration Fontanel: sunken, soft, normal Sensory alterations: presence of thirst SOURCE: Hokenberry, M. Wongs Essentials of Pediatric Nursing 7th ed. pp 842 45. The orders for a child with dehydration secondary to gastroenteritis include changing the I.V. solution from D5W in half normal saline to D5W in normal saline with 10 mEq of potassium chloride. Before changing the solution, the nurse should assess: A. Weight B. Urine output C. Blood pressure D. Apical pulse Answer B Rationale: Before administering potassium chloride, it is important for the nurse to take note if the patient is able to urinate because potassium chloride can be excreted through the urine. If the patient is unable to urinate, withhold the medication for it may cause hyperkalemia in the long term use. The other options are not directly related to the administration of potassium chloride. Although important, it is not necessary to determine the weight, blood pressure and apical pulse before giving potassium chloride. Source:http://www.drugs.com/pro/potassium-chloride.html Situation 10 - Ervin, 3 years old, was admitted to the hospital with a diagnosis of cystic fibrosis. 46. A nurse is reviewing the results of sweat test performed on Ervin with cystic fibrosis. The nurse would expect to note which finding? A. A sweat sodium concentration less than 40 mEq/L B. A sweat potassium concentration less than 40 mEq/L C. A sweat potassium concentration greater than 40 mEq/L D. A sweat chloride concentration greater than 60 mEq/L Answer: D Rationale: A consistent finding of an abnormally high sodium and chloride concentrations in the sweat is a unique characteristic of CF. Normally, the sweat chloride concentration is less than 40mEq/L. a chloride concentration greater than 60 mEq/L is diagnostic of CF. Potassium concentration is unrelated to sweat test. Source: Saunders 2nd ed by Silvestri 47. When developing the plan of care for Ervin with Cystic Fibrosis (CF) who is scheduled to receive postural drainage at which of the following times? A. after meals


B. before meals C. after rest periods D. before inhalation treatments Answer: B Rationale: Cystic fibrosis causes mucus to become thick and sticky, which can clog the lungs and cause serious problems. You can help your child maintain lung function and avoid complications from mucus buildup and blockage by performing an airway clearance technique (ACT). Postural drainage and chest percussion (PD & P) is one of several airway clearance techniques that help clear mucus from your child's lungs. The best time is early morning, before breakfast, to help clear mucus that has built up during the night. (http://www.webmd.com/a-to-z-guides/performing-postural-drainage-and-chest-percussion-for-cystic-fibrosis) Option A: This should not be done right after a meal. Wait an hour after eating to allow food to digest. Option C: An hour before bedtime is another good time to perform postural drainage. Option D: postural drainge shoul be done after nebulization and not before. For example with acetylcysteine: Since increased bronchial secretions may develop after inhalation, percussion, postural drainage and suctioning should follow; if bronchospasm occurs, administer a bronchodilator; discontinue acetylcysteine if bronchospasm progresses (http://www.alternativemedicine.com/common/adam/DisplayMonograph.asp? DocID=41_001200&storeID=02AD61F001A74B5887D3BD11F6C28169) 48. When teaching the parents of Ervin with CF about what type of diet should the child consume? Which of the following would be most appropriate? A. Low protein diet B. High fat diet C. Low carbohydrate diet D. High caloric diet Answer: D Rationale Children with CF are managed with a high calorie, high protein diet, pancreatic enzyme replacement therapy, fat soluble vitamin supplements. Fats are not restricted unless steatorrhea cannot be controlled by pancreatic enzyme replacement therapy. Calories: Most toddlers need 1,000 1,300 calories daily. However, a toddler with CF may need 3050% more calories, or 1,3001,900 calories daily. It is important to remember that a balanced diet is vital for the whole family. This includes dairy products, grains and starches, fruits and vegetables, and protein like meat, poultry, fish, and eggs. Since toddlers with CF will eat the same amount as other toddlers, more calories should be added to their diet. Give the toddler with CF whole milk to drink at every meal. Serving whole milk dairy products (like cottage cheese, yogurt, and pudding), and adding cream on cereal, margarine or butter in everything, and extra cheese in casseroles or on pizza, put more calories in the meal for the child with CF. Toddlers with CF lose more salt when they sweat than toddlers who dont have CF. Add salt to your childs food and plan salty snacks, like pretzels to help replace this salt loss. High-Calorie Finger Foods: Noodles with Alfredo sauce (with butter, cream, and cheese) Grated whole milk cheese (like cheddar, Monterey jack, American) Crackers with cheese or peanut butter Blueberry muffins Pancakes or waffles Sliced avocado Soft-cooked vegetables with butter and cheese Scrambled eggs with cream and cheese Tuna or egg salad sandwich with mayonnaise Breaded fish or fish sticks High-Calorie Spoon-Thick Foods: Applesauce mixed with cream Ice cream Cooked cereal with cream, butter, and brown sugar Whole milk cottage cheese or yogurt Pudding made with whole milk and cream Mashed potatoes with butter, gravy, and sour cream Thick cream soups (like cream of potato, cheese, and broccoli) Mashed avocado Refried beans

Source: http://www.cff.org/UploadedFiles/treatments/Therapies/Nutrition/ForToddler/Nutrition%20-%20For %20Your%20Toddler.pdf


49. Which of the following, if describe by the parents of Ervin with CF indicates that the parents understand the underlying problem of the disease? A. an abnormality in the bodys mucus-secreting glands B. formation of fibrous cysts in various body organs C. failure of pancreatic ducts to develop properly D. reaction to the formation of antibodies against streptococcus Answer: A Rationale: Cystic fibrosis is an inherited condition, it affects the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in cystic fibrosis, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. (http://www.mayoclinic.com/health/cystic-fibrosis/DS00287) The other options do not describe the underlying problem related to cystic fibrosis. 50. A. B. C. D. Toddlers usually establish ritualistic behavior patterns to: manipulate and control adults in their environment establish learning behavior pattern feel secure among the changes and inconsistencies of their world reestablish their sense of identity.

Answer: C Rationale: In ritualism, toddlers need to maintain sameness and reliability, provides a sense of comfort. Toddlers can venture out with security when they know that familiar people, places and routines still exist. One can easily understand why changes, such as hospitalization, represent such as threat to these children. Without the comfortable rituals, there is little opportunity to exert autonomy. Option A: Temper Tantrums are more on manipulative behaviors rather than performing ritualistic behaviors. Toddlers may assert their independence by violently objecting to discipline. They may lie down to the floor, kick their feet, and scream at the top of their lungs. Option B: Toddler learns through experimentation and not through ritualistic behavior. The child uses active experimentation to achieve previously unattainable goals. Option D: This is the developmental task of adolescents. Identity vs. Role confusion and is not related to toddlerhood. In toddler, gender identity is formed at 3 years old. Situation 11- Glenn, a 40 year old banker is admitted o the medical unit with a tentative diagnosis of Hepatitis A. 51. A. B. C. D. Which laboratory test result is most conclusive in confirming a diagnosis of hepatitis A? An elevated serum alanine transferase level Alcoholic stool Hepatitis A virus antibodies (anti-HAV IgM) in serum An elevated serum alkaline phosphatase level

Answer C Rationale: The antihepatitis A virus IgM test is the preferred confirmatory test for acute hepatitis A because it has high sensitivity and specificity when used on specimens from persons with typical symptoms. Serum antihepatitis A virus IgM usually can be detected five to 10 days before symptom onset, and the level remains elevated for four to six months.7,9,11,16 The antihepatitis A virus IgG level begins to rise soon after the IgM level, and antihepatitis A virus IgG is present throughout the persons lifetime, conferring immunity. (http://www.aafp.org/afp/20060615/2162.pdf) Option A: ALT is commonly used as a way of screening for liver problems. However, elevated levels of ALT do not automatically mean that medical problems exist. Medical conditions associated with increased in ALT are the following: viral hepatitis, congestive heart failure, liver damage, biliary duct problems, infectious mononucleosis, or myopathy. Option B: alcoholic stools are stools that are pale, or clay- or putty-colored may result from problems in the biliary system (the drainage system of the gallbladder, liver, and pancreas). Possible causes for clay-colored stool result from problems in the biliary system, and may include: Cancer or benign tumors Strictures (narrowing) Congenital anatomic problems (present at birth) Gallstones Cysts Medications Sclerosing cholangitis Biliary cirrhosis Protein or infectious infiltration Alcoholic hepatitis Viral hepatitis (A,B, or C) http://www.healthline.com/adamcontent/stools-pale-or-clay-colored


