SET II

All the questions in the quiz along with their answers are shown below. Your answers are
bolded. The correct answers have a green background while the incorrect ones have a red
background.
1. The student nurse is assigned to take the vital signs of the clients in the pediatric ward.
The student nurse reports to the staff nurse that the parent of a toddler who is 2 days
postoperative after a cleft palate repair has given the toddler a pacifier. What would be
the best immediate action of the nurse?
A) Notify the pediatrician of this finding
B) Reassure the student that this is an acceptable action on the parents part
C) Discuss this action with the parents
D) Ask the student nurse to remove the pacifier from the toddlers mouth
Nothing must be placed in the mouth of a toddler who just undergone a cleft palate repair
until the suture line has completely healed. It is the nurses responsibility to inform the
parent of the client. Spoon, forks, straws, and tongue blades are other unacceptable items
to place in the mouth of a toddler who just undergone cleft palate repair. The general
principle of care is that nothing should enter the mouth until the suture line has
completely healed.
2. The nurse is providing a health teaching to the mother of an 8-year-old child with
cystic fibrosis. Which of the following statement if made by the mother would indicate to
the nurse the need for further teaching about the medication regimen of the child?
A) My child might need an extra capsule if the meal is high in fat
B) Ill give the enzyme capsule before every snack
C) Ill give the enzyme capsule before every meal
D) My child hates to take pills, so Ill mix the capsule into a cup of hot chocolate
The pancreatic capsules contain pancreatic enzyme that should be administered in a cold,
not a hot, medium (example: chilled applesauce versus hot chocolate) to maintain the
medications integrity.
3. The mother brought her child to the clinic for follow-up check up. The mother tells
the nurse that 14 days after starting an oral iron supplement, her childs stools are black.
Which of the following is the best nursing response to the mother?
I will notify the physician, who will probably decrease the dosage slightly
This is a normal side effect and means the medication is working
You sound quite concerned. Would you like to talk about this further?
I will need a specimen to check the stool for possible bleeding
When oral iron preparations are given correctly, the stools normally turn dark green or
black. Parents of children receiving this medication should be advised that this side effect
indicates the medication is being absorbed and is working well.

4. An 8-year-old boy with asthma is brought to the clinic for check up. The mother
asks the nurse if the treatment given to her son is effective. What would be the
appropriate response of the nurse?
A) I will review first the childs height on a growth chart to know if the treatment
is working
B) I will review first the childs weight on a growth chart to know if the treatment
is working
C) I will review first the number of prescriptions refills the child has required over
the last 6 months to give you an accurate answer
D) I will review first the number of times the child has seen the pediatrician
during the last 6 months to give you an accurate answer
Reviewing the number of prescription refills the child has required over the last 6 months
would be the best indicator of how well controlled and thus how effective the childs
asthma treatment is. Breakthrough wheezing, shortness of breath, and upper respiratory
infections would require that the child take additional medication. This would be
reflected in the number of prescription refills.
5. The nurse is caring to a child client who is receiving tetracycline. The nurse is aware
that in taking this medication, it is very important to:
A) Administer the drug between meals
B) Monitor the childs hearing
C) Give the drug through a straw
D) Keep the child out of the sunlight
Tetracycline may cause a phototoxic reaction.
6. A 14 day-old infant with a cyanotic heart defects and mild congestive heart failure is
brought to the emergency department. During assessment, the nurse checks the apical
pulse rate of the infant. The apical pulse rate is 130 beats per minute. Which of the
following is the appropriate nursing action?
A) Retake the apical pulse in 15 minutes
B) Retake the apical pulse in 30 minutes
C) Notify the pediatrician immediately
D) Administer the medication as scheduled
The normal heart rate of an infant is 120-160 beats per minute.
7. The physician prescribed gentamicin (Garamycin) to a child who is also receiving
chemotherapy. Before administering the drug, the nurse should check the results of the
childs:
A) CBC and platelet count
B) Auditory tests
C) Renal Function tests
D) Abdominal and chest x-rays

Both gentamicin and chemotherapeutic agents can cause renal impairment and acute
renal failure; thus baseline renal function must be evaluated before initiating either
medication.
8. Which of the following is the suited size of the needle would the nurse select to
administer the IM injection to a preschool child?
A) 18 G, 1-1/2 inch
B) 25 G, 5/8 inch
C) 21 G, 1 inch
D) 18 G, 1inch
In selecting the correct needle to administer an IM injection to a preschooler, the nurse
should always look at the child and use judgment in evaluating muscle mass and amount
of subcutaneous fat. In this case, in the absence of further data, the nurse would be most
correct in selecting a needle gauge and length appropriate for the average preschool
child. A medium-gauge needle (21G) that is 1 inch long would be most appropriate.
9. A 9-year-old boy is admitted to the hospital. The boy is being treated with salicylates
for the migratory polyarthritis accompanying the diagnosis of rheumatic fever. Which of
the following activities performed by the child would give a best sign that the medication
is effective?
A) Listening to story of his mother
B) Listening to the music in the radio
C) Playing mini piano
D) Watching movie in the dvd mini player
The purpose of the salicylate therapy is to relieve the pain associated with the migratory
polyarthritis accompanying the rheumatic fever. Playing mini piano would require
movement of the childs joints and would provide the nurse with a means of evaluating
the childs level of pain.
10. The physician decided to schedule the 4-year-old client for repair of left
undescended testicle. The Injection of a hormone, HCG finds it less successful for
treatment. To administer a pentobarbital sodium (Nembutal) suppository preoperatively
to this client, in which position should the nurse place him?
A) Supine with foot of bed elevated
B) Prone with legs abducted
C) Sitting with foot of bed elevated
D) Side-lying with upper leg flexed
The recommended position to administer rectal medications to children is side-lying with
the upper leg flexed. This position allows the nurse to safely and effectively administer
the medication while promoting comfort for the child.
11. The nurse is caring to a 24-month-old child diagnosed with congenital heart
defect. The physician prescribed digoxin (Lanoxin) to the client. Before the

administration of the drug, the nurse checks the apical pulse rate to be 110 beats per
minute and regular. What would be the next nursing action?
A) Check the other vital signs and level of consciousness
B) Withhold the digoxin and notify the physician
C) Give the digoxin as prescribed
D) Check the apical and radial simultaneously, and if they are the same, give the
digoxin.
For a 12month-old child, 110 apical pulse rate is normal and therefore it is safe to give
the digoxin. A toddlers normal pulse rate is slightly lower than an infants (120).
12. An 8-year-old client with cystic fibrosis is admitted to the hospital and will undergo
a chest physiotherapy treatment. The therapy should be properly coordinated by the
nurse with the respiratory therapy department so that treatments occur during:
A) After meals
B) Between meals
C) After medication
D) Around the childs play schedule
Chest physiotherapy treatments are scheduled between meals to prevent aspiration of
stomach contents, because the child is placed in a variety of positions during the
treatment process.
13. The nurse is providing health teaching about the breastfeeding and family planning
to the client who gave birth to a healthy baby girl. Which of the following statement
would alert the nurse that the client needs further teaching?
A) I understand that the hormones for breastfeeding may affect when my periods
come
B) Breastfeeding causes my womb to tighten and bleed less after birth
C) I may not have periods while I am breastfeeding, so I dont need family
planning
D) I can get pregnant as early as one month after my baby was born
It is common misconception that breastfeeding may prevent pregnancy.
14. A toddler is brought to the hospital because of severe diarrhea and vomiting. The
nurse assigned to the client enters the clients room and finds out that the client is using a
soiled blanket brought in from home. The nurse attempts to remove the blanket and
replace it with a new and clean blanket. The toddler refuses to give the soiled blanket.
The nurse realizes that the best explanation for the toddlers behavior is:
A) The toddler did not bond well with the maternal figure
B) The blanket is an important transitional object
C) The toddler is anxious about the hospital experience
D) The toddler is resistive to nursing interventions

The security blanket is an important transitional object for the toddler. It provides a
feeling of comfort and safety when the maternal figure is not present or when in a new
situation for which the toddler was not prepared. Virtually any object (stuffed animal,
doll, book etc) can become a security blanket for the toddler.
15. The nurse has knowledge about the developmental task of the child. In caring a 3year-old-client, the nurse knows that the suited developmental task of this child is to:
A) Learn to play with other children
B) Able to trust others
C) Express all needs through speaking
D) Explore and manipulate the environment
Toddlers need to meet the developmental milestone of autonomy versus shame and doubt.
In order to accomplish this, the toddler must be able to explore and manipulate the
environment.
16. A mother who gave birth to her second daughter is so concerned about her 2-year
old daughter. She tells the nurse, I am afraid that my 2-year-old daughter may not
accept her newly born sister. It is appropriate to the nurse to response that:
A) The older daughter be given more responsibility and assure her that she is a
big girl now, and doesnt need Mommy as much
B) The older daughter not have interaction with the baby at the hospital, because
she may harm her new sibling
C) The older daughter stay with her grandmother for a few days until the parents
and new baby are settled at home
D) The mother spend time alone with her older daughter when the baby is
sleeping
The introduction of a baby into a family with one or more children challenges parent to
promote acceptance of the baby by siblings. The parents attitudes toward the arrival of
the baby can set the stage for the other childrens reaction. Spending time with the older
siblings alone will also reassure them of their place in the family, even though the older
children will have to eventually assume new positions within the family hierarchy.
17. A 2-year-old client with cystic fibrosis is confined to bed and is not allowed to go to
the playroom. Which of the following is an appropriate toy would the nurse select for the
child:
A) Puzzle
B) Musical automobile
C) Arranging stickers in the album
D) Pounding board and hammer
The autonomous toddler would be frustrated by being confined to be. The pounding
board and hammer is developmentally appropriate and an excellent way for the toddler to
release frustration.

18.

Which of the following clients is at high risk for developmental problem?

A) A toddler with acute Glomerulonephritis on antihypertensive and antibiotics
B) A 5-year-old with asthma on cromolyn sodium
C) A preschooler with tonsillitis
D) A 2 1/2 year old boy with cystic fibrosis

It is the developmental task of an 18-month-old toddler to explore and learn about the
environment. The respiratory complications associated with cystic fibrosis (which are
present in almost all children with cystic fibrosis) could prevent this development task
from occurring.
19. Which of the following would be the best divesionary activity for the nurse to select
for a 2 weeks hospitalized 3-year-old girl?
A) Crayons and coloring books
B) doll
C) xylophone toy
D) puzzles
The best diversion for a hospitalized child aged 2-3 years old would be anything that
makes noise or makes a mess; xylophone which certainly makes noise or music would be
the best choice.
20. A nurse is providing safety instructions to the parents of the 11-month-old child.
Which of the following will the nurse includes in the instructions?
A) Plugging all electrical outlets in the house
B) Installing a gate at the top and bottom of any stairs in the home
C) Purchasing an infant car seat as soon as possible
D) Begin to teach the child not to place small objects in the mouth
An 11-month-old child stands alone and can walk holding onto people or objects.
Therefore the installation of a gate at the top and bottom of any stairs in the house is
crucial for the childs safety.
21. An 8-year-old girl is in second grade and the parents decided to enroll her to a new
school. While the child is focusing on adjusting to new environment and peers, her
grades suffer. The childs father severely punishes the child and forces her daughter to
study after school. The father does not allow also her daughter to play with other
children. These data indicate to the nurse that this child is deprived of forming which
normal phase of development?
A) Heterosexual relationships
B) A love relationship with the father
C) A dependency relationship with the father
D) Close relationship with peers
In second grade a child needs to form a close relationships with peers.

