Vous êtes sur la page 1sur 17


1. ANSWER: A- Although letters b, c, and d are also functions of community health nursing, health promotion is the primary focus of CHN practice especially
in maintaining the people’s OLOF. (Nisce, et al, 2001).
2. ANSWER: C- According to Nisce, et al (2001), drug abuse and lifestyle diseases are the emerging and pressing health problem being seen in the
communities among higher income groups.
3. ANSWER: A- Persons form low-income groups are the one’s mostly served by the CH nurses because they have greater number of illness and health
problems (Nisce, et al, 2001).
4. ANSWER: D- Environmental influences refer to air, water, food, water waste, noise, radiation and pollution (Nisce, et al, 2001).
5. ANSWER: D- Political factors include safety, oppression, and people empowerment (Nisce, et al, 2001).
6. ANSWER: B- One qualifies for this position with the following: BSN, RN, Masters Degree in Nursing/Public Health and 5 years experience as a PHN.
7. ANSWER: D- The qualifications of a regional nurse supervisor are: BSN, RN, five years experience in CHN with 2 years in a supervisory position
8. ANSWER: A- The qualifications of a chief nurse in city health departments and health offices are: BSN, RN, master’s degree in nursing major in CHN or
Master’s degree in Public Health major in CHN administration , 5 years experience, 3years supervisory with leadership ability
9. ANSWER: B- Community health nurses are generalist as they provide a wide range of nursing responsibilities to different types of patients (Nisce, et al,
11. ANSWER: A- The JOINT