Option D: this is more associated with Pagets disease. Serum alkaline phosphatase (SAP) is a chemical (enzyme) that is produced by bone cells called osteoblasts. Too much serum alkaline phosphatase is produced by bone with Paget's disease. (http://www.pagetsdisease.com/info/answers/faqs/diagnosing-pagets.jsp) 52. Glenn asks the nurse why his eyes are so yellow. The nurses answer is based on her knowledge that jaundice is caused by: A. decreased destruction of hemoglobin B. excessive bilirubin in the blood C. disturbance of the livers detoxification process D. faulty synthesis of prothrombin in the liver Answer: B Rationale: Jaundice or icterus, is the yellow pigment of the sclerae, skin and deeper tissues caused by excessive accumulation of bile pigments in the blood. Bilirubin (bile pigment), a product of RBC breakdown, is deposited in the skin and excrete in the urine when present in the blood in excessive amounts (hyperbilirubinemia). Option A: For jaundice to develop there should be above normal breakdown of hemoglobin from RBC by the macrophages. Bilirubin is a product of the breakdown of hemoglobin, which is the protein inside red blood cells. If bilirubin cannot leave the body, it accumulates and discolors other tissues. The normal total level of bilirubin in blood serum is between 0.2 mg/dL and 1.2 mg/dL. When it rises to 3 mg/dL or higher, the person's skin and the whites of the eyes become noticeably yellow. http://www.answers.com/topic/jaundice?cat=health Option C: The liver removes harmful substances (such as ammonia and toxins) from the blood and then breaks them down or transforms them into less harmful compounds. In addition, the liver metabolizes most hormones and ingested drugs to either more or less active products. Nearly all drugs are modified or degraded in the liver. In particular, oral drugs are absorbed by the gut and transported via the portal circulation to the liver. In the liver, drugs may undergo first-pass metabolism, a process in which they are modified, activated, or inactivated before they enter the systemic circulation, or they may be left unchanged. Alcohol is primarily metabolized by the liver, and accumulation of its products can lead to cell injury and death. In patients with liver disease, drug detoxification and excretion may be dangerously altered, resulting in drug concentrations that are too low or too high or the production of toxic drug metabolites. Therefore, medications that are metabolized by the liver must be used with caution in patients with hepatic disease; these patients may need lower doses of the drug. http://janis7hepc.com/Your%20Liver%20Functions.htm Option D: Due to faulty synthesis of prothrombin, bleeding may occur. http://janis7hepc.com/Your%20Liver%20Functions.htm 53. The physician determines that Glenn is in icteric stage of hepatitis A infection. Which of the following interventions is not appropriate during this stage? A. Forcing fluids (3,000 mL or more daily) B. Administering Vitamin K as ordered C. Encouraging ambulation to prevent pneumonia D. providing mittens to the patients Answer: C Rationale Ambulation is not encouraged at this stage of illness because the patient usually experiences fatigue, at this stage there is also liver cell destruction. Rest rather that ambulation is to encourage to conserve energy and prevent further trauma. Icterus is the medical term for jaundice, or yellowing of the skin. This is different from carotenemia in that the skin is patently yellow, not orange. A hallmark of jaundice caused by hepatitis is that the whites of the eyes turn yellow. This phase begins one to two weeks after the prodromal phase and can last two to six weeks. Liver cell destruction and bile stasis cause jaundice. Urine is dark (tea-colored) and stools clay-colored before the onset of jaundice. The icteric phase is the actual phase of illness. The liver is smooth, enlarged and tender, and the accompanying fatigue and abdominal pain may persist or become more severe. Jaundice may last two to six weeks or longer and is usually accompanied by mild itching. The other options are appropriate for the icteric stage of hepatitis A. Source: http://www.drhoffman.com/page.cfm/622 54. A. B. C. D. Which discharge instruction should the nurse stress with Glenn? wear a medical alert bracelet at all times never donate blood use a condom during sexual intercourse wash your hands before and after bowel movements

Answer: D Rationale: Hepatitis A is transmitted through fecal-oral route so it is necessary to wash your hands before and after bowel movement to prevent the spread of infection.


(http://en.wikipedia.org/wiki/Hepatitis_A) Option A: this can be helpful however this is not a priority in the discharge instruction for Glenn. Medical alert bracelets are used for Alzheimers, asthma, persons with pacemakers, diabetes, autism, heart disease. http://en.wikipedia.org/wiki/MedicAlert Option B and C: Hepatitis B is transmitted through contaminated blood, sweat, tears, saliva, semen, saliva, vaginal secretions, menstrual blood and breast milk. Hepatitis C is primarily transmitted through blood to blood contact. Hepatitis D is transmitted in the same way as hepatitis B. Hepatitis D can only exist with the hepatitis B virus. Source: http://menshealth.about.com/cs/diseases/a/hepatitis_4.htm 55. A. B. C. D. Hepatitis A is differentiated from Hepatitis B. Hepatitis B is transmitted though: Urine Transfusion and infection Insect bite Fecal waste

Answer: B Rationale: Hepatitis B is transmitted through contaminated blood, sweat, tears, saliva, semen, saliva, vaginal secretions, menstrual blood and breast milk. Option D: Hepatitis A Virus is transmitted from person-to-person via the fecal-oral route. As Hepatitis A Virus is abundantly excreted in feces, and can survive in the environment for prolonged periods of time, it is typically acquired by ingestion of feces-contaminated food or water. Direct person-to-person spread is common under poor hygienic conditions. Option A and C: Hepatitis cannot be acquired though urine and insect bite. Source: http://menshealth.about.com/cs/diseases/a/hepatitis_4.htm http://www.who.int/csr/disease/hepatitis/HepatitisA_whocdscsredc2000_7.pdf Situation 12- Cindy a 42 year-old is admitted to the hospital with a diagnosis of Rheumatoid arthritis 56. A. B. C. D. Cindy reports the onset of early symptoms of RA. Which of the following would the nurse most likely to assess? Limited motion of the joints Deformed joint of the hands Early morning stiffness Heberdens Nodes

Answer: C Rationale: RA usually begins gradually, over a perio of several weeks to months; accompanied by systemic manifestations such as anorexia, weight loss, fatigue, muscle ching and stiffness. Joint pain and sewlling are associated with morning stiffness that can last several hours. Option A and B: this is usually a late symptom: there is bilateral involvement of the hands, (wrist, metacarpopharyngeal joints and proximal interphalangeal joints) is a characteristic of RA. Inflammation of the PIP contributes to the spinle shaped appearnce of the fingers. Option D: this is present in osteoarthritis and not in rheumatoid arthritis. SOURCE: Black.Medical-Surgical Nursing.7th Ed.Vol. 2.pp. 2335 57. When developing the plan of care during the acute phase of RA, which of the following would the nurse identify as the lowest priority? A. Relieving pain B. Preserving joint function C. Maintaining usual ways of accomplishing tasks D. Preventing joint deformity Answer: C Rationale: There should be changes done in order for patients to accomplish tasks easily. An example is patients should have easy-to-grip combs and brushes with large handles. Using a long handled bath brush to reach the feet and back during bathing is much less stressful on the joints. Options A, B and D are all important in planning care for patients in acute arthritis. SOURCE: Black.Medical-Surgical Nursing.7th Ed.Vol. 2.pp. 2341 58. A. B. C. D. Which assessment finding should the nurse expect in a patient with RA? An asymmetrical pattern of affected joints A positive rheumatoid factor titer The presence of heberdens nodes A positive antinuclear antibody titer

Answer: B Rationale


Rheumatoid arthritis. This is the most common reason for a rheumatoid factor (RF) level greater than 43 and a titer greater than 1:201:40. Normal values may vary from lab to lab. Rheumatoid factor (RF) T iters U nits less Less than 43 1:201:40 or