22. A 5-year-old boy client is scheduled for hernia surgery. The nurse is preparing to
do preoperative teaching with the child. The nurse should knows that the 5-year-old
would:
A) Expect a simple yet logical explanation regarding the surgery
B) Asks many questions regarding the condition and the procedure
C) Worry over the impending surgery
D) Be uninterested in the upcoming surgery
A 5-year-old is highly concerned with body integrity. The preschool-age child normally
asks many questions and in a situation such as this, could be expected to ask even more.
23. The nine-year-old client is admitted in the hospital for almost 1 week and is on bed
rest. The child complains of being bored and it seems tiresome to stay on bed and doing
nothing. What activity selected by the nurse would the child most likely find
stimulating?
A) Watching a video
B) Putting together a puzzle
C) Assembling handouts with the nurse for an upcoming staff development
meeting
D) Listening to a compact disc
A 9-year-old enjoys working and feeling a sense of accomplishment. The school-age
child also enjoys showing off, and doing something with the nurse on the pediatric unit
would allow this. This activity also provides the school-age child a needed opportunity to
interact with others in the absence of school and personal friends.
24. The parent of a 16-year-old boy tells the nurse that his son is driving a motorbike
very fast and with one hand. It is making me crazy! What would be the best
explanation of the nurse to the behavior of the boy?
A) The adolescent might have an unconscious death wish
B) The adolescent feels indestructible
C) The adolescent lacks life experience to realize how dangerous the behavior is
D) The adolescent has found a way to act out hostility toward the parent
Adolescents do feel indestructible, and this is reflected in many risk-taking behaviors.
25. An 8-month-old infant is admitted to the hospital due to diarrhea. The nurse caring
for the client tells the mother to stay beside the infant while making assessment. Which
of the following developmental milestones the infant has reached?
A) Has a three-word vocabulary
B) Interacts with other infants
C) Stands alone
D) Recognizes but is fearful of strangers
An 8-month-old infant both recognizes and is fearful of strangers. This developmental
milestone is known as stranger anxiety.

26. The community nurse is conducting a health teaching in the group of married
women. When teaching a woman about fertility awareness, the nurse should emphasize
that the basal body temperature:
A) Should be recorded each morning before any activity
B) Is the average temperature taken each morning
C) Can be done with a mercury thermometer but not a digital one
D) Has a lower degree of accuracy in predicting ovulation than the cervical mucus
test
The basal body temperature (BBT) is the lowest body temperature of a healthy person
that is taken immediately after waking and before getting out of bed. The BBT usually
varies from 36.2 36.3 degree Celsius during menses and for about 5-7 days afterward.
About the time of ovulation, a slight drop approximately 0.05 degree Celsius in
temperature may be seen; after ovulation, in concert with the increasing progesterone
levels of the early luteal phase, the BBT rises 0.2-0.4 degree Celsius. This elevation
remains until 2-3 days before menstruation, or if pregnancy has occurred.
27. The community nurse is providing an instruction to the clients in the health center
about the use of diaphragm for family planning. To evaluate the understanding of the
woman, the nurse asks her to demonstrate the use of the diaphragm. Which of following
statement indicates a need for further health teaching?
A) I should check the diaphragm carefully for holes every time I use it.
B) The diaphragm must be left in place for at least 6 hours after intercourse.
C) I really need to use the diaphragm and jelly most during the middle of my
menstrual cycle
D) I may need a different size diaphragm if I gain or lose more than 20 pounds
The woman must understand that, although the fertile period is approximately
midcycle, hormonal variations do occur and can result in early or late ovulations. To be
effective, the diaphragm should be inserted before every intercourse.
28. The client visits the clinic for prenatal check-up. While waiting for the physician,
the nurse decided to conduct health teaching to the client. The nurse informed the client
that primigravida mother should go to the hospital when which patter is evident?
A) Contractions are 2-3 minutes apart, lasting 90 seconds, and membranes have
ruptured
B) Contractions are 5-10 minutes apart, lasting 30 seconds, and are felt as strong
menstrual cramps
C) Contractions are 3-5 minutes apart, accompanied by rectal pressure and bloody
show
D) Contractions are 5 minutes apart, lasting 60 seconds, and increasing in
intensity
Although instructions vary among birth centers, primigravidas should seek care when
regular contractions are felt about 5 minutes apart, becoming longer and stronger.

29. A nurse is planning a home visit program to a new mother who is 2 weeks
postpartum and breastfeeding, the nurse includes in her health teaching about the
resumption of fertility, contraception and sexual activity. Which of the following
statement indicates that the mother has understood the teaching?
A) Because breastfeeding speeds the healing process after birth, I can have sex
right away and not worry about infection
B) Because I am breastfeeding and my hormones are decreased, I may need to
use a vaginal lubricant when I have sex
C) After birth, you have to have a period before you can get pregnant again
D) Breastfeeding protects me from pregnancy because it keeps my hormones
down, so I dont need any contraception until I stop breastfeeding
Prolactin suppresses estrogen, which is needed to stimulate vaginal lubrication during
arousal.
30. A community nurse enters the home of the client for follow-up visit. Which of the
following is the most appropriate area to place the nursing bag of the nurse when
conducting a home visit?
A) cushioned footstool
B) bedside wood table
C) kitchen countertop
D) living room sofa
A wood surface provides the least chance for organisms to be present.
31. The nurse in the health center is making an assessment to the infant client. The
nurse notes some rashes and small fluid-filled bumps in the skin. The nurse suspects that
the infant has eczema. Which of the following is the most important nursing goal:
A) Preventing infection
B) Providing for adequate nutrition
C) Decreasing the itching
D) Maintaining the comfort level
Preventing infection in the infant with eczema is the nurses most important goal. The
infant with eczema is at high risk for infection due to numerous breaks in the skins
integrity. Intact skin is always the infants first line of defense against infection.
32. The nurse in the health center is providing immunization to the children. The nurse
is carefully assessing the condition of the children before giving the vaccines. Which of
the following would the nurse note to withhold the infants scheduled immunizations?
A) a dry cough
B) a skin rash
C) a low-grade fever
D) a runny nose

A skin rash could indicate a concurrent infectious disease process in the infant. The
scheduled immunizations should be withheld until the status of the infants health can be
determined. Fevers above 38.5 degrees Celsius, alteration in skin integrity, and
infectious-appearing secretions are indications to withhold immunizations.
33. A mother brought her child in the health center for hepatitis B vaccination in a
series. The mother informs the nurse that the child missed an appointment last month to
have the third hepatitis B vaccination. Which of the following statements is the
appropriate nursing response to the mother?
A) I will examine the child for symptoms of hepatitis B
B) Your child will start the series again
C) Your child will get the next dose as soon as possible
D) Your child will have a hepatitis titer done to determine if immunization has
taken place.
Continuity is essential to promote active immunity and give hepatitis B lifelong
prophylaxis. Optimally, the third vaccination is given 6 months after the first.
34. The community health nurse implemented a new program about effective breast
cancer screening technique for the female personnel of the health department of
Valenzuela. Which of the following technique should the nurse consider to be of the
lowest priority?
A) Yearly breast exam by a trained professional
B) Detailed health history to identify women at risk
C) Screening mammogram every year for women over age 50
D) Screening mammogram every 1-2 years for women over age of 40.
Because of the high incidence of breast cancer, all women are considered to be at risk
regardless of health history.
35. Which of the following technique is considered an aseptic practice during the home
visit of the community health nurse?
A) Wrapping used dressing in a plastic bag before placing them in the nursing bag
B) Washing hands before removing equipment from the nursing bag
C) Using the clients soap and cloth towel for hand washing
D) Placing the contaminated needles and syringes in a labeled container inside the
nursing bag
Handwashing is the best way to prevent the spread of infection.
36. The nurse is planning to conduct a home visit in a small community. Which of the
following is the most important factor when planning the best time for a home care visit?
A) Purpose of the home visit
B) Preference of the patients family
C) Location of the patients home
D) Length of time of the visit will take

The purpose of the visit takes priority.

37. The nurse assigned in the health center is counseling a 30-year-old client requesting
oral contraceptives. The client tells the nurse that she has an active yeast infection that
has recurred several times in the past year. Which statement by the nurse is inaccurate
concerning health promotion actions to prevent recurring yeast infection?
A) During treatment for yeast, avoid vaginal intercourse for one week
B) Wear loose-fitting cotton underwear
C) Avoid eating large amounts of sugar or sugar-bingeing
D) Douche once a day with a mild vinegar and water solution
Frequent douching interferes with the natural protective barriers in the vagina that resist
yeast infection and should be avoided.
38. During immunization week in the health center, the parent of a 6-month-old infant
asks the health nurse, Why is our baby going to receive so many immunizations over a
long time period? The best nursing response would be:
A) The number of immunizations your baby will receive shows how many
pediatric communicable and infectious diseases can now be prevented.
B) You need to ask the physician
C) The number of immunizations your baby will receive is determined by your
babys health history and age
D) It is easier on your baby to receive several immunizations rather than one at a
time
Completion for the recommended schedule of infant immunizations does not require a
large number of immunizations, but it also provides protection against multiple pediatric
communicable and infectious diseases.
39. The community health nurse is conducting a health teaching about nutrition to a
group of pregnant women who are anemic and are lactose intolerant. Which of the
following foods should the nurse especially encourage during the third trimester?
A) Cheese, yogurt, and fish for protein and calcium needs plus prenatal vitamins
and iron supplements
B) Prenatal iron and calcium supplements plus a regular adult diet
C) Red beans, green leafy vegetables, and fish for iron and calcium needs plus
prenatal vitamins and iron supplements
D) Red meat, milk and eggs for iron and calcium needs plus prenatal vitamins and
iron supplements
This is appropriate foods that are high in iron and calcium but would not affect lactose
intolerance.
40. A woman with active tuberculosis (TB) and has visited the health center for regular
therapy for five months wants to become pregnant. The nurse knows that further
information is necessary when the woman states:

A) Spontaneous abortion may occur in one out of five women who are infected
B) Pulmonary TB may jeopardize my pregnancy
C) I know that I may not be able to have close contact with my baby until
contagious is no longer a problem
D) I can get pregnant after I have been free of TB for 6 months

Intervention is needed when the woman thinks that she needs to wait only 6 months after
being free of TB before she can get pregnant. She needs to wait 1.5-2years after she is
declared to be free of TB before she should attempt pregnancy.
41. The Department of Health is alarmed that almost 33 million people suffer from food
poisoning every year. Salmonella enteritis is responsible for almost 4 million cases of
food poisoning. One of the major goals is to promote proper food preparation. The
community health nurse is tasks to conduct health teaching about the prevention of food
poisoning to a group of mother everyday. The nurse can help identify signs and
symptoms of specific organisms to help patients get appropriate treatment. Typical
symptoms of salmonella include:
A) Nausea, vomiting and paralysis
B) Bloody diarrhea
C) Diarrhea and abdominal cramps
D) Nausea, vomiting and headache
Salmonella organisms cause lower GI symptoms
42. A community health nurse makes a home visit to an elderly person living alone in a
small house. Which of the following observation
would be a great concern?
A) Big mirror in a wall
B) Scattered and unwashed dishes in the sink
C) Shiny floors with scattered rugs
D) Brightly lit rooms
It is a safety hazard to have shiny floors and scattered rugs because they can cause falls
and rugs should be removed.
43. The health nurse is conducting health teaching about safe sex to a group of high
school students. Which of the following statement about the use of condoms should the
nurse avoid making?
A) Condoms should be used because they can prevent infection and because they
may prevent pregnancy
Condoms should be used even if you have recently tested negative for HIV
Condoms should be used every time you have sex because condoms prevent all
forms of sexually transmitted diseases
Condoms should be used every time you have sex even if you are taking the pill
because condoms can prevent the spread of HIV and gonorrhea
Condoms do not prevent ALL forms of sexually transmitted diseases.

44. The department of health is promoting the breastfeeding program to all newly
mothers. The nurse is formulating a plan of care to a woman who gave birth to a baby
girl. The nursing care plan for a breast-feeding mother takes into account that breastfeeding is contraindicated when the woman:
A) Is pregnant
B) Has genital herpes infection
C) Develops mastitis
D) Has inverted nipples
Pregnancy is one contraindication to breast-feeding. Milk secretion is inhibited and the
babys sucking may stimulate uterine contractions.
45. The City health department conducted a medical mission in Barangay Marulas.
Majority of the children in the Barangay Marulas were diagnosed with pinworms. The
community health nurse should anticipate that the childrens chief complaint would be:
A) Lack of appetite
B) Severe itching of the scalp
C) Perianal itching
D) Severe abdominal pain
Perianal itching is the childs chief complaint associated with the diagnosis of pinworms.
The itching, in this instance, is often described as being intense in nature. Pinworms
infestation usually occurs because the child is in the anus-to-mouth stage of development
(child uses the toilet, does not wash hands, places hands and pinworm eggs in mouth).
Teaching the child hand washing before eating and after using the toilet can assist in
breaking the cycle.
46. The mother brought her daughter to the health center. The child has head lice. The
nurse anticipates that the nursing diagnosis most closely correlated with this is:
A) Fluid volume deficit related to vomiting
B) Altered body image related to alopecia
C) Altered comfort related to itching
D) Diversional activity deficit related to hospitalization
Severe itching of the scalp is the classic sign and symptom of head lice in a child. In turn,
this would lead to the nursing diagnosis of altered comfort.
47. The mother brings a child to the health care clinic because of severe headache and
vomiting. During the assessment of the health care nurse, the temperature of the child is
40 degree Celsius, and the nurse notes the presence of nuchal rigidity. The nurse is
suspecting that the child might be suffering from bacterial meningitis. The nurse
continues to assess the child for the presence of Kernigs sign. Which finding would
indicate the presence of this sign?
A) Flexion of the hips when the neck is flexed from a lying position
B) Calf pain when the foot is dorsiflexed
C) Inability of the child to extend the legs fully when lying supine

D) Pain when the chin is pulled down to the chest

Kernigs sign is the inability of the child to extend the legs fully when lying supine. This
sign is frequently present in bacterial meningitis. Nuchal rigidity is also present in
bacterial meningitis and occurs when pain prevents the child from touching the chin to
the chest.
48. A community health nurse makes a home visit to a child with an infectious and
communicable disease. In planning care for the child, the nurse must determine that
the primary goal is that the:
A) Child will experience mild discomfort
B) Child will experience only minor complications
C) Child will not spread the infection to others
D) Public health department will be notified
The primary goal is to prevent the spread of the disease to others. The child should
experience no complication. Although the health department may need to be notified at
some point, it is no the primary goal. It is also important to prevent discomfort as much
as possible.
49. The mother brings her daughter to the health care clinic. The child was diagnosed
with conjunctivitis. The nurse provides health teaching to the mother about the proper
care of her daughter while at home. Which statement by the mother indicates a need for
additional information?
A) I do not need to be concerned about the spreading of this infection to others in
my family
B) I should apply warm compresses before instilling antibiotic drops if purulent
discharge is present in my daughters eye
C) I can use an ophthalmic analgesic ointment at nighttime if I have eye
discomfort
D) I should perform a saline eye irrigation before instilling, the antibiotic drops
into my daughters eye if purulent discharge is present"
Conjunctivitis is highly contagious. Antibiotic drops are usually administered four times a
day. When purulent discharge is present, saline eye irrigations or eye applications of
warm compresses may be necessary before instilling the medication. Ophthalmic
analgesic ointment or drops may be instilled, especially at bedtime, because discomfort
becomes more noticeable when the eyelids are closed.
50. A community health nurse is caring for a group of flood victims in Marikina area.
In planning for the potential needs of this group, which is the most immediate concern?
A) Finding affordable housing for the group
B) Peer support through structured groups
C) Setting up a 24-hour crisis center and hotline
D) Meeting the basic needs to ensure that adequate food, shelter and clothing are
available

The question asks about the immediate concern. The ABCs of community health care are
always attending to peoples basic needs of food, shelter, and clothing.

TEST III
All the questions in the quiz along with their answers are shown below. Your answers are
bolded. The correct answers have a green background while the incorrect ones have a red
background.

1. The nurse is going to replace the Pleur-O-Vac attached to the client with a small,
persistent left upper lobe pneumothorax with a Heimlich Flutter Valve. Which of the
following is the best rationale for this?
A) Promote air and pleural drainage
B) Prevent kinking of the tube
C) Eliminate the need for a dressing
D) Eliminate the need for a water-seal drainage
The Heimlich flutter valve has a one-way valve that allows air and fluid to drain.
Underwater seal drainage is not necessary. This can be connected to a drainage bag for
the patients mobility. The absence of a long drainage tubing and the presence of a oneway valve promote effective therapy
2. The client with acute pancreatitis and fluid volume deficit is transferred from the ward
to the ICU. Which of the following will alert the nurse?
A) Decreased pain in the fetal position
B) Urine output of 35mL/hr
C) CVP of 12 mmHg
D) Cardiac output of 5L/min
2. C = the normal CVP is 0-8 mmHg. This value reflects hypervolemia. The right
ventricular function of this client reflects fluid volume overload, and the physician should
be notified.
3. The nurse in the morning shift is making rounds in the ward. The nurse enters the
clients room and found the client in discomfort condition. The client complains of
stiffness in the joints. To reduce the early morning stiffness of the joints of the client, the
nurse can encourage the client to:
A) Sleep with a hot pad
B) Take to aspirins before arising, and wait 15 minutes before attempting
locomotion
C) Take a hot tub bath or shower in the morning
D) Put joints through passive ROM before trying to move them actively
A hot tub bath or shower in the morning helps many patients limber up and reduces the
symptoms of early morning stiffness. Cold and ice packs are used to a lesser degree,
though some clients state that cold decreases localized pain, particularly during acute
attacks.
4. The nurse is planning of care to a client with peptic ulcer disease. To avoid the
worsening condition of the client, the nurse should carefully plan the diet of the client.
Which of the following will be included in the diet regime of the client?
A) Eating mainly bland food and milk or dairy products
B) Reducing intake of high-fiber foods
C) Eating small, frequent meals and a bedtime snack
D) Eliminating intake of alcohol and coffee

These substances stimulate the production of hydrochloric acid, which is detrimental in

peptic ulcer disease.
5. The physician has given instruction to the nurse that the client can be ambulated on
crutches, with no weight bearing on the affected limb. The nurse is aware that the
appropriate crutch gait for the nurse to teach the client would be:
A) Tripod gait
B) Two-point gait
C) Four-point gait
D) Three-point gait
The three-point gait is appropriate when weight bearing is not allowed on the affected
limb. The swing-to and swing-through crutch gaits may also be used when only one leg
can be used for weight bearing
6. The client is transferred to the nursing care unit from the operating room after a
transurethral resection of the prostate. The client is complaining of pain in the
abdomen area. The nurse suspects of bladder spasms, which of the following is the best
nursing action to minimize the pain felt by the client?
A) Advising the client not to urinate around catheter
B) Intermittent catheter irrigation with saline
C) Giving prescribed narcotics every 4 hour
D) Repositioning catheter to relieve pressure
The client needs to be told before surgery that the catheter causes the urge to void.
Attempts to void around the catheter cause the bladder muscles to contract and result in
painful spasms.
7. A client is diagnosed with peptic ulcer. The nurse caring for the client expects the
physician to order which diet?
A) NPO
B) Small feedings of bland food
C) A regular diet given frequently in small amounts
D) Frequent feedings of clear liquids
Bland feedings should be given in small amounts on a frequent basis to neutralize the
hydrochloric acid and to prevent overload
8. The nurse is going to insert a Miller-Abbott tube to the client. Before insertion of the
tube, the balloon is tested for patency and capacity and then deflated. Which of the
following nursing measure will ease the insertion to the tube?
A) Positioning the client in Semi-Fowlers position
B) Administering a sedative to reduce anxiety
C) Chilling the tube before insertion
D) Warming the tube before insertion

Chilling the tube before insertion assists in relieving some of the nasal discomfort. Watersoluble lubricants along with viscous lidocaine (Xylocaine) may also be used. It is
usually only lightly lubricated before insertion
9. The physician ordered a low-sodium diet to the client. Which of the following food
will the nurse avoid to give to the client?
A) Orange juice.
B) Whole milk.
C) Ginger ale.
D) Black coffee.
Whole milk should be avoided to include in the clients diet because it has 120 mg of
sodium in 8 0z of milk.
10. Mr. Bean, a 70-year-old client is admitted in the hospital for almost one month. The
nurse understands that prolonged immobilization could lead to decubitus ulcers. Which
of the following would be the least appropriate nursing intervention in the prevention of
decubitus?
A) Giving backrubs with alcohol
B) Use of a bed cradle
C) Frequent assessment of the skin
D) Encouraging a high-protein diet
Alcohol is extremely drying and contributes to skin break down. An emollient lotion
should be used.
11. The physician prescribed digoxin 0.125 mg PO qd to a client and instructed the nurse
that the client is on high-potassium diet. High potassium foods are recommended in the
diet of a client taking digitalis preparations because a low serum potassium has which of
the following effects?
A) Potentiates the action of digoxin
B) Promotes calcium retention
C) Promotes sodium excretion
D) Puts the client at risk for digitalis toxicity
Potassium influences the excitability of nerves and muscles. When potassium is low and
the client is on digoxin, the risk of digoxin toxicity is increased.
12. The nurse is caring for a client who is transferred from the operating room for
pneumonectomy. The nurse knows that immediately following pneumonectomy; the
client should be in what position?
A) Supine on the unaffected side
B) Low-Fowlers on the back
C) Semi-Fowlers on the affected side
D) Semi-Fowlers on the unaffected side

This position allows maximum expansion, ventilation, and perfusion of the remaining
lung.
13. A client is placed on digoxin, high potassium foods are recommended in the diet of
the client. Which of the following foods will the nurse give to the client?
A) Whole grain cereal, orange juice, and apricots
B) Turkey, green bean, and Italian bread
C) Cottage cheese, cooked broccoli, and roast beef
D) Fish, green beans and cherry pie
These foods are high in potassium
14. The nurse is assigned to care to a client who undergone thyroidectomy. What nursing
intervention is important during the immediate postoperative period following a
thyroidectomy?
A) Assess extremities for weakness and flaccidity
B) Support the head and neck during position changes
C) Position the client in high Fowlers
D) Medicate for restlessness and anxiety
Stress on the suture line should be avoided. Prevent flexion or hyperextension of the
neck, and provide a small pillow under the head and neck. Neck muscles have been
affected during a thyroidectomy, support essential for comfort and incisional support.
15. What would be the recommended diet the nurse will implement to a client with burns
of the head, face, neck and anterior chest?
A) Serve a high-protein, high-carbohydrate diet
B) Encourage full liquid diet
C) Serve a high-fat diet, high-fiber diet
D) Monitor intake to prevent weight gain
A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and
resistance to infection. Caloric goals may be as high as 5000 calories per day.
16. A client with multiple fractures of both lower extremities is admitted for 3 days ago
and is on skeletal traction. The client is complaining of having difficulty in bowel
movement. Which of the following would be the most appropriate nursing intervention?
A) Administer an enema
B) Perform range-of-motion exercise to all extremities
C) Ensure maximum fluid intake (3000ml/day)
D) Put the client on the bedpan every 2 hours
The best early intervention would be to increase fluid intake, because constipation is
common when activity is decreased or usual routines have been interrupted.