A rheumatoid factor (RF) blood test measures the amount of the RF antibody present in the blood. The results of the rheumatoid factor (RF) test may be reported in titers or units: A titer is a measure of how much the blood sample can be diluted before RF can no longer be detected. A titer of 1 to 20 (1:20) means that RF can be detected when 1 part of the blood sample is diluted by up to 20 parts of a salt solution (saline). A larger second number means there is more RF in the blood. Therefore, a titer of 1 to 80 shows more RF in the blood than a titer of 1 to 20. Source: http://www.questdiagnostics.com/kbase/topic/medtest/hw42783/results.htm Option A: joint involvement in RA are usually polyarticular and symmetrical, with the most frequently affected joints being those in the fingers, hands, wrists, knees and feet Option C: Heberdens nodes are present in osteoarthritis and not in rheumatoid arthritis. Option D: The antinuclear antibody (ANA) test is a test done early in the evaluation of a person for autoimmune or rheumatic disease, particularly systemic lupus erythematosus (SLE). http://www.answers.com/topic/antinuclear-antibody-test?cat=health 59. A. B. C. D. Which type of medication is most commonly used to treat RA? Glucocorticoids NSAIDs Antimalarial drugs Gold salts

Answer: B Rationale: NSAIDS are used to treat inflammation and swelling. NSAIDS suppresses inflammation by interfering with the boys production of prostaglandins. Prostaglandins play a major role in the process of inflammation and NSAIDs act by inhibiting their synthesis. Option A: Corticosteroids produce an immediate and profound anti inflammatory response in clients with RA. Low doses corticosteroid is used as a bridge to carry clients from unsuccessful NSAID therapy until they experience the benefits of slow acting, disease modifying agents. However most recent research found that low dose long term corticosteroid of less than 5mg/day to be correlated with the development of adverse effects specifically serious infections. (pages 2343-2344. Med-Surg by Black and Hawks) Option C: Anti-Malarial drugs/agents such as hydroxychloroquine ( HCQ) are widely used and have an acceptable toxicity profile and can be safely combined with other DMARDs ( Disease Modifying rheumatic agents). SOURCE: page 2342 Black and Hawks Medical-Surgical Nursing Option D: Gold Salts is used to reduce inflammation and slow disease progression in people with rheumatoid arthritis. Gold is not usually the first treatment given to people with rheumatoid arthritis (http://www.webmd.com/rheumatoid-arthritis/Gold-salts-for-rheumatoid-arthritis) 60. The nurse teaches a client with rheumatoid arthritis technique to reduce stress on the joints. The statement by the nurse that best describes a technique to reduce joint stress would be: A. Respond to pain in your joints B. Use your smaller muscles more frequently C. Do your heavy tasks all at once to reduce muscle strain D. If your joint are warm or swollen, increase exercise to reduce swelling Answer: A Rationale: Respect Pain: carry out activities and exercises only to the point of fatigue or discomfort. Reduce the time spent in doing painful activities. Avoid doing activities when joints are inflamed. Option B: Use larger or stronger joints: Lift with palm and forearm instead of fingers. Use backpack, waistpack or shoulder bag instead of handbag. Option C: Balance Work and Rest: Rest 5 to 10 minute periodically when doing tasks that take more time. Option D; when the joints are swollen, avoid activities and let the joint rest for a while. SOURCE: Black.Medical-Surgical Nursing.7th Ed.Vol. 2.pp. 2344 Situation 13- The nurse in the oncology unit assist in the care of patients diagnosed with cancer


61. A patient had just completed a course in the radiation therapy and is experiencing radiodermatitis. Which of the following is MOST effective method in treating the skin? A. leave the skin alone until it is clear B. wash the area with soap and warm water C. avoid applying creams and lotion to the area D. apply cream and lotion. Answer: C Rationale: Here are the skin Care within the treatment field: Keep skin dry Do not wash the treatment area until you are instructed to do so. When permitted, wash the treated area with mild soap, rinse well, and pat dry. Use warm or cool water, not hot water. Do not remove the lines or ink marks placed on your skin. Avoid using powder, lotions, creams, alcohol and deodorants on the treated skin. Wear loose-fitting clothing to avoid friction over treatment field. Do not apply tape on the treatment area if dressing are applied. Shave with an electric razor. Do not use pre shaved or after shaved lotions Protect your skin from exposure to direct sunlight, chlorinated pools, and temperature extremes. SOURCE: Black.Medical-Surgical Nursing.7th Ed.Vol. 1.pp.365 62. A nurse reviews the record of a client receiving external radiation therapy and notes documentation of a skin finding referred to as moist desquamation. The nurse expects to observe which of the following assessment of the client? A. Reddened skin B. A rash C. Weeping of the skin D. Dermatitis Answer: C Rationale: Moist desquamation occurs when the basal cells of the skin are destroyed. The dermal level is exposed, which results in the leakage of serum. Reddened skin, a rash, and dermatitis may occur with external radiation but are not described as moist desquamation. Source: Saunder 2nd ed. by Silvetri 63. The client asks the nurse how the chemotherapeutic drugs will work. The most accurate explanation the nurse can give is which of the following? A. Chemotherapy affects all rapidly dividing cells B. The molecular structure of the DNA is altered C. Cancer cells are susceptible to rug toxins D. Chemotherapy encourages cancer cells to divide Answer: A Rationale: There are many mechanisms of action for chemotherapeutic agents, but most affect the rapidly dividing cellsboth cancerous and noncencerous. Cancer cells are characterized by rapid cell division. Chemotherapy slows cell division. Not all chemotherapeutic agents affect molecular structure. All cells are susceptible to drug toxins, but not all chemotherapeutic agents are toxins. Source: Billings Lippincotts Review for NCLEX-RN 8th ed. 64. The nurse is aware that antineoplastic drugs are dangerous because they affect normal as well as cancer tissues. Normal cells that divide and proliferate rapidly are more at risk. Which of the following areas of the body would be LEAST at risk? A. Nervous tissue B. Lining of the GI tract C. Hair follicle D. Bone marrow Answer: A Rationale: Nervous tissue is the fourth major class of vertebrate tissue. The function of the nervous tissue is in communication between parts of the body. It is composed of neurons, which transmit impulses, and the neuroglia, which assist propagation of the nerve impulse as well as provide nutrients to the neuron. Since chemotherapy affects the rapidly dividing cells, nervous tissue is less affected because it is not rapidly dividing unlike lining of the GI tract, hair follicle, bone marrow and others. http://en.wikipedia.org/wiki/Nervous_tissue Option B: Diarrhea is the passage of increased volume of loose or watery stools several times a day with or without discomfort. Along with diarrhea, you may have gas, cramping, and bloating. Diarrhea occurs in about 3


out of 4 people who receive chemotherapy because of the damage to the rapidly dividing cells in the digestive (gastrointestinal) tract. Option C: Some chemotherapy drugs affect the rapidly growing cells of hair follicles. Your hair may become brittle and break off at the surface of the scalp, or it may simply fall out from the hair follicle. Basic facts about hair loss: Whether or not hair loss occurs depends on which drugs are given, their doses, and the length of treatment. Hair loss can be very individual. Some people may have complete loss of hair while others may see just a thinning of their hair. Loss of eyebrows, eyelashes, pubic hair, and body hair is usually less severe because the growth is less active in these hair follicles than in the scalp. If hair is going to be affected, you may see "shedding" start 2 to 3 weeks after treatment begins. Option D: Cells are constantly produced in the bone marrow where they are growing rapidly and, as a result, are sensitive to the effects of chemotherapy. Until your bone marrow cells recover from chemotherapy damage, you may have abnormally low numbers of WBCs, RBCs, and/or platelets. Damage to the bone marrow is called bone marrow suppression, or myelosuppression, and is one of the most common side effects of chemotherapy. Source: http://www.cancer.org/docroot/ETO/content/ETO_1_4X_What_Are_The_Side_Effects_of_Chemotherapy.asp? sitearea=ETO&viewmode=print& 65. A client receiving chemotherapy has an infiltrated intravenous line and extravasation at site. The nurse avoids doing which of the following in the management of this situation? A. Stopping the administration of the medication B. Leaving the needle in place and aspirating any residual medication C. Administering an available antidote as prescribed D. Applying direct manual pressure to the site Answer: D Rationale: General recommendations for managing extravasation of chemotherapeutic agent include stopping the infusion, leaving the needle in place and attempting to aspirate any residual medication from the site, administering an antidote if available, and assessing the site for complications. Direct pressure is not applied to the site because it could further injure tissues exposed to the chemotherapeutic agent. Source: Saunders 3rd ed. by Silvestri Situation 14- the nurse is caring for client admitted with severe burns. 66. A. B. C. D. The best approach for preventing hypovolemic shock in a client with severe burns is to: Administer dopamine Apply medical antishock trousers Infuse IV fluids infuse fresh frozen plasma