17. John is diagnosed with Addisons disease and admitted in the hospital. What would
be the appropriate nursing care for John?
A) Reducing physical and emotional stress
B) Providing a low-sodium diet
C) Restricting fluids to 1500ml/day
D) Administering insulin-replacement therapy
because the clients ability is to react to stress is decreased, maintaining a quiet
environment becomes A nursing priority. Dehydration is a common problem in Addisons
disease, so close observation of the clients hydration level is crucial. To promote optimal
hydration and sodium intake, fluid intake is increased, particularly fluid containing
electrolytes, such as broths, carbonated beverages, and juices.
18. Mr. Smith is scheduled for an above-the-knee amputation. After the surgery he was
transferred to the nursing care unit. The nurse assigned to him knows that 72 hours after
the procedure the client should be positioned properly to prevent contractures. Which of
the following is the best position to the client?
A) Side-lying, alternating left and right sides
B) Sitting in a reclining chair twice a day
C) Lying on abdomen several times daily
D) Supine with stump elevated at least 30 degrees
At about 48-72 hours, the client must be turned onto the abdomen to prevent flexion
contractures.
19. A client is scheduled to have an inguinal herniorraphy in the outpatient surgical
department. The nurse is providing health teaching about post surgical care to the client.
Which of the following statement if made by the client would reflect the need for more
teaching?
A) I should call the physician if I have a cough or cold before surgery
B) I will be able to drive soon after surgery
C) I will not be able to do any heavy lifting for 3-6 weeks after surgery
D) I should support my incision if I have to cough or turn
The client should not drive for 2 weeks after surgery to avoid stress on the incision. This
reflects a need for additional teaching.
20. Ms Jones is brought to the emergency room and is complaining of muscle spasms,
numbness, tremors and weakness in the arms and legs. The client was diagnosed with
multiple sclerosis. The nurse assigned to Ms. Jones is aware that she has to prevent
fatigue to the client to alleviate the discomfort. Which of the following teaching is
necessary to prevent fatigue?
A) Avoid extremes in temperature
B) Install safety devices in the home
C) Attend support group meetings
D) Avoid physical exercise

Extremes in heat and cold will exacerbate symptoms. Heat delays transmission of
impulses and increases fatigue.
21. Mr. Stewart is in sickle cell crisis and complaining pain in the joints and difficulty of
breathing. On the assessment of the nurse, his temperature is 38.1 C. The physician
ordered Morphine sulfate via patient-controlled analgesia (PCA), and oxygen at 4L/min.
A priority nursing diagnosis to Mr. Stewart is risk for infection. A nursing intervention to
assist in preventing infection is:
A) Using standard precautions and medical asepsis
B) Enforcing a no visitors rule
C) Using moist heat on painful joints
D) Monitoring a vital signs every 2 hour
Vigilant implementation of standard precautions and medical asepsis is an effective
means of preventing infection
22. Mrs. Maupin is a professor in a prestigious university for 30 years. After lecture, she
experience blurring of vision and tiredness. Mrs. Maupin is brought to the emergency
department. On assessment, the nurse notes that the blood pressure of the client is
139/90. Mrs. Maupin has been diagnosed with essential hypertension and placed on
medication to control her BP. Which potential nursing diagnosis will be a priority for
discharge teaching?
A) Sleep Pattern disturbance
B) Impaired physical mobility
C) Noncompliance
D) Fluid volume excess
Noncompliance is a major problem in the management of chronic disease. In
hypertension, the client often does not feel ill and thus does not see a need to follow a
treatment regimen.
23. Following a needle biopsy of the kidney, which assessment is an indication that the
client is bleeding?
A) Slow, irregular pulse
B) Dull, abdominal discomfort
C) Urinary frequency
D) Throbbing headache
An accumulation of blood from the kidney into the abdomen would manifest itself with
these symptoms
24. A client with acute bronchitis is admitted in the hospital. The nurse assigned to the
client is making a plan of care regarding expectoration of thick sputum. Which nursing
action is most effective?
A) Place the client in a lateral position every 2 hour
B) Splint the patients chest with pillows when coughing

C) Use humified oxygen

D) Offer fluids at regular intervals

Fluids liquefy secretions and therefore make it easier to expectorate

25. The nurse is going to assess the bowel sound of the client. For accurate assessment of
the bowel sound, the nurse should listen for at least:
A) 5 minutes
B) 60 seconds
C) 30 seconds
D) 2 minutes
Physical assessment guidelines recommend listening for atleast 2 minutes in each
quadrant (and up to 5 minutes, not at least 5 minutes).
26. The nurse encourages the client to wear compression stockings. What is the rationale
behind in using compression stockings?
A) Compression stockings promote venous return
B) Compression stockings divert blood to major vessels
C) Compression stockings decreases workload on the heart
D) Compression stockings improve arterial circulation
Compression stockings promote venous return and prevent peripheral pooling.
27. Mr. Whitman is a stroke client and is having difficulty in swallowing. Which is the
best nursing intervention is most likely to assist the client?
A) Placing food in the unaffected side of the mouth
B) Increasing fiber in the diet
C) Asking the patient to speak slowly
D) Increasing fluid intake
Placing food in the unaffected side of the mouth assists in the swallowing process
because the client has sensation on that side and will have more control over the
swallowing process.
28. Following nephrectomy, the nurse closely monitors the urinary output of the client.
Which assessment finding is an early indicator of fluid retention in the postoperative
period?
A) Periorbital edema
B) Increased specific gravity of urine
C) A urinary output of 50mL/hr
D) Daily weight gain of 2 lb or more
Daily weights are taken following nephrectomy. Daily increases of 2 lb or more are
indicative of fluid retention and should be reported to the physician. Intake and output
records may also reflect this imbalance.

29. A nurse is completing an assessment to a client with cirrhosis. Which of the

following nursing assessment is important to notify the physician?
A) Expanding ecchymosis
B) Ascites and serum albumin of 3.2 g/dl
C) Slurred speech
D) Hematocrit of 37% and hemoglobin of 12g/dl
Clients with cirrhosis have already coagulation due to thrombocytopenia and vitamin K
deficiency. This could be a sign of bleeding
30. Mr. Park is 32-year-old, a badminton player and has a type 1 diabetes mellitus. After
the game, the client complains of becoming diaphoretic and light-headedness. The client
asks the nurse how to avoid this reaction. The nurse will recommend to:
A) Allow plenty of time after the insulin injection and before beginning the match
B) Eat a carbohydrate snack before and during the badminton match
C) Drink plenty of fluids before, during, and after bed time
D) Take insulin just before starting the badminton match
Exercise enhances glucose uptake, and the client is at risk for an insulin reaction. Snacks
with carbohydrates will help.
31. A client is rushed to the emergency room due to serious vehicle accident. The nurse
is suspecting of head injury. Which of the following assessment findings would the nurse
report to the physician?
A) CVP of 5mmHa
B) Glasgow Coma Scale score of 13
C) Polyuria and dilute urinary output
D) Insomnia
These are symptoms of diabetes insipidus. The patient can become hypovolemic and
vasopressin may reverse the Polyuria.
32. Mrs. Moore, 62-year-old, with diabetes is in the emergency department. She stepped
on a sharp sea shells while walking barefoot along the beach. Mrs. Moore did not notice
that the object pierced the skin until later that evening. What problem does the client
most probably have?
A) Nephropathy
B) Macroangiopathy
C) Carpal tunnel syndrome
D) Peripheral neuropathy
Peripheral neuropathy refers to nerve damage of the hands and feet. The client did not
notice that the object pierced the skin.

33. A client with gangrenous foot has undergone a below-knee amputation. The nurse in
the nursing care unit knows that the priority nursing intervention in the immediate post
operative care of this client is:
A) Elevate the stump on a pillow for the first 24 hours
B) Encourage use of trapeze
C) Position the client prone periodically
D) Apply a cone-shaped dressing
The elevation of the stump on a pillow for the first 24 hours decreases edema and
increases venous return.
34. A client with a diagnosis of gastric ulcer is complaining of syncope and vertigo.
What would be the initial nursing intervention by the nurse?
A) Monitor the clients vital signs
B) Keep the client on bed rest
C) Keep the patient on bed rest
D) Give a stat dose of Sucralfate (Carafate)
The priority is to maintain clients safety. With syncope and vertigo, the client is at high
risk for falling.
35. After a right lower lobectomy on a 55-year-old client, which action should the nurse
initiate when the client is transferred from the post anesthesia care unit?
A) Notify the family to report the clients condition
B) Immediately administer the narcotic as ordered
C) Keep client on right side supported by pillows
D) Encourage coughing and deep breathing every 2 hours
Coughing and deep breathing are essential for re-expansion of the lung
36. The nurse is providing a discharge instruction about the prevention of urinary stasis to
a client with frequent bladder infection. Which of the following will the nurse include in
the instruction?
A) Drink 3-4 quarts of fluid every day
B) Empty the bladder every 2-4 hours while awake
C) Encourage the use of coffee, tea, and colas for their diuretic effect
D) Teach Kegel exercises to control bladder flow
Avoiding stasis of urine by emptying the bladder every 2-4 hours will prevent
overdistention of the bladder and future urinary tract infections.
37. A male client visits the clinic for check-up. The client tells the nurse that there is a
yellow discharge from his penis. He also experiences a burning sensation when
urinating. The nurse is suspecting of gonorrhea. What teaching is necessary for this
client?
A) Sex partner of 3 months ago must be treated

B) Women with gonorrhea are symptomatic

C) Use a condom for sexual activity
D) Sex partner needs to be evaluated

If infected, the sex partner must be evaluated and treated

38. A client with AIDS is admitted in the hospital. He is receiving intravenous therapy.
While the nurse is assessing the IV site, the client becomes confused and restless and the
intravenous catheter becomes disconnected and minimal amount of the clients blood
spills onto the floor. Which action will the nurse take to remove the blood spill?
A) Promptly clean with a 1:10 solution of household bleach and water
B) Promptly clean up the blood spill with full-strength antimicrobial cleaning
solution
C) Immediately mop the floor with boiling water
D) Allow the blood to dry before cleaning to decrease the possibility of crosscontamination
A 1:10 solution of household bleach and water is recommended by the Centers for
Disease Control and Prevention to kill the human immunodeficiency virus (HIV).
39. Before surgery, the physician ordered pentobarbital sodium (Nembutal) for the client
to sleep. The night before the scheduled surgery, the nurse gave the pre-medication. One
hour later the client is still unable to sleep. The nurse review the clients chart and note
the physicians prescription with an order to repeat. What should the nurse do next?
A) Rub the clients back until relaxed
B) Prepare a glass of warm milk
C) Give the second dose of pentobarbital sodium
D) Explore the clients feelings about surgery
Given the data, presurgical anxiety is suspected. The client needs an opportunity to talk
about concerns related to surgery before further actions (which may mask the anxiety).
40. The nurse on the night shift is making rounds in the nursing care unit. The nurse is
about to enter to the clients room when a ventilator alarm sounds, what is the first action
the nurse should do?
A) Assess the lung sounds
B) Suction the client right away
C) Look at the client
D) Turn and position the client
A quick look at the client can help identify the type and cause of the ventilator alarm.
Disconnection of the tube from the ventilator, bronchospasm, and anxiety are some of the
obvious reasons that could trigger an alarm.
41. What effective precautions should the nurse use to control the transmission of
methicillin-resistant Staphylococcus aureus (MRSA)?

A) Use gloves and handwashing before and after client contact

B) Do nasal cultures on healthcare providers
C) Place the client on total isolation
D) Use mask and gown during care of the MRSA client

Contact isolation has been advised by the Centers for Disease Control and Prevention
(CDC) to control transmission of MRSA, which includes gloves and handwashing.
42. The postoperative gastrectomy client is scheduled for discharge. The client asks the
nurse, When I will be allowed to eat three meals a day like the rest of my family?. The
appropriate nursing response is:
A) You will probably have to eat six meals a day for the rest of your life.
B) Eating six meals a day can be a bother, cant it?
C) Some clients can tolerate three meals a day by the time they leave the
hospital. Maybe it will be a little longer for you.
D) It varies from client to client, but generally in 6-12 months most clients can
return to their previous meal patterns
In response to the question of the client, the nurse needs to provide brief, accurate
information. Some clients who have had gastrectomies are able to tolerate three meals a
day before discharge from the hospital. However, for the majority of clients, it takes 6-12
months before their surgically reduced stomach has stretched enough to accommodate a
larger meal.
43. A male client with cirrhosis is complaining of belly pain, itchiness and his breasts are
getting larger and also the abdomen. The client is so upset because of the discomfort and
asks the nurse why his breast and abdomen are getting larger. Which of the following is
the appropriate nursing response?
A) How much of a difference have you noticed
B) Its part of the swelling your body is experiencing
C) Its probably because you have been less physically active
D) Your liver is not destroying estrogen hormones that all men produce
This allows the client to elaborate his concern and provides the nurse a baseline of
assessment
44. A client is diagnosed with detached retina and scheduled for surgery. Preoperative
teaching of the nurse to the client includes:
A) No eye pain is expected postoperatively
B) Semi-fowlers position will be used to reduce pressure in the eye.
C) Eye patches may be used postoperatively
D) Return of normal vision is expected following surgery
Use of eye patches may be continued postoperatively, depending on surgeon preference.
This is done to achieve >90% success rate of the surgery.

45. A 70-year-old client is brought to the emergency department with a caregiver. The
client has manifestations of anorexia, wasting of muscles and multiple bruises. What
nursing interventions would the nurse implement?
A) Talk to the client about the caregiver and support system
B) Complete a gastrointestinal and neurological assessment
C) Check the lab data for serum albumin, hematocrit and hemoglobin
D) Complete a police report on elder abuse
Assessment and more data collection are needed. The client may have gastrointestinal or
neurological problems that account for the symptoms. The anorexia could result from
medications, poor dentition, or indigestion, the bruises may be attributed to ataxia,
frequent falls, vertigo, or medication.
46. A nurse is providing a discharge instruction to the client about the self-catheterization
at home. Which of the following instructions would the nurse include?
A) Wash the catheter with soap and water after each use
B) Lubricate the catheter with Vaseline
C) Perform the Valsalva maneuver to promote insertion
D) Replace the catheter with a new one every 24 hour
The catheter should be washed with soap and water after withdrawal and placed in a
clean container. It can be reused until it is too hard or too soft for insertion. Self-care,
prevention of complications, and cost-effectiveness are important in home management.
47. The nurse in the nursing care unit is assigned to care to a client who is
Immunocompromised. The client tells the nurse that his chest is painful and the blisters
are itchy. What would be the nursing intervention to this client?
A) Call the physician
B) Give a prn pain medication
C) Clarify if the client is on a new medication
D) Use gown and gloves while assessing the lesions
The client may have herpes zoster (shingles), a viral infection. The nurse should use
standard precautions in assessing the lesions. Immunocompromised clients are at risk for
infection.
48. A client is admitted and has been diagnosed with bacterial (meningococcal)
meningitis. The infection control registered nurse visits the staff nurse caring to the
client. What statement made by the nurse reflects an understanding of the management
of this client?
A) speech pattern may be altered
B) Respiratory isolation is necessary for 24 hours after antibiotics are started
C) Perform skin culture on the macular popular rash
D) Expect abnormal general muscle contractions

After a minimum of 24 hours of IV antibiotics, the client is no longer considered

communicable. Evaluation of the nurses knowledge is needed for safe care and
continuity of care.
49. A 18-year-old male client had sustained a head injury from a motorbike accident. It is
uncertain whether the client may have minimal but permanent disability. The family is
concerned regarding the clients difficulty accepting the possibility of long term effects.
Which nursing diagnosis is best for this situation?
A) Nutrition, less than body requirements
B) Injury, potential for sensory-perceptual alterations
C) Impaired mobility, related to muscle weakness
D) Anticipatory grieving, due to the loss of independence
Stem of the question supports this choice by stating that the client has difficulty accepting
the potential disability.
50. A client with AIDS is scheduled for discharge. The client tells the nurse that one of
his hobbies at home is gardening. What will be the discharge instruction of the nurse to
the client knowing that the client is prone to toxoplasmosis?
A) Wash all vegetables before cooking
B) Wear gloves when gardening
C) Wear a mask when travelling to foreign countries
D) Avoid contact with cats and birds
Toxoplasmosis is an opportunistic infection and a parasite of birds and mammals. The
oocysts remain infectious in moist soil for about 1 year.

TEST IV
All the questions in the quiz along with their answers are shown below. Your answers are
bolded. The correct answers have a green background while the incorrect ones have a red
background.

1. Following spinal injury, the nurse should encourage the client to drink fluids to avoid:
A) Urinary tract infection.
B) Fluid and electrolyte imbalance.
C) Dehydration.
D) Skin breakdown.
Clients in the early stage of spinal cord damage experience an atonic bladder, which is
characterized by the absence of muscle tone, an enlarged capacity, no feeling of
discomfort with distention, and overflow with a large residual. This leads to urinary stasis
and infection. High fluid intake limits urinary stasis and infection by diluting the urine
and increasing urinary output.
2. The client is transferred from the operating room to recovery room after an open-heart
surgery. The nurse assigned is taking the vital signs of the client. The nurse notified the
physician when the temperature of the client rises to 38.8 C or 102 F because elevated
temperatures:
A) May be a forerunner of hemorrhage.
B) Are related to diaphoresis and possible chilling.
C) May indicate cerebral edema.
D) Increase the cardiac output.
The temperature of 102 F (38.8C) or greater lead to an increased metabolism and
cardiac workload.
3. After radiation therapy for cancer of the prostate, the client experienced irritation in
the bladder. Which of the following sign of bladder irritability is correct?
A) Hematuria
B) Dysuria
C) Polyuria
D) Dribbling
Dysuria, nocturia, and urgency are all signs an irritable bladder after radiation therapy.
4. A client is diagnosed with a brain tumor in the occipital lobe. Which of the following
will the client most likely experience?
A) Visual hallucinations.
B) Receptive aphasia.
C) Hemiparesis.
D) Personality changes.
The occipital lobe is involve with visual interpretation.
5. A client with Addisons disease has a blood pressure of 65/60. The nurse understands
that decreased blood pressure of the client with Addisons disease involves a disturbance
in the production of:
A) Androgens

B) Glucocorticoids
C) Mineralocorticoids
D) Estrogen

Mineralocorticoids such as aldosterone cause the kidneys to retain sodium ions. With
sodium, water is also retained, elevating blood pressure. Absence of this hormone thus
causes hypotension.
6. The nurse is planning to teach the client about a spontaneous pneumothorax. The
nurse would base the teaching on the understanding that:
A) Inspired air will move from the lung into the pleural space.
B) There is greater negative pressure within the chest cavity.
C) The heart and great vessels shift to the affected side.
D) The other lung will collapse if not treated immediately.
As a person with a tear in the lung inhales, air moves through that opening into the
intrapleural and causes partial or complete collapse of the lungs.
7. During an assessment, the nurse recognizes that the client has an increased risk for
developing cancer of the tongue. Which of the following health history will be a
concern?
A) Heavy consumption of alcohol.
B) Frequent gum chewing.
C) Nail biting.
D) Poor dental habits.
Heavy alcohol ingestion predisposes an individual to the development of oral cancer.
8. The client in the orthopedic unit asks the nurse the reason behind why compact bone is
stronger than cancellous bone. Which of the following is the correct response of the
nurse?
A) Compact bone is stronger than cancellous bone because of its greater size.
B) Compact bone is stronger than cancellous bone because of its greater weight.
C) Compact bone is stronger than cancellous bone because of its greater volume.
D) Compact bone is stronger than cancellous bone because of its greater density.
The greater the density of compact bone makes it stronger than the cancellous bone.
Compact bone forms from cancellous bone by the addition of concentric rings of bones
substances to the marrow spaces of cancellous bone. The large marrow spaces are
reduced to haversian canals.
9. The nurse is reviewing the laboratory results of the client. In reviewing the results of
the RBC count, the nurse understands that the higher the red blood cell count, the :
A) Greater the blood viscosity.
B) Higher the blood pH.
C) Less it contributes to immunity.

D) Lower the hematocrit.

Viscosity, a measure of a fluids internal resistance to flow, is increased as the number of

red cells suspended in plasma.
10. The physician advised the client with Hemiparesis to use a cane. The client asks the
nurse why cane will be needed. The nurse explains to the client that cane is advised
specifically to:
A) Aid in controlling involuntary muscle movements.
B) Relieve pressure on weight-bearing joints.
C) Maintain balance and improve stability.
D) Prevent further injury to weakened muscles.
Hemiparesis creates instability. Using a cane provides a wider base of support and,
therefore greater stability.
11. The nurse is conducting a discharge teaching regarding the prevention of further
problems to a client who undergone surgery for carpal tunnel syndrome of the right
hand. Which of the following instruction will the nurse includes?
A) Learn to type using your left hand only.
B) Avoid typing in a long period of time.
C) Avoid carrying heavy things using the right hand.
D) Do manual stretching exercise during breaks.
Manual stretching exercises will assist in keeping the muscles and tendons supple and
pliable, reducing the traumatic consequences of repetitive activity.
12. A female client is admitted because of recurrent urinary tract infections. The client
asks the nurse why she is prone to this disease. The nurse states that the client is most
susceptible because of:
A) Continuity of the mucous membrane.
B) Inadequate fluid intake.
C) The length of the urethra.
D) Poor hygienic practices.
The length of the urethra is shorter in females than in males; therefore microorganisms
have a shorter distance to travel to reach the bladder. The proximity of the meatus to the
anus in females also increases this incidence.
13. A 55-year-old client is admitted with chest pain that radiates to the neck, jaw and
shoulders that occurs at rest, with high body temperature, weak with generalized sweating
and with decreased blood pressure. A myocardial infarction is diagnosed. The nurse
knows that the most accurate explanation for one of these presenting adaptations is:
A) Catecholamines released at the site of the infarction causes intermittent
localized pain.
B) Parasympathetic reflexes from the infarcted myocardium causes diaphoresis.

C) Constriction of central and peripheral blood vessels causes a decrease in blood

pressure.
D) Inflammation in the myocardium causes a rise in the systemic body
temperature.

Temperature may increase within the first 24 hours and persist as long as a week.
14. Following an amputation of a lower limb to a male client, the nurse provides an
instruction on how to prevent a hip flexion contracture. The nurse should instruct the
client to:.
A) Perform quadriceps muscle setting exercises twice a day.
B) Sit in a chair for 30 minutes three times a day.
C) Lie on the abdomen 30 minutes every four hours.
D) Turn from side to side every 2 hours.
The hips are in extension when the client is prone; this keeps the hips from flexing.
15. The physician scheduled the client with rheumatoid arthritis for the injection of
hydrocortisone into the knee joint. The client asks the nurse why there is a need for this
injection. The nurse explains that the most important reason for doing this is to:
A) Lubricate the joint.
B) Prevent ankylosis of the joint.
C) Reduce inflammation.
D) Provide physiotherapy.
Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.
16. The nurse is assigned to care for a 57-year-old female client who had a cataract
surgery an hour ago. The nurse should:
A) Advise the client to refrain from vigorous brushing of teeth and hair.
B) Instruct the client to avoid driving for 2 weeks.
C) Encourage eye exercises to strengthen the ocular musculature.
D) Teach the client coughing and deep-breathing techniques.
Activities such as rigorous brushing of hair and teeth cause increased intraocular pressure
and may lead to hemorrhage in the anterior chamber.
17. A client with AIDS develops bacterial pneumonia is admitted in the emergency
department. The clients arterial blood gases is drawn and the result is PaO2 80mmHg.
then arterial blood gases are drawn again and the level is reduced from 80 mmHg to 65
mmHg. The nurse should;
A) Have arterial blood gases performed again to check for accuracy.
B) Increase the oxygen flow rate.
C) Notify the physician.
D) Decrease the tension of oxygen in the plasma.