Answer: C Rationale: To prevent burn shock: In adults with burn injuries affecting more than 15% of the TBSA, IV resuscitation is generally required. Two peripheral large bore IV lines placed through non-burned skin, proximal to any extremity burns, is recommended. IV lines may be placed through burned skin if necessary; however these lines should be secured with a suture. For clients with extensive burns or limited peripheral IV access sites, cannulation of the central vein ( subclavian, internal or external jugular or femoral) by a physician may be necessary. fluid resuscitation is used to minimize the deleterious effects of fluid shifts. The goal of fluid resuscitation is to maintain vital organ perfusion while avoiding complications of inadequate or excessive fluids. Option A: Dopamine is used to treat heart and blood flow problems in shock (reduction of blood flow to all parts of the body). Shock may be caused by a heart attack, kidney failure, severe injury, or heart failure. This medication acts quickly to cause the heart to pump blood more effectively and therefore increase the blood flow from the heart, raise a dropping blood pressure, and increase urine flow. This helps in treatment of shock however this is not the best option in treating hypovolemic shock caused b burns. (http://www.webmd.com/drugs/drug-6226-Dopamine+IV.aspx?drugid=6226&drugname=Dopamine+IV) Option B: Medical Anti-Shock Trousers (MAST),also known as the Pneumatic Anti-Shock Garment (PASG), a garment for the lower half of the body that by applying pressure to this part increases the amount of blood in the upper half of the body. MAST has limited use and function. http://dictionary.reference.com/browse/military%20antishock%20trousers MAST (PASG) are "usually indicated, useful, and effective" (Class I evidence) for: None. MAST (PASG) are "acceptable, of uncertain efficacy, [although the] weight of evidence favors usefulness and efficacy" (Class IIa evidence) for: "Hypotension due to suspected pelvic fracture; Severe traumatic hypotension (palpable pulse, blood pressure not obtainable). *" MAST (PASG) are "acceptable, of uncertain efficacy, may be helpful, probably not harmful" (Class IIb evidence) for:


"Penetrating abdominal injury; Lower extremity hemorrhage (otherwise uncontrolled); * Pelvic fracture without hypotension; * Spinal shock. *" MAST (PASG) are "inappropriate, not indicated, may be harmful" (Class III evidence) for: "Adjunct to CPR; Diaphragmatic rupture; Penetrating thoracic injury; Pulmonary edema; To splint fractures of the lower extremities; Extremity trauma; Abdominal evisceration; Acute myocardial infarction; Cardiac tamponade; Cardiogenic shock; Gravid uterus." (http://www.health.state.ny.us/nysdoh/ems/policy/s97-04.htm) Option D: Fresh frozen plasma has a variety of uses. It can be given whole, or is processed to provide specific parts for certain purposes. Whole plasma is only used when someone is bleeding and has lost a lot of blood, for example after childbirth or during cardiac (heart) surgery. It helps the blood to clot and decreases bleeding. Processed plasma is also used to help produce stronger antibodies against diseases like tetanus, hepatitis, chickenpox and rabies. The albumin contained in plasma is extremely beneficial for burn victims. Adults with hypotension, burns or hypoproteinemia who were given albumin had a higher mortality rate than those given normal saline or no treatment. Source: http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=632&sectionId=18 http://www.med.umich.edu/pediatrics/ebm/cats/albumin.htm SOURCE: Black.Medical-Surgical Nursing.7th Ed.Vol. 2.pp. 1445 67. A. B. C. D. Which of the following metabolic alterations is expected during the first 8 hours post burn? hyponatremia and hyperkalemia hyponatremia and hypokalemia hypernatremia and hypokalemia hypernatremia and hyperkalemia

Answer: A Rationale: The patient has a decrease in cardiac output, increased peripheral vascular resistance and decreased perfusion to vital organs. Fluid is lost from the vascular, interstitial and cellular compartments. Sodium is lost from the vascular and interstitial fluid compartments and potassium is lost from the intracellular compartment. The direct damage to the vessels from heat further increase capillary permeability, which permits sodium ions to enter the cell and potassium ions to exit. This causes hyponatremia and hyperkalemia. SOURCE:Porth. Pathophysiology.Concepts of Altered health Status.6 th ed. pp.1435 Black.Medical-Surgical Nursing.7th Ed.Vol. 2.pp. 1436 68. A. B. C. D. What is the primary therapeutic goal during the acute phase? wound healing reconstructive surgery emotional support fluid reconstruction

Answer: A Rationale: The acute phase of recovery following a major burn begins when the client is hemodynamically stable, capillary integrity is restored, and diuresis has begun. This is generally 48-72 hours after the injury. Once fluid balance is achieved, the client moves into the acute phase of burn care. During this phase, closure of the wounds becomes one of the major foci of care. Many of the same principles of acre outlined for the emergent phase apply to the acute phase; however more emphasis is placed on restorative therapies. The acute phase continues until wound closure is achieved. Option B: Reconstructive surgery such as autografting, the surgical removal of a superficial layer of the clients own unburned skin, which is subsequently grafted to the excised or clean and granulating burn wound. Because the epidermis is split rather than taken in full, these grafts are referred to as split-thickness grafts. This procedure is performed in the operating room while the client is under general anesthesia. Autografts can be applied either as sheets (sheet graft) or in a meshed form (meshed graft). Reconstructive surgery is encompassed by wound healing. Option C: This should be eliminated since physiologic needs must be done first before psychosocial needs. Option D; Fluid reconstruction is primarily done in the emergent phase SOURCE: Black.Medical-Surgical Nursing.7th Ed.Vol. 2.pp. 1448, 1450, 1459


69. A client sustained major burn is beginning to take an oral diet again. The nurse plans to encourage the client to eat variety of which of the following types of foods to best help in continued wound healing and tissue repair? A. high carbohydrate and low protein B. high fat and low carbohydrate C. high protein and high fat D. high protein and high carbohydrate Answer: D Rationale: To promote adequate healing and to meet continued high metabolic needs, the client with a major burn should eat a diet that is high in calories, protein, and carbohydrate. This type of diet also keeps the client in positive nitrogen balance. There is no need to increase the amount of fat in the diet. Source: Saunders Q&A NCLEX Review 3rd edition 70. Ben is cleaning in the garage and accidentally splashes the eye with chemicals. What is the initial action following chemical burns? A. apply sterile gauze over eyes B. irrigate water 15 minutes longer C. irrigate with normal saline 1 to 15 minutes D. apply topical antibiotics Answer: B Rationale: After chemical exposure, the first step is to immediately (within seconds) begin flushing the eye with water. The easiest way to irrigate at home is for the patient to hold his or her head over a sink while the helper continuously pours water over the eye with a glass or cup. It is important to gently hold the lids apart while irrigating in order to rinse underneath the lids and wash away as much of the chemical as possible. Using a dry cloth is helpful because the lids are difficult to hold back when they are wet. Continue flushing the eye for approximately 20 minutes. Option A: Applying sterile gauze over the eye can cause additional harm because the chemical will cause more damage if it is not flushed. Option C: Water is acceptable to irrigate the eyes after chemical burn Option D: applying topical antibiotic should be prescribed by the physician and applying it as an emergency treatment for chemical burn in the eyes is not an option. (http://www.stlukeseye.com/Conditions/ChemicalBurn.asp) 71. A. B. C. D. What does R in the RACE during fire stands? Respond Rescue Run Rest

Answer: B Rationale: RACE stands for: Rescue, Activate alarm, Confine the Fire, Evacuate/Extinguish. When responding to a fire the staff should remember the acronym RACE: ' Rescue' anyone in immediate danger, pull the nearest fire ' Alarm' and phone your health care system's fire emergency number; 'Contain' the fire and smoke by closing every door and window and 'Extinguish' the fire with the right type fire extinguisher, but ONLY if you can do so without endangering yourself or others. Source: http://www.acronymfinder.com/af-query.asp?Acronym=RACE&String=exact&p=ol http://www.va.gov/vanthcs/orientation/MET/fire_safety.pdf Situation 15 - TM comes to the ER complaining of sudden and persistent pain in the anterior chest and back. Diagnosis: Dissecting Aortic Aneurysms 72. A. B. C. D. Which of the following is the most common cause of aortic aneurysm? Atherosclerosis Hepatomegaly Diabetes Mellitus Thromboembolism

Answer: A Rationale: The most common cause of aortic aneurysms is "hardening of the arteries" called arteriosclerosis. At least 80% of aortic aneurysms are from arteriosclerosis. The arteriosclerosis can weaken the aortic wall and the pressure of the blood being pumped through the aorta causes expansion at the site of weakness.


Other causes of aortic aneurysms include: Cigarette smoking - cigarette smoking not only increases the risk of developing an abdominal aortic aneurysm, the chance of aneurysm rupture (a life threatening complication of abdominal aneurysm) is also more common among active smokers. High blood pressure High serum cholesterol Diabetes mellitus Genetic - There is a familial tendency to developing abdominal aortic aneurysms. Individuals with firstdegree relatives having abdominal aortic aneurysms have a higher risk of developing abdominal aortic aneurysm than the general population. They also tend to develop the aneurysms at younger ages and have a higher tendency to suffer aneurysm rupture than individuals without family history. Post-traumatic: After physical trauma to the aorta. Arteritis (inflammation of blood vessels) as occurs in Takayasu disease, giant cell arteritis, and relapsing polychondritis. Mycotic (fungal) infection that may be associated with immunodeficiency, IV drug abuse, heart valve surgery. Source: http://www.medicinenet.com/abdominal_aortic_aneurysm/page2.htm 73. A. B. C. D. TM should be monitored of which of the following major complications? Hypertension Aortic Dissection Coarctation of the Aorta Polyphagia

Answer: B Rationale: Aortic dissection occurs when the layers of the aorta tear and separate from each other. The presence of an aortic aneurysm increases your risk of having an aortic dissection, but aortic dissection can also occur in people with a normal sized aorta. If left untreated, these conditions could lead to a fatal rupture. Option A: hypertension is one of the risk factors/causes of aortic aneurysm. Option C: Coarctation of the aorta can have a complication of aortic aneurysm, aortic dissection, aortic rupture, and hypertension. Option D: Polyphagia is more associated with Diabetes Mellitus which happens to be a risk factor for aortic aneurysm. Source: http://www.nlm.nih.gov/medlineplus/ency/article/000191.htm http://www.clevelandclinic.org/heartcenter/pub/guide/disease/aorta_marfan/aorticaneurysm.htm http://www.clevelandclinic.org/heartcenter/pub/guide/disease/aorta_marfan/aorticaneurysm.htm 74. A nurse is caring for TM with dissecting abdominal aortic aneurysm. The nurse avoids which of the following while caring for the client? A. Turning the client to the side o look for ecchymoses on the lower back B. Auscultating the arteries for bruits C. Performing deep palpation of the abdomen D. Telling the patient to report back, shoulder and neck pain Answer: C Rationale: The nurse avoids deep palpation in the client in which a dissecting aneurysm is known or suspected. Doing so can place a client in rupture. The nurse looks for ecchymoses on the lower back to determine whether the aneurysm is leaking, and tells he client to report back, neck, shoulder, or extremity pain. The nurse may auscultate the arteries for bruits. Source: saunder 2nd ed. by Silvetri 75. TM who has had an abdominal aortic aneurysm repair is on post operative day 1. The nurse performs an abdominal assessment and notes the absence of bowel sounds. The nurse best action is to: A. call the physician immediately B. remove the nasogastric tube C. feed the patient D. continue to assess for bowel sounds Answer: D Rationale: Bowel sounds may be absent for 3 to 4 days after surgery because of bowel manipulation during the procedure. The nurse should continue to monitor the client, the nasogastric tube should stay in place if present, and the client is kept on NPO until after the onset of bowel sounds. There is no need to call the physician immediately at this time. Source: Saunders 2nd ed. by Silvetri 76. A nurse has provided instructions to a client being discharged from the hospital to home after an abdominal aortic aneurysm (AAA) resection. The nurse determines that the client understands the instructions if the client stated that an appropriate activity would be to:


A. B. C. D.

Lift objects up to 30 pounds Walk as tolerated, including stairs and out of doors Mow the lawn Play a game of 18- hole golf

Answer: B Rationale: The client can walk as tolerated after repair or resection of an AAA, including climbing stairs and walking outdoors. The client should not lift objects that weigh more than 15 to 20 pounds for 6 to 8 weeks or engage in any activities that involve pushing, pulling, or straining. Driving is also prohibited for several weeks. Source: Saunders 3rd ed. by Silvetri page 550 Situation 16- Administer basic life support or CPR is a necessary skill for a nurse which is essential during emergency situations. 77. A nurse on the day shift walks into the clients room and finds the client to be unresponsive. The client is not breathing and does not have a pulse. The nurse immediately calls out for help. The next nursing action is which of the following? A. ventilate with mouth-to mouth mask device B. start chest compressions C. give the client oxygen D. open the airway Answer: D Rationale: After ensuring that the environment and safe and attempt to wake the victim by briskly rubbing your knuckles against the victim and still he wasnt awoke then begin rescue breathing. Open the victim's airway using the headtilt, chin-lift method. Put your ear to the victim's open mouth: look for chest movement ,listen for air flowing through the mouth or nose ,feel for air on your cheek . Option A: If there is no breathing, pinch the victim's nose; make a seal over the victim's mouth with yours. Use a CPR mask if available. Give the victim a breath big enough to make the chest rise. Let the chest fall, then repeat the rescue breath once more. Option B: After opening the airway, then begin chest compression. Place the heel of your hand in the middle of the victim's chest. Put your other hand on top of the first with your fingers interlaced. Compress the chest about 11/2 to 2 inches (4-5 cm). Allow the chest to completely recoil before the next compression. Compress the chest at a rate equal to 100/minute. Perform 30 compressions at this rate. Option D: Giving the client oxygen is given when the medical team arrives. The person who gives CPR follow the following steps: a. Stay safe b. Attempt to wake the victim c. begin rescue breathing d. begin chest compression e. Repeat rescue breaths f. Perform 30 more chest compressions g. Stop compressions and recheck victim for breathing. If the victim is not breathing, continue chest compressions and rescue breaths. h. Keep going until help arrives Source: http://firstaid.about.com/od/cpr/ht/06_cpr.htm 78. A. B. C. D. When performing chest compressions, the nurse understands the correct hand placement is located over the: Lower third of the sternum Upper half of the sternum Upper third of the sternum Lower half of the sternum

Answer D: Rationale: Proper hand placement is established by identifying the lower half of the sternum. A simplified method of achieving correct hand position has also been used in various settings for teaching laypersons the chest compression technique. To find a position on the lower half of the sternum, the rescuer is instructed to place the heel of one hand in the center of the chest between the nipples. This method has been used with success for >10 years in dispatcher-assisted CPR and other settings. The heel of one hand is placed on the lower half of the sternum and the other hand on top of the first, so that the hands are parallel. The sternum is depressed approximately 1and 1/2 to 2 inches (4 to 5 cm) for the normalsized adult. In very small victims, lesser degrees of compression may be sufficient, and in large victims, a slightly greater depth of chest compression may be needed to generate a carotid or femoral pulse. Between compressions the pressure on the sternum is released to enable blood to flow into the chest and heart. Source:http://www.americanheart.org/downloadable/heart/1101928707591b.CPR_hand_position_Adult.PF_AG.2 2nov04.Final.pdf 79. The nurse understands that when performing chest compressions on an adult client, the sternum should be depressed:


A. B. C. D.

to inches to 1 inch 1 to 2 inches 2 to 3 inches

Answer: C Rationale: Perform chest compressions: (adult) Place the heel of one hand on the breastbone -- right between the nipples. Place the heel of your other hand on top of the first hand. Position your body directly over your hands. Your shoulders should be in line with your hands. DO NOT lean back or forward. As you gaze down, you should be looking directly down on your hands. Give 15 chest compressions. Each time, press down about 2 inches into the chest. These compressions should be FAST with no pausing. Count the 15 compressions quickly: "a, b, c, d, e, f, g, h, i, j, k, l, m, n, off." Perform chest compressions: (child 1-8 years old) Place the heel of one hand on the breastbone just below the nipples. Make sure your heel is not at the very end of the breastbone. Keep your other hand on the child's forehead, keeping the head tilted back. Press down on the child's chest so that it compresses about 1 to 1 inch of the chest Give 5 chest compressions. Each time, let the chest rise completely. These compressions should be FAST with no pausing. Count the 5 compressions quickly: "a, b, c, d, off." Perform chest compressions: (infant) Place 2-3 fingers on the breastbone -- just below the nipples. Make sure not to press at the very end of the breastbone. Keep your other hand on the infant's forehead, keeping the head tilted back. Press down on the infant's chest so that it compresses about to 1 inch the depth of the chest. Give 5 chest compressions. Each time, let the chest rise completely. These compressions should be FAST with no pausing. Count the 5 compressions quickly: "a, b, c, d, off." Source: http://adam.about.com/encyclopedia/000011trt.htm http://library.advanced.org/10624/cpr.html 80. When performing basic life support on a 7 year old child. The nurse delivers how many breaths per minute to the child? A. 12 B. 16 C. 18 D. 20 Answer: D Rationale: Continued breaths should be given at a rate of normal respirations (20/min) in both infants and older children. When respiratory arrest has occurred and mechanical ventilation is anticipated, the child needs to be intubated, the child needs to be intubated to provide an open airway. SOURCE: Pilliterri. Maternal and child Nursing. .5th Edition. pp. 1317 81. A. B. C. D. The nurse understands that compression rate for an infant is: 60 times per minute 80 times per minute 100 times per minute 160 times per minutes

Answer: C Rationale: In a newborn, enough pressure will be generated by two fingers pressed on the Midsternum about a fingerbreadth below the nipple line in a depth of 0.5 to 1 inch. midsternal compression is used in newborn and infants to prevent excessive pressure on the ribs and possibility o breaking either a rib or a xiphoid process 9which then might puncture the heart or the liver). In the older child, you need to apply the heel of your palm over the sternum (measure one or two fingerbreadths up from the sternal-costal notch and place the palm there) and compress at the depth of 1 to 1.5 inch. Compress the chest at the rate of 100 beats/min in both infants and older children. SOURCE: Pilliterri. Maternal and child Nursing. .5th Edition. pp. 1317 Situation 17 - A mother calls the ER stating she found her 7 year old daughter taking childrens aspirin. She suspects that she took 8 to 10 aspirin. 82. A. B. C. D. The most important instruction for the nurse to give the mother before bringing the child to ER is: give the child a glass of milk administer 1 tbsp of syrup of ipecac to your child give your child a fleet enema let your child rest quietly in the car

Answer: B


Rationale: Syrup of Ipecac is very effective in aspirin or iron ingestion. This induces vomiting and is effective within 60 minutes of ingestion. (http://www.fpnotebook.com/ER76.htm) Option A: The best first aid is to dilute the poison as quickly as possible. For acids or alkalis (bases), give the patient water or preferably milk or ice cream - one (1) cup for victims under five (5) years; or one (1) to two (2) glasses for patients over five (5) years. Milk or ice cream is better than water because it dilutes and helps neutralize the poison. Water only dilute as the poison. (http://pmep.cce.cornell.edu/facts-slides-self/facts/gen-posaf-treat.html) Option C: Generic Name: sodium biphosphate and sodium phosphate Sodium biphosphate and sodium phosphate are forms of phosphorus, which is a naturally occurring substance that is important in every cell in the body. Sodium biphosphate and sodium phosphate is used to treat constipation and to clean the bowel before surgery, xrays, endoscopy, or other intestinal procedures. Sodium biphosphate and sodium phosphate enemas are also used for general care after surgery and to help relieve impacted bowels. (http://www.drugs.com/mtm/fleet-enema.html) Option D: doing nothing can let the patient experience aspirin toxicity and may manifest the following symptoms: Large overdoses may also cause: Ringing in the ears Tempoary deafness Hyperactivity Dizziness Drowsiness Hyperactivity Seizures Coma 83. A. B. C. D. The child was given aquamephyton and the nurse explains to the childs mother that it is given to: promote metabolism of aspirin prevent bleeding decrease absorption of aspirin prevent hepatotoxicity

Answer: B Rationale: PHYTONADIONE (Aquamephyton) is a man-made form of vitamin K. Vitamin K is found naturally in foods such as green, leafy vegetables, soybeans, and meats, especially liver. Phytonadione treats vitamin K deficiency or bleeding problems caused by various disorders. (http://www.drugdigest.org/DD/DVH/Uses/0,3915,7345|AquaMEPHYTON,00.html) The other options are distractors and are not related to the action of vitamin K and why it is given to the child. 84. The nurse is discussing safety measures to prevent poisoning with the mother. The nurse knows the mother understands safety precaution when she states: A. I have child protection locks on my cabinet under the sink B. My child is not potty-trained so the bathroom is safe C. I keep all poisons and cleaners above the fridge D. I dont think I have any poison in my house Answer: A Rationale: Store all medications - prescription and nonprescription - in a locked cabinet, far from children's reach. Even items that seem harmless, such as toothpaste, can be extremely dangerous if ingested in large quantities by children. Just because cabinets are up high doesn't mean kids can't get their hands on what's in them - children will climb up (using the toilet and countertops) to get to items in the medicine cabinet. (http://www.kidshealth.org/parent/firstaid_safe/home/safety_poisoning.html) Option B: Whether the child is potty trained or not, there may be some chemicals in the bathroom that should be placed in a safe place. Option C: Putting the poisons above the fridge is not safe because children may tend to climb it in order to reach it. Option D: although the parent may think that she might not have poison at home, simple things may be considered as dangerous like medication, batteries from watches, perfume, hair dye, hairspray, nail and shoe polish, and nail polish remover. These simple things may be neglected however can pose a great threat especially to children. 85. The mother brought her 16 year old daughter to the ER after swallowing a bottle of Tylenol (Acetaminophen). The nurse implements treatment of choice which is: A. Ipecac syrup B. Activated charcoal C. Mucomyst


D. Milk and observation Answer: C Rationale: Acetylcysteine (Mucomyst) is the drug of choice/antidote for acetaminophen toxicity/overdosage. (http://www.answers.com/topic/acetylcysteine?cat=technology) Option A: Ipecac syrup is indicated for acute oral drug or toxin overdose in alert patients. Ipecac syrup is usually given in patients who have aspirin overdosage as an emergency treatment. (http://www.templejc.edu/dept/ems/drugs/syrup_ipecac.html) Option B: Activated charcoal is widely used in the treatment of acute poisoning (overdose) with such substances as acetaminophen, salicylates, barbiturates and tricyclic antidepressants. Activated charcoal strongly adsorbs aromatic substances such as the above, reducing their absorption from the gastrointestinal tract. (http://www.pdrhealth.com/drug_info/nmdrugprofiles/nutsupdrugs/act_0014.shtml) Although activated charcoal is used is treatment of acute poisoning Mucomyst is the specific antidote for Tylenol overdosage. Option D: The best first aid is to dilute the poison as quickly as possible. For acids or alkalis (bases), give the patient water or preferably milk or ice cream - one (1) cup for victims under five (5) years; or one (1) to two (2) glasses for patients over five (5) years. Milk or ice cream is better than water because it dilutes and helps neutralize the poison. Water only dilute as the poison. (http://pmep.cce.cornell.edu/facts-slides-self/facts/gen-posaf-treat.html Situation 18 - Allen a 4 year old, newly diagnose with leukemia is admitted in the hospital. 86. Allen is place on bed rest. While assisting in morning care, the nurse notes bloody expectorant after the child brushed her teeth. The nurse should first: A. secure a smaller toothbrush for the childs use B. tell the child to be more careful when brushing the teeth C. record and report the incident without alarming the child D. rinse the childs mouth with half strength hydrogen peroxide Answer: C Rationale: Preschoolers have a wide variety of fear. At this stage, they have a wide imagination. They have a fear of boy mutilation and will imagine that that their body fluids or blood will leak out. It is important not to alarm the child when abnormal assessment findings were observed. Teach the significant others or family members to institute bleeding precautions during periods of thrombocytopenia. Monitor the client at least every 4 hours for manifestations of bleeding, such as petechiae, epistaxis, gingival bleeding, hematuria and others. Take and record vital signs routinely, noting manifestations of altered tissue perfusion, it is also important to document all findings and report to the attending physician after necessary assessment was done. SOURCE: Black.Medical-Surgical Nursing.7th Ed.Vol. 2.pp. 2409 http://www.netwellness.org/question.cfm/18844.htm Option A: Provide a soft toothbrush or oral sponges for oral hygiene. Although the toothbrush is small, it may still cause oral bleeding. Avoid hard toothbrush, flossing and commercial mouthwashes containing alcohol. SOURCE: Black.Medical-Surgical Nursing.7th Ed.Vol. 2.pp. 2409 Option B: At the age of four years old, the child may not be able to perform the correct way of brushing his teeth. The adult usually do the brushing at this age until the child reaches 5 or 6 when she is old enough to handle the toothbrush on her own. Even though she knows how to handle the brush at 5 or 6 years of age, adult supervision is still required until she is 7 to 8 years of age. http://www.yourhealthconnection.com/topic/toothgum Option D: The continued use of hydrogen peroxide solution as a mouthwash, even in half strength, may cause hypertrophied filiform papillae of the tongue (hairy tongue) but these disappear after drug is discontinued. http://www.gasdetection.com/TECH/h2o2.html 87. A. B. C. D. The nurse should consider it unusual to observe Allen: marked fatigue and pallor multiple bruises and petechiae enlarged lymph nodes marked jaundice and generalize edema

Answer: D Rationale: Marked jaundice and generalized edema is more common in liver problems such as Liver cirrhosis compared to leukemia. In leukemia there is only hepatomegaly and this is more common in adult type leukemia (ANLL) than in ALL. Option A: Clinical manifestations of bone marrow depression include fatigue caused by anemia and bleeding resulting from thrombocytopenia. Option B: Bleeding may occur in the skin. Gums, mucous membrane, GI tract, and genitourinary tract. Bleeding is the underlying cause of petechiae and ecchymosis. Option C: Liver, spleen and lymph nodes enlargement are more common in acute lymphoblastic leukemia (ALL), which is most common in children, than in Acute nonlymphocytic leukemia, which is more common in adult.


88. A. B. C. D.

Which of the following assessment findings in Allen would indicate that the cancer has involved the brain? Headache and vomiting restlessness and tachycardia hypervigilant and anxious behaviors increased heart rate and decreased blood pressure

Answer: A Rationale: There is the presence of brain metastasis if the patient experiences headache and vomiting; this is due to the increase in intracranial pressure caused by the growing tumor. Option B and D: Tachycardia or an increased heart rate may be due to the following and may not directly indicate brain metastasis. Exercise, Nervousness, Anxiety, fever, high blood pressure, congestive heart failure, asthma, anemia, and panic attack may some of the things that can contribute in the heart rate. Option C: Anxiety and hypervigilant behaviors may be due to a lot of factors however it may not directly indicate brain metastasis of cancer. Source: http://www.wrongdiagnosis.com/t/tachycardia/causes.htm 89. Which of the following test is performed on a client with leukemia before initiation of therapy to evaluate Allen to metabolize chemotherapeutic agents? A. lumbar puncture B. liver function studies C. complete blood count D. peripheral blood smear Answer: B Rationale: The liver has the following functions: Stores iron reserves, as well as vitamins and minerals. Detoxifies poisonous chemicals, including alcohol, beer, wine, and drugs - prescribed and over-the-counter as well as illegal substances. Acts as a filter to convert them to substances that can be used or excreted from the body Liver function tests are a battery of tests that give your doctor an idea of how well your liver is working. From these studies, your doctor can identify possible liver disease, medication stress on liver function, or infections of the liver such as hepatitis. There are several different tests that comprise LFT's. Albumin (ALB) Albumin is a protein produced by the liver that helps maintain osmotic pressure in the vascular space. By maintaining this pressure, fluid stays in the vascular system instead of leaking out into the tissues resulting in swelling (edema). Albumin also carries certain minerals in the blood stream. Normal values: 4 - 6 Elevated: Usually indicates dehydration Below normal: Can indicate liver dysfunction or insufficient protein intake. Alkaline Phosphatase (ALK PHOS) Alkaline phosphatase is an enzyme found in many organs in the body, including the liver. Normal values: 30 - 120 Elevated: A warning sign that there is some type of liver dysfunction resulting in liver tissue damage. Below normal: Usually not significant. Alanine Aminotransferase (ALT or SGPT) This protein is found primarily in the liver. http://aids.about.com/od/hepatitisbasics/qt/lfts.htm Option A: A lumbar puncture is done to: Find a cause for symptoms possibly caused by an infection (such as meningitis), inflammation, cancer, or bleeding in the area around the brain or spinal cord (such as subarachnoid hemorrhage). Measure the pressure of cerebrospinal fluid (CSF) in the space surrounding the spinal cord. If the pressure is high, it may be causing certain symptoms.

Put anesthetics or medicines into the CSF. Medicines may be injected to treat leukemia and other types of cancer of the central nervous system.
Put a dye in the CSF that makes the spinal cord and fluid clearer on X-ray pictures (myelogram). This may be done to see whether a disc or a cancer is bulging into the spinal canal. CSF. In rare cases, a lumbar puncture may be used to lower the pressure in the brain caused by too much

http://www.webmd.com/brain/lumbar-puncture Option C: The complete blood count (CBC) is a very common blood test. It evaluates the three major types of cells in blood: red blood cells, white blood cells, and platelets. Doctors often order a CBC for a child to check for anemia, infections, or other health problems. http://kidshealth.org/parent/system/medical/labtest4.html


Option D: A blood film or peripheral blood smear is a slide made from a drop of blood, that allows the cells to be examined microscopically. Blood films are usually done to investigate hematological problems (disorders of the blood itself) and, occasionally, to look for parasites within the blood such as malaria and filaria. http://en.wikipedia.org/wiki/Peripheral_blood_smear 90. Which of the following statements would the nurse use to describe to the parents why their child with leukemia is at risk for infection? A. B. C. D. Play activities are too strenuous Vitamin C intake is reduced over a period of time The number of red blood cells is inadequate for carrying oxygen Immature white blood cells are incapable of handling an infectious process.

Answer: D Rationale: In leukemia, the number of normal white blood cells that are capable of fighting an infection is decreased. Although there is an increased number of an immature white blood cell, they are unable to combat infection. Therefore, a child with leukemia is subject to infection. The major morbidity and mortality factor associated with leukemia is infection resulting from the presence of granulocytopenia. Source: Lippincotts Review for NCLEX-RN Examination. Situation 19- An 80 year old woman has come to the clinic for annual physical examination. 91. Which assessment finding in the elderly is caused by decreased vessel elasticity and increased peripheral resistance? A. Confusion and disorientation B. An irregular peripheral pulse rate C. An increased in blood pressure D. Wide QRS complexes on the ECG Answer C: Rationale: The increase in diastolic and systolic blood pressure is due to the inelasticity of systemic arteries and increased peripheral resistance. Our blood vessels, including the aorta and other arteries also become stiffer and are less responsive to hormones that relax the blood vessel walls. The stiffening of blood vessels contributes to the increasing systolic blood pressure with aging observed in most cultures. SOURCE: Kozier. Fundamentals of Nursing.7th Edition.pp. 404-405 Option A: In older persons, changes in cognitive abilities are more often a difference in speed than in ability. Overall the older adults maintain intelligence, problem solving, judgment, creativity, and other well practiced cognitive skills. Intellectual loss generally reflects a disease process such as atherosclerosis, which causes blood vessel to narrow and diminish perfusion of nutrients to the brain. Most older adult do not experience cognitive impairments SOURCE: Kozier. Fundamentals of Nursing.7th Edition.pp. 409 Option B and D: The pacemaker of the heart loses cells and develops fibrous tissue and fat deposits. These changes may cause a slightly slower heart rate and even heart block. Abberant heart rhythms and extra heart beats become more common. Our heart rate may be slightly slower as we grow older due to a loss in the number of pacemaker cells. The electrical pathways may develop fibrous tissue and fat deposits that can make dysrhythmias more common. Shifts in the circulation of blood to various organs can also change-- the blood flow to the kidneys may decrease by 50 percent and to the brain by 15 to 20 percent. Finally, heart murmurs are more common with age because our heart valves become less flexible and calcium deposits build up. (http://www.ageworks.com/course_demo/513/module3/module3.htm#cardio) 92. A. B. C. D. The mental process most sensitive to deterioration with aging seems to be: Creativity Judgment Intelligence Short Tem memory

Answer: D Rationale: In older adults, retrieval of information from long term memory can be slower, especially if the information is not frequently used. Most age related differences occur in shot term memory. Older adults tend to forget recent past. Other options: Overall the older adults maintain intelligence, problem solving, judgment, creativity, and other well practiced cognitive skills. SOURCE: Kozier. Fundamentals of Nursing.7th Edition.pp. 409 93. What is the caused of urinary incontinence in elderly? A. decreased glomerular filtration rate B. dilated urethra


C. decreased bladder capacity D. diuretic use Answer: C Rationale: Urinary urgency and frequency is caused by enlarged prostate gland in men, weakened muscle supporting the bladder or weakness of the urinary sphincter in women. Also the capacity of the bladder and its ability to completely empty diminish with age. SOURCE: Kozier. Fundamentals of Nursing.7th Edition.pp. 406 Option A: the excretory function of the kidney diminishes with age, but usually not significant below normal levels unless a disease process intervenes. The kidneys filtering abilities may be also impaired; thus waste products may be filtered and excreted more slowly. Option B and D: and diuretic use does not contribute to the urinary incontinence in elderly. 94. A. B. C. D. In communicating with an elderly, which verbal communication is used minimally? Interacting with him one at a time Giving him information step by step Restating Asking open ended questions

Answer: D Rationale: Using open ended question in an adult may cause the elder to have difficulty in expressing self because older adults have cognitive problems that necessitate nursing interventions for improvement of communication skills. Older adults may experience the following that makes communication difficult: Sensory deficit, cognitive impairment (dementia), neurological deficits from stroke o other neurological conditions such as aphasia, psychosocial problems. Other options: Recognition of specific needs and obtaining appropriate resources for clients can greatly increase their socialization and quality of life; interventions directed towards improving communication with these special needs are as follows: make use of communication aids such as communication boards, computers, or pictures when possible. Keep the environment distractions to a minimum. Speak in a short, simple sentences, one subject at a time- reinforce or repeat what is said when necessary. Include family and friends in conversation. Use reminiscing, either in individual conversation or in groups to maintain memory connections and to enhance self identity and self-esteem in older adults. SOURCE: Kozier. Fundamentals of Nursing.7th Edition.pp. 438 95. A. B. C. D. The physical findings that are normal in older people include: a loss of skin elasticity and a decreased libido impaired fat digestion and increased salivary secretions an increase in body warmth increased blood pressure and decreased hormone production in women .

Answer: D Rationale: Increased blood pressure is caused by inelasticity of the systemic arteries and increased peripheral resistance. In women, there is also diminished secretion of female hormones and more alkaline vaginal pH. This is caused by shrinkage of the reproductive organs in women. SOURCE: Kozier. Fundamentals of Nursing.7th Edition.pp. 404-405 Option A: there is just lesser skin elasticity a people gets older but it is not loss completely as well as the skin becomes thinner. Option B: Saliva production decreases and incidences of periodontal disease increase with aging. With aging, esophageal peristalsis slows and sphincters in the digestive system are less effective; this causes delayed entry of food into the stomach, increased risk of choking, and increased heartburn. Peristalsis and nerve sensation slows in the large intestine, increasing the incidence of constipation with aging. OPTION C: In aging, subcutaneous fat diminishes, causing feelings of coldness, even in warm temperatures. Source: http://www.nursinghomelawyer.com/nursing_home_law_firm/nursing_home_research/aging_disease/normal_agin g_changes.htm Situation 20- Leandro, 70 year old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis is CVA.


96. Considering Leandros conditions, which of the following is important to include in preparing Leandros Bedside equipment? A. Hand bell and extra bed linen B. Sandbag and trochanter rolls C. Footboard and splint D. Suction machine and gloves Answer: D Rationale: CVA patients have impaired swallowing ability if not absent, depressed gag reflex. Client is at high risk for aspiration when eating or drinking that is why NGT is initiated early in the hospitalization. Option A: not specific for clients with fractures. Option B: prevent External Rotation in the hip or leg fracture. Option C: Footboard and splints prevent footdrop that is seen in clients that has severed peroneal nerve or prolonged immobilized usually due to fractures that eventually puts pressure on the peroneal nerves. 97. When a client arrives in the emergency department with an ischemic CVA. Which is the priority for the nurse to assess in relation to the treatment of tissue plasminogen activator (t-PA) administration? A. current medications B. Complete physical and history C. time of onset of CVA D. upcoming surgical procedures Answer: C Rationale: Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a CVA have better outcomes. The time from the onset of stroke to t-PA treatment is a priority assessment. A complete physical history is not possible when a client is receiving emergency care. 98. During the first 24 hours after thrombolytic treatment for an ischemic CVA, the primary goal is to control the clients: A. Pulse B. Respirations C. Blood pressure D. Temperature Answer: C Rationale: Patients receiving thrombolytic therapy for acute ischemic stroke must have constant neurologic and cardiovascular reevaluation. Blood pressure checks must be every 15 minutes for 2 hours, then every 30 minutes for 6 hours and finally every hour for 16 hours. Strict blood pressure monitoring is essential during and after thrombolytic treatment in order to prevent complications. If a patient has signs of neurologic deterioration, stop thrombolytic therapy and obtain an emergent CT scan. (http://www.emedicine.com/emerg/topic831.htm) OPTIONS A, B, and D: Temperature, Respirations and Pulse are also important however it is not a priority in the during the first 24 hours after thrombolytic therapy of a stroke patient 99. A. B. C. D. Which of the following statements can best describe stroke or brain attack? occurs when circulation to four parts of the brain is interrupted usually caused by abuse in medicines cerebral hemorrhage results to TIA

Answer: A Rationale: Stroke or brain attack is an acute focal neurologic deficit from an interruption of blood flow in a cerebral vessel (ischemic stroke, the most common type) due to thrombi or emboli or to bleeding into the brain tissue (hemorrhagic stroke) Option B: The risk factors or stroke includes age, sex, race, heart disease, hypertension, high cholesterol levels, cigarette smoking, prior stroke, and diabetes mellitus. Other risk factors include sickle cell disease, polycythemia, blood dyscrasias, excess alcohol abuse, cocaine and illicit drug abuse, obesity, sedentary lifestyle. Option C: A subarachnoid or cerebral hemorrhage occurs when a blood vessel on the brain's surface ruptures bleeds into the space between the brain and the skull (but not into the brain itself). This belongs to the two types of stroke which is ischemic and hemorrhagic stroke. (http://www.americanheart.org/presenter.jhtml?identifier=4755)


Option D: transient Ischemic Attack belongs to Ischemic stroke. This is characterized by focal, ischemic cerebral neurologic deficits that last for less than 24 hours (usually less than 1 to 2 hours). TIA or mini stroke is equivalent to brain angina. SOURCE:Porth. Pathophysiology.Concepts of Altered health Status.6 th ed. pp.1174-1175 100. Which of the following techniques does the nurse avoid when changing a clients position in bed if the client has hemiparalysis? A. rolling the client into her side B. sliding the client to move her up in bed C. lifting the client when moving her up in bed D. having the client help lift herself off the bed using a trapeze

Answer: B Rationale: Shear force, or a force created when the skin of a patient stays in one place as the deep fascia and skeletal muscle slide down with gravity. This can also cause the pinching off of blood vessels which may lead to ischemia and tissue necrosis. (http://en.wikipedia.org/wiki/Pressure_ulcer) The other options are acceptable ways to move the patient up in bed.