This decrease in PaO2 indicates respiratory failure; it warrants immediate medical

evaluation.
18. An 18-year-old college student is brought to the emergency department due to serious
motor vehicle accident. Right above-knee-amputation is done. Upon awakening from
surgery the client tells the nurse, What happened to me? I cannot remember anything?
Which of the following would be the appropriate initial nursing response?
A) You sound concerned; Youll probably remember more as you wake up.
B) Tell me what you think happened.
C) You were in a car accident this morning.
D) An amputation of your right leg was necessary because of an accident.
This is truthful and provides basic information that may prompt recollection of what
happened; it is a starting point.
19. A 38-year-old client with severe hypertension is hospitalized. The physician
prescribed a Captopril (Capoten) and Alprazolam (Xanax) for treatment. The client tells
the nurse that there is something wrong with the medication and nursing care. The nurse
recognizes this behavior is probably a manifestation of the clients:
A) Reaction to hypertensive medications.
B) Denial of illness.
C) Response to cerebral anoxia.
D) Fear of the health problem.
Clients adapting to illness frequently feel afraid and helpless and strike out at health team
members as a way of maintaining control or denying their fear.
20. Before discharge, the nurse scheduled the client who had a colostomy for colorectal
cancer for discharge instruction about resuming activities. The nurse should plan to help
the client understands that:
A) After surgery, changes in activities must be made to accommodate for the
physiologic changes caused by the operation.
B) Most sports activities, except for swimming, can be resumed based on the
clients overall physical condition.
C) With counseling and medical guidance, a near normal lifestyle, including
complete sexual function is possible.
D) Activities of daily living should be resumed as quickly as possible to avoid
depression and further dependency.
There are few physical restraints on activity postoperatively, but the client may have
emotional problems resulting from the body image changes.
21. A client is scheduled for bariatric surgery. Preoperative teaching is done. Which of
the following statement would alert the nurse that further teaching to the client is
necessary?

A) I will be limiting my intake to 600 to 800 calories a day once I start eating
again.
B) Im going to have a figure like a model in about a year.
C) I need to eat more high-protein foods.
D) I will be going to be out of bed and sitting in a chair the first day after
surgery..

clients need to be prepared emotionally for the body image changes that occur after
bariatric surgery. Clients generally experience excessive abdominal skin folds after
weight stabilizes, which may require a panniculectomy. Body image disturbance often
occurs in response to incorrectly estimating ones size; it is not uncommon for the client
to still feel fat no matter how much weight is lost.
22. The client who had transverse colostomy asks the nurse about the possible effect of
the surgery on future sexual relationship. What would be the best nursing response?
A) The surgery will temporarily decrease the clients sexual impulses.
B) Sexual relationships must be curtailed for several weeks.
C) The partner should be told about the surgery before any sexual activity.
D) The client will be able to resume normal sexual relationships.
Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance.
However, the nurse should encourage verbalization.
23. A 75-year-old male client tells the nurse that his wife has osteoporosis and asks what
chances he had of getting also osteoporosis like his wife. Which of the following is the
correct response of the nurse?
A) This is only a problem for women.
B) You are not at risk because of your small frame.
C) You might think about having a bone density test,
D) Exercise is a good way to prevent this problem.
Osteoporosis is not restricted to women; it is a potential major health problem of all older
adults; estimates indicate that half of all women have at least one osteoporitic fracture
and the risk in men is estimated between 13% and 25%; a bone mineral density
measurement assesses the mass of bone per unit volume or how tightly the bone is
packed.
24. An older adult client with acute pain is admitted in the hospital. The nurse
understands that in managing acute pain of the client during the first 24 hours, the nurse
should ensure that:
A) Ordered PRN analgesics are administered on a scheduled basis.
B) Patient controlled analgesia is avoided in this population.
C) Pain medication is ordered via the intramuscular route.
D) An order for meperidine (Demerol) is secured for pain relief.

Around-the-clock administration of analgesics is recommended for acute pain in the older

adult population; this help to maintain a therapeutic blood level of pain medication.
25. A nurse is caring to an older adult with presbycusis. In formulating nursing care plan
for this client, the nurse should expect that hearing loss of the client that is caused by
aging to have:
A) Overgrowth of the epithelial auditory lining.
B) Copious, moist cerumen.
C) Difficulty hearing womens voices.
D) Tears in the tympanic membrane.
Generally, female voices have a higher pitch than male voices; older adults with
presbycusis (hearing loss caused by the aging process) have more difficulty hearing
higher-pitched sounds.
26. The nurse is reviewing the clients chart about the ordered medication. The nurse
must observe for signs of hyperkalemia when administering:
A) Furosemide (Lasix)
B) Hydrochlorothiazide (HydroDIURIL)
C) Metolazone (Zaroxolyn)
D) Spironolactone (Aldactone)
Aldactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect.
27. The physician prescribed Albuterol (Proventil) to the client with severe asthma. After
the administration of the medication the nurse should monitor the client for:
A) Palpitation
B) Visual disturbance
C) Decreased pulse rate
D) Lethargy
Albuterols sympathomimetic effect causes cardiac stimulation that may cause
tachycardia and palpitation.
28. A client is receiving diltiazem (Cardizem). What should the nurse include in a
teaching plan aimed at reducing the side effects of this medication?
A) Take the drug with an antacid.
B) Lie down after meals.
C) Avoid dairy products in diet.
D) Change positions slowly.
Changing positions slowly will help prevent the side effect of orthostatic hypotension.
29. A client is receiving simvastatin (Zocor). The nurse is aware that this medication is
effective when there is decrease in:
A) The triglycerides

B) The INR
C) Chest pain
D) Blood pressure

Therapeutic effects of simvastatin include decreased serum triglyceries, LDL and

cholesterol.
30. A client is taking nitroglycerine tablets, the nurse should teach the client the
importance of:
A) Increasing the number of tablets if dizziness or hypertension occurs.
B) Limiting the number of tablets to 4 per day.
C) Making certain the medication is stored in a dark container.
D) Discontinuing the medication if a headache develops.
Nitroglycerine is sensitive to light and moisture ad must be stored in a dark, airtight
container.
31. The physician prescribes Ibuprofen (Motrin) and hydroxychloroquine sulfate
(Plaquenil) for a 58-year-old male client with arthritis. The nurse provides information
about toxicity of the hydroxychloroquine. The nurse can determine if the information is
clearly understood if the client states:
A) I will contact the physician immediately if I develop blurred vision.
B) I will contact the physician immediately if I develop urinary retention.
C) I will contact the physician immediately if I develop swallowing difficulty.
D) I will contact the physician immediately if I develop feelings of irritability.
Visual disturbance are a sign of toxicity because retinopathy can occur with this drug.
32. The client with an acute myocardial infarction is hospitalized for almost one week.
The client experiences nausea and loss of appetite. The nurse caring for the client
recognizes that these symptoms may indicate the:
A) Adverse effects of spironolactone (Aldactone)
B) Adverse effects of digoxin (Lanoxin)
C) Therapeutic effects of propranolol (Indiral)
D) Therapeutic effects of furosemide (Lasix)
Toxic levels of Lanoxin stimulate the medullary chemoreceptor trigger zone, resulting in
nausea and subsequent anorexia.
33. A client with a partial occlusion of the left common carotid artery is scheduled for
discharge. The client is still receiving Coumadin. The nurse provided a discharge
instruction to the client regarding adverse effects of Coumadin. The nurse should tell the
client to consult with the physician if:
A) Swelling of the ankles increases.
B) Blood appears in the urine.
C) Increased transient Ischemic attacks occur.

D) The ability to concentrate diminishes.

Warfarin derivatives cause an increase in the prothrombin time and INR, leading to an
increased risk for bleeding. Any abnormal or excessive bleeding must be reported,
because it may indicate toxic levels of the drug.
34. Levodopa is ordered for a client with Parkinsons disease. Before starting the
medication, the nurse should know that:
A) Levodopa is inadequately absorbed if given with meals.
B) Levodopa may cause the side effects of orthostatic hypotension.
C) Levodopa must be monitored by weekly laboratory tests.
D) Levodopa causes an initial euphoria followed by depression.
Levodopa is the metabolic precursor of dopamine. It reduces sympathetic outflow by
limiting vasoconstriction, which may result in orthostatic hypotension.
35. In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used.
The nurse knows that this drug will cause a temporary increase in:
A) Muscle strength
B) Symptoms
C) Blood pressure
D) Consciousness
Tensilon, an anticholinesterase drug, causes temporary relief of symptoms of myasthenia
gravis in client who have the disease and is therefore an effective diagnostic aid.
36. The nurse can determine the effectiveness of carbamazepine (Tegretol) in the
management of trigeminal neuralgia by monitoring the clients:
A) Seizure activity
B) Liver function
C) Cardiac output
D) Pain relief
Carbamazepine ( Tegretol) is administered to control pain by reducing the transmission of
nerve impulses in clients with trigeminal neuralgia.
37. Administration of potassium iodide solution is ordered to the client who will undergo
a subtotal thyroidectomy. The nurse understands that this medication is given to:
A) Ablate the cells of the thyroid gland that produce T4.
B) Decrease the total basal metabolic rate.
C) Decrease the size and vascularity of the thyroid.
D) Maintain function of the parathyroid gland.
Potassium iodide, which aids in decreasing the vascularity of the thyroid gland, decreases
the risk for hemorrhage.

38. A client with Addisons disease is scheduled for discharge. Before the discharge, the
physician prescribes hydrocortisone and fludrocortisone. The nurse expects the
hydrocortisone to:
A) Increase amounts of angiotensin II to raise the clients blood pressure.
B) Control excessive loss of potassium salts.
C) Prevent hypoglycemia and permit the client to respond to stress.
D) Decrease cardiac dysrhythmias and dyspnea.
Hydrocortisone is a glucocorticoid that has anti-inflammatory action and aids in
metabolism of carbohydrate, fat, and protein, causing elevation of blood glucose. Thus it
enables the body to adapt to stress.
39. A client with diabetes insipidus is taking Desmopressin acetate (DDAVP). To
determine if the drug is effective, the nurse should monitor the clients:
A) Arterial blood pH
B) Pulse rate
C) Serum glucose
D) Intake and output
DDAVP replaces the ADH, facilitating reabsorption of water and consequent return of
normal urine output and thirst.
40. A client with recurrent urinary tract infections is to be discharged. The client will be
taking nitrofurantoin (Macrobid) 50 mg po every evening at home. The nurse provides
discharge instructions to the client. Which of the following instructions will be correct?
A) Strain urine for crystals and stones
B) Increase fluid intake.
C) Stop the drug if the urinary output increases
D) Maintain the exact time schedule for drug taking.
To prevent crystal formation, the client should have sufficient intake to produce 1000 to
1500 mL of urine daily while taking this drug.
41. A client with cancer of the lung is receiving chemotherapy. The physician orders
antibiotic therapy for the client. The nurse understands that chemotherapy destroys
rapidly growing leukocytes in the:
A) Bone marrow
B) Liver
C) Lymph nodes
D) Blood
Prolonged chemotherapy may slow the production of leukocytes in bone marrow, thus
suppressing the activity of the immune system. Antibiotics may be required to help
counter infections that the body can no longer handle easily.

42. The physician reduced the clients Dexamethasone (Decadron) dosage gradually and
to continue a lower maintenance dosage. The client asks the nurse about the change of
dosage. The nurse explains to the client that the purpose of gradual dosage reduction is to
allow:
A) Return of cortisone production by the adrenal glands.
B) Production of antibodies by the immune system
C) Building of glycogen and protein stores in liver and muscle
D) Time to observe for return of increases intracranial pressure
Any hormone normally produced by the body must be withdrawn slowly to allow the
appropriate organ to adjust and resume production.
43. The nurse is assigned to care for a client with diarrhea. Excessive fluid loss is
expected. The nurse is aware that fluid deficit can most accurately be assessed by:
A) The presence of dry skin
B) A change in body weight
C) An altered general appearance
D) A decrease in blood pressure
Dehydration is most readily and accurately measured by serial assessment of body
weight; 1 L of fluid weighs 2.2 pounds.
44. Which of the following is the most important electrolyte of intracellular fluid?
A) Potassium
B) Sodium
C) Chloride
D) Calcium
The concentration of potassium is greater inside the cell and is important in establishing a
membrane potential, a critical factor in the cells ability to function.
45. Which of the following client has a high risk for developing hyperkalemia?
A) Crohns disease
B) End-Stage renal disease
C) Cushings syndrome
D) Chronic heart failure
The kidneys normally eliminate potassium from the body; hyperkalemia may necessitate
dialysis.
46. The nurse is reviewing the laboratory result of the client. The clients serum
potassium level is 5.8 mEq/L. Which of the following is the initial nursing action?
A) Call the cardiac arrest team to alert them
B) Call the laboratory and repeat the test
C) Take the clients vital signs and notify the physician
D) Obtain an ECG strip and have lidocaine available

Vital signs monitor cardiorespiratory status; hyperkalemia causes serious cardiac

dysrhythmias.
47. Potassium chloride, 20 mEq, is ordered and to be added in the IV solution of a client
in a diabetic ketoacidosis. The primary reason for administering this drug is:
A) Replacement of excessive losses
B) Treatment of hyperpnea
C) Prevention of flaccid paralysis
D) Treatment of cardiac dysrhythmias
Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the
cell, causing hypokalemia; therefore potassium, along with the replacement fluid, is
generally supplied.
48. A female client is brought to the emergency unit. The client is complaining of
abdominal cramps. On assessment, client is experiencing anorexia and weight is
reduced. The physicians diagnosis is colitis. Which of the following symptoms of fluid
and electrolyte imbalance should the nurse report immediately?
A) Skin rash, diarrhea, and diplopia
B) Development of tetaniy with muscles spasms
C) Extreme muscle weakness and tachycardia
D) Nausea, vomiting, and leg and stomach cramps.
Potassium, the major intracellular cation, functions with sodium and calcium to regulate
neuromuscular activity and contraction of muscle fibers, particularly the heart muscle. In
hypokalemia these symptoms develop.
49. The client is to receive an IV piggyback medication. When preparing the medication
the nurse should be aware that it is very important to:
A) Use strict sterile technique
B) Use exactly 100mL of fluid to mix the medication
C) Change the needle just before adding the medication
D) Rotate the bag after adding the medication
Because IV solutions enter the bodys internal environment, all solutions and medications
utilizing this route must be sterile to prevent the introduction of microbes.
50. The nurse is reviewing the laboratory result of the client. An arterial blood gas report
indicates the clients pH is 7.20, PCO2 35 mmHg and HCO3 is 19 mEq/L. The results
are consistent with:
A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis
A low pH and bicarbonate level are consistent with metabolic acidosis.

TEST V
All the questions in the quiz along with their answers are shown below. Your answers are
bolded. The correct answers have a green background while the incorrect ones have a red
background.
1. A 17-year-old client has a record of being absent in the class without permission, and
borrowing other peoples things without asking permission. The client denies stealing;
rationalizing instead that as long as no one was using the items, there is no problem to use
it by other people. It is important for the nurse to understand that psychodynamically, the
behavior of the client may be largely attributed to a development defect related to the:
A) Oedipal complex
B) Superego
C) Id
D) Ego

This shows a weak sense of moral consciousness. According to Freudian theory,

personality disorders stem from a weak superego.
2. A client tells the nurse, Yesterday, I was planning to kill myself. What is the best
nursing response to this cient?
A) What are you going to do this time?
B) Say nothing. Wait for the clients next comment
C) You seem upset. I am going to be here with you; perhaps you will want to talk
about it
D) Have you felt this way before?
The client needs to have his or her feelings acknowledged, with encouragement to discuss
feelings, and be reassured about the nurses presence.
3. In crisis intervention therapy, which of the following principle that the nurse will use to
plan her/his goals?
A) Crises are related to deep, underlying problems
B) Crises seldom occur in normal peoples lives
C) Crises may go on indefinitely.
D) Crises usually resolved in 4-6 weeks.
Part of the definition of a crisis is a time span of 4-6 weeks.
4. The nurse enters the room of the male client and found out that the client urinates on
the floor. The client hides when the nurse is about to talk to him. Which of the following
is the best nursing intervention?
A) Place restriction on the clients activities when his behavior occurs.
B) Ask the client to clean the soiled floor.
C) Take the client to the bathroom at regular intervals.
D) Limit fluid intake.
The client is most likely confused, rather than exhibiting acting-out, hostile behavior.
Frequent toileting will allow urination in an appropriate place.
5. A young lady with a diagnosis of schizophrenic reaction is admitted to the psychiatric
unit. In the past two months, the client has poor appetite, experienced difficulty in
sleeping, was mute for long periods of time, just stayed in her room, grinning and
pointing at things. What would be the initial nursing action on admitting the client to the
unit?
A) Assure the client that You will be well cared for.
B) Introduce the client to some of the other clients.
C) Ask Do you know where you are?
D) Take the client to the assigned room.
The client needs basic, simple orientation that directly relates to the here-and-now, and
does not require verbal interaction.

6. A 16-year-old girl was diagnosed with anorexia. What would be the first assessment of
the nurse?
A) What food she likes.
B) Her desired weight.
C) Her body image.
D) What causes her behavior.
Although all options may appear correct. A is the best because it focuses on a range of
possible positive reinforcers, a basis for an effective behavior modification program. It
can lead to concrete, specific nursing interventions right away and provides a
therapeutic use of control for the 16-year-old.
7. On an adolescent unit, a nurse caring to a client was informed that her clients closest
roommate dies at night. What would be the most appropriate nursing action?
A) Do not bring it up unless the client asks.
B) Tell the client that her roommate went home.
C) Tell the client, if asked, You should ask the doctor.
D) Tell the client that her closest roommate died.
The nurse needs to wait and see: do not jump the gun; do not assume that the client
wants to know now.
8. A woman gave birth to an unhealthy infant, and with some body defects. The nurse
should expect the womans initial reactions to include:
A) Depression
B) Withdrawal
C) Apathy
D) Anger
The woman is experiencing an actual loss and will probably exhibit many of the same
symptoms as a person who has lost someone to death.
9. A client in the psychiatric unit is shouting out loud and tells the nurse, Please, help
me. They are coming to get me. What would be the appropriate nursing response?
A) I wont let anyone get you.
B) Who are they?
C) I dont see anyone coming.
D) You look frightened.
This option is an example of pointing out reality- the nurses perception.
10. A client who is severely obese tells the nurse, My therapist told me that I eat a lot
because I didnt get any attention and love from my mother. What does the therapist
mean? What is the best nursing response?
A) What do you think is the connection between your not getting enough love
and overeating?

B) Tell me what you think the therapist means.

C) You need to ask your therapist.
D) We are here to deal with your diet, not with your psychological problems.

This response asks information that the nurse can use. If the client understands the
statement, the nurse can support the therapist when focusing on connection between food,
love, and mother. If the client does not understand the statement, the nurse can help get
clarification from the therapist.
11. After the discussion about the procedure the physician scheduled the client for
mastectomy. The client tells the nurse, If my breasts will be removed, Im afraid my
husband will not love me anymore and maybe he will never touch me. What should the
nurses response?
A) I doubt that he feels that way.
B) What makes you feel that way?
C) Have you discussed your feelings with your husband?
D) Ask the husband, in front of the wife, how he feels about this.
This option redirects the client to talk to her husband.
12. The child is brought to the hospital by the parents. During assessment of the nurse,
what parental behavior toward a child should alert the nurse to suspect child abuse?
A) Ignoring the child.
B) Flat affect.
C) Expressions of guilt.
D) Acting overly solicitous toward the child
This is an example of reaction formation, a coping mechanism.
13. A nurse is caring to a client with manic disorder in the psychiatric ward. On the
morning shift, the nurse is talking with the client who is now exhibiting a manic episode
with flight of ideas. The nurse primarily needs to:
A) Focus on the feelings conveyed rather than the thoughts expressed.
B) Speak loudly and rapidly to keep the clients attention, because the client is
easily distracted.
C) Allow the client to talk freely.
D) Encourage the client to complete one thought at a time.
Often the verbalized ideas are jumbled, but the underlying feelings are discernible and
must be acknowledged.
14. The nurse is caring to an autistic child. Which of the following play behavior would
the nurse expect to see in a child?
A) competitive play
B) nonverbal play
C) cooperative play

D) solitary play

Autistic children do best with solitary play because they typically do not interact with
others in a socially comprehensible and acceptable way.
15. The client is telling the nurse in the psychiatric ward, I hate them. Which of the
following is the most appropriate nursing response to the client?
A) Tell me about your hate.
B) I will stay with you as long as you feel this way.
C) For whom do you have these feelings?
D) I understand how you can feel this way.
The nurse is asking the client to clarify and further discuss feelings.
16. The mother visits her son with major depression in the psychiatric unit. After the
conversation of the client and the mother, the nurse asks the mother how it is talking to
her son. The mother tells the nurse that it was a stressful time. During an interview with
the client, the client says, we had a marvelous visit. Which of the following coping
mechanism can be described to the statement of the client?
A) Identification.
B) Rationalization.
C) Denial.
D) Compensation.
Denial is the act of avoiding disagreeable realities by ignoring them.
17. A male client is quiet when the physician told him that he has stage IV cancer and has
4 months to live. The nurse determines that this reaction may be an example of:
A) Indifference
B) Denial
C) Resignation
D) Anger
Reactions when told of a life-threatening illness stem from Kbler-Ross ideas on death
and dying. Denial is a typical grief response, and usually is a first reaction.
18. A nurse is caring to a female client with five young children. The family member told
the client that her ex-husband has died 2 days ago. The reaction of the client is stunned
silence, followed by anger that the ex-husband left no insurance money for their young
children. The nurse should understand that:
A) The children and the injustice done to them by their fathers death are the
womans main concern.
B) To explain the womans reaction, the nurse needs more information about the
relationship and breakup.
C) The woman is not reacting normally to the news.
D) The woman is experiencing a normal bereavement reaction.

Shock and anger are commonly the primary initial reactions.

19. A client who is manic comes to the outpatient department. The nurse is assigning an
activity for the client. What activity is best for the nurse to encourage for a client in a
manic phase?
A) Solitary activity, such as walking with the nurse, to decrease stimulation.
B) Competitive activity, such as bingo, to increase the clients self-esteem.
C) Group activity, such as basketball, to decrease isolation.
D) Intellectual activity, such as scrabble, to increase concentration.
This option avoids external stimuli, yet channels the excess motor activity that is often
part of the manic phase.
20. The nurse is about to administer Imipramine HCI (Tofranil) to the client, the client
says, Why should I take this? The doctor started me on this 10days ago; it didnt help
me at all. Which of the following is the best nursing response:
A) What were you expecting to happen?
B) It usually takes 2-3 weeks to be effective.
C) Do you want to refuse this medication? You have the right.
D) Thats a long time wait when you feel so depressed.
The patient needs a brief, factual answer.
21. Which of the following drugs the nurse should choose to administer to a client to
prevent pseudoparkinsonism?
A) Isocarboxazid (Marplan)
B) Chlorpromazine HCI (Thorazine)
C) Trihexyphenidyl HCI (Artane)
D) Trifluoperazine HCI (Stelazine)
Trihexyphenidyl HCI (Artane) is often used to counteract side effect of
pseudoparkinsonism, which often accompanies the use of phenothiazine, such as
chlorpromazine HCI (Thorazine or Trifluoperazine HCI (Stelazine).
22. The nurse is caring to an 80-year-old client with dementia? What is the most
important psychosocial need for this client?
A) Focus on the there-and-then rather the here-and-now.
B) Limit in the number of visitors, to minimize confusion.
C) Variety in their daily life, to decrease depression.
D) A structured environment, to minimize regressive behaviors.
Persons with dementia needs sameness, consistency, structure, routine, and predictability.
23. A client tells the nurse, I dont want to eat any meals offered in this hospital because
the food is poisoned. The nurse is aware that the client is expressing an example of:
A) Delusion.

B) Hallucination.
C) Negativism.
D) Illusion.

This is a false belief developed in response to an emotional need.

24. A client is admitted in the hospital. On assessment, the nurse found out that the client
had several suicidal attempts. Which of the following is the most important nursing
action?
A) Ignore the client as long as he or she is talking about suicide, because suicide
attempt is unlikely.
B) Administer medication.
C) Relax vigilance when the client seems to be recovering from depression.
D) Maintain constant awareness of the clients whereabouts.
The client must be constantly observed.
25. The nurse suspects that the client is suffering from depression. During assessment,
what are the most characteristic signs and symptoms of depression the nurse would note?
A) Constipation, increased appetite.
B) Anorexia, insomnia.
C) Diarrhea, anger.
D) Verbosity, increased social interaction.
The appetite is diminished and sleeping is affected to a client with depression.
26. The client in the psychiatric unit states that, The goodas are coming! I must be
ready. In response to this neologism, the nurses initial response is to:
A) Acknowledge that the word has some special meaning for the client.
B) Try to interpret what the client means.
C) Divert the clients attention to an aspect of reality.
D) State that what the client is saying has not been understood and then divert
attention to something that is really bound.
It is important to acknowledge a statement, even if it is not understood.
27. A male client diagnosed with depression tells the nurse, I dont want to look weak
and I dont even cry because my wife and my kids cant bear it. The nurse understands
that this is an example of:
A) Repression.
B) Suppression.
C) Undoing.
D) Rationalization.
Rationalization is the process of constructing plausible reasons for ones responses.

28. A female client tells the nurse that she is afraid to go out from her room because she
thinks that the other client might kill her. The nurse is aware that this behavior is related
to:
A) Hallucination.
B) Ideas of reference.
C) Delusion of persecution.
D) Illusion.
The client has ideas that someone is out to kill her.
29. A female client is taking Imipramine HCI (Tofranil) for almost 1 week and shows
less awareness of the physical body. What problem would the nurse be most concerned?
A) Nausea.
B) Gait disturbances.
C) Bowel movements.
D) Voiding.
A serious side effect of Imipramine HCI (Tofranil) is urinary retention (voiding
problems)
30. A 6-year-old client dies in the nursing unit. The parents want to see the child. What
is the most appropriate nursing action?
A) Give the parents time alone with the body.
B) Ask the physician for permission.
C) Complete the postmortem care and quietly accompany the family to the childs
room.
D) Suggest the parents to wait until the funeral service to say good-bye.
This allows the parents/family to grieve over the loss of the child, by going through the
steps of leave taking.
31. A 20-year-old female client is diagnosed with anxiety disorder. The physician
prescribed Flouxetine (Prozac). What is the most important side effects should a nurse be
concerned?
A) Tremor, drowsiness.
B) Seizures, suicidal tendencies.
C) Visual disturbance, headache.
D) Excessive diaphoresis, diarrhea.
Assess for suicidal tendencies, especially during early therapy. There is an increased risk
of seizures in debilitated client and those with a history of seizures.
32. A nurse is assigned to activate a client who is withdrawn, hears voices and
negativistic. What would be the best nursing approach?
A) Mention that the voices would want the client to participate.
B) Demand that the client must join a group activity.

C) Give the client a long explanation of the benefits of activity.

D) Tell the client that the nurse needs a partner for an activity.

The nurse helps to activate by doing something with the client.

33. A nurse is going to give a rectal suppository as a preoperative medication to a 4-yearold boy. The boy is very anxious and frightened. Which of the following statement by the
nurse would be most appropriate to gain the childs cooperation?
A) Be a big kid! Everyones waiting for you.
B) Lie still now and Ill let you have one of your presents before you even have
your operation.
C) Take a nice, big, deep breath and then let me hear you count to five.
D) You look so scared. Want to know a secret? This wont hurt a bit!
Preschool children commonly experience fears and fantasies regarding invasive
procedures. The nurse should attempts to momentarily distract the child with a simple
task that can be easily accomplished while the child remains in the side-lying position.
The suppository can be slipped into place while the child is counting, and then the nurse
can praise the child for cooperating, while holding the buttocks together to prevent
expulsion of the suppository.
34. A depressed client is on an MAO inhibitor? What should the nurse watch out for?
A) Hypertensive crisis.
B) Diet restrictions.
C) Taking medication with meals.
D) Exposure to sunlight.
This is the more inclusive answer, although diet restrictions (answer1) are important,
their purpose is to prevent hypertensive crisis (answer 2).
35. A 16-year-old girl is admitted for treatment of a fracture. The client shares to the
nurse caring to her that her step-father has made sexual advances to her. She got the
chance to tell it to her mother but refuses to believe. What is the most therapeutic action
of the nurse would be:
A) Tell the client to work it out with her father.
B) Tell the client to discuss it with her mother.
C) Ask the father about it.
D) Ask the mother what she thinks.
This comes closest to beginning to focus on family-centered approach to intervene in the
conspiracy of silence. This is therefore the best among the options.
36. A client with a diagnosis of paranoid disorder is admitted in the psychiatric hospital.
The client tells the nurse, the FBI is following me. These people are plotting against
me. With this statement the nurse will need to:
A) Acknowledge that this is the clients belief but not the nurses belief.

B) Ask how that makes the client feel.

C) Show the client that no one is behind.
D) Use logic to help the client doubt this belief.

The nurse should neither challenge nor use logic to dispel an irrational belief.
37. A nurse is completing the routine physical examination to a healthy 16-year-old male
client. The client shares to the nurse that he feels like killing his girlfriend because he
found out that her girlfriend had another boyfriend. He then laughs, and asks the nurse to
keep this a secret just between the two of them. The nurse reviews his chart and notes
that there is no previously history of violence or psychiatric illness. Which of the
following would be the best action of the nurse to take at this time?
A) Suggest the teen meet with a counselor to discuss his feelings about his
girlfriend.
B) Tell the teen that his feelings are normal, and recommend that he find another
girlfriend to take his mind off the problem.
C) Recall the teenage boys often say things they really do not mean and ignore the
comment.
D) Regard the comment seriously and notify the teens primary health care
provider and parents
Any threat to the safety of oneself or other should always be taken seriously and never
disregarded by the nurse.
38. Which of the following person will be at highest risk for suicide?
A) A student at exam time
B) A married woman, age 40, with 6 children.
C) A person who is an alcoholic.
D) A person who made a previous suicide attempt.
The likelihood of multiple contributing factors may make this person at higher risk for
suicide. Some factors that may exist are physical illness related to alcoholism, emotional
factors ( anxiety, guilt, remorse), social isolation due to impaired relationships and
economic problems related to employment.
39. A male client is repetitively doing the handwashing every time he touches things. It is
important for a nurse to understand that the clients behavior is probably an attempt to:
A) Seek attention from the staff.
B) Control unacceptable impulses or feelings.
C) Do what the voices the patient hears tell him or her to do.
D) Punish himself or herself for guilt feeling.
A ritual, such as compulsive handwashing, is an attempt to allay anxiety caused by
unconscious impulses that are frightening.
40. In a mental health settings, the basic goal of nursing is to:

A) Advance the science of psychiatry by initiating research and gathering data for
current statistics on emotional illness.
B) Plan activity programs for clients.
C) Understand various types of family therapy and psychological tests and how to
interpret them.
D) Maintain a therapeutic environment.

This is the most neutral answer by process of elimination.

41. A 3-year-old boy is brought to the emergency department. After an hour, the boy dies
of respiratory failure. The mother of the boy becomes upset, shouting and abusive,
saying to the nurse, If it had been your son, they would have done more to save it.
What should the nurse say or do?
A) Touch her and tell her exactly what was done for her baby.
B) Allow the mother to continue her present behavior while sitting quietly with
her.
C) No, all clients are given the same good care.
D) Yes, youre probably right. Your son did not get better care.
This option allows a normal grief response (anger).
42. The nurse is interacting to a client with an antisocial personality disorder. What
would be the most therapeutic approach of the nurse to an antisocial behavior?
A) Gratify the clients inner needs.
B) Give the client opportunities to test reality.
C) Provide external controls.
D) Reinforce the clients self-concept.
Personality disorders stem from a weak superego, implying a lack of adequate controls.
43. A 55-year-old male client tells the nurse that he needs his glasses and hearing aid with
him in the recovery room after the surgery, or he will be upset for not granting his
request. What is the appropriate nursing response?
A) Do you get upset and confused often?
B) You wont need your glasses or hearing aid. The nurses will take care of you.
C) I understand. You will be able to cooperate best if you know what is going on,
so I will find out how I can arrange to have your glasses and hearing aid available
to you in the recovery room.
D) I understand you might be more cooperative if you have your aid and glasses,
but that is just not possible. Rules, you know.
The client will be easier to care for if he has his hearing aid and glasses.
44. The male client had fight with his roommates in the psychiatric unit. The client
agitated client is placed in isolation for seclusion. The nurse knows it is essential that:
A) A staff member has frequent contacts with the client.

B) Restraints are applied.

C) The client is allowed to come out after 4 hours.
D) All the furniture is removed form the isolation room.

Frequent contacts at times of stress are important, especially when a client is isolated.
45. A medical representative comes to the hospital unit for the promotion of a new
product. A female client, admitted for hysterical behavior, is found embracing him.
What should the nurse say?
A) Have you considered birth control?
B) This isnt the purpose of either of you being here.
C) I see youve made a new friend.
D) Think about what you are doing.
This response is aimed at redirecting the inappropriate behavior.
46. A client with dementia is for discharge. The nurse is providing a discharge instruction
to the family member regarding safety measures at home. What suggestion can the nurse
make to the family members?
A) Avoid stairs without banisters.
B) Use restraints while the client is in bed to keep him or her from wandering off
during the night.
C) Use restraints while the client is sitting in a chair to keep him or her from
wandering off during the day.
D) Provide a night-light and a big clock.
This option is best to decrease confusion and disorientation to place and time.
47. A 30-year-old married woman comes to the hospital for treatment of fractures. The
woman tells the nurse that she was physically abused by her husband. The woman
receives a call from her husband telling her to get home and things will be different. He
felt sorry of what he did. What can the nurse advise her?
A) Do you think so?
B) Its not likely.
C) What will be different?
D) I hope so, for your sake.
This option helps the woman to think through and elaborate on her own thoughts and
prognosis.
48. A female client was diagnosed with breast cancer. It is found to be stage IV, and a
modified mastectomy is performed. After the procedure, what behaviors could the nurse
expects the client to display?
A) Denial of the possibility of carcinoma.
B) Signs of grief reaction.
C) Relief that the operation is over.

D) Signs of deep depression.

It is mostly likely that grief would be expressed because of object loss.

49. A client is withdrawn and does not want to interact to anybody even to the nurse.
What is the best initial nursing approach to encourage communication with this client?
A) Use simple questions that call for a response.
B) Encourage discussion of feelings.
C) Look through a photo album together.
D) Bring up neutral topics.
Neutral, nonthreatening topics are best in attempting to encourage a response.
50. Which of the following nursing approach is most important in a client with
depression?
A) Deemphasizing preoccupation with elimination, nourishment, and sleep.
B) Protecting against harm to others.
C) Providing motor outlets for aggressive, hostile feelings.
D) Reducing interpersonal contacts.
It is important to externalize the anger away from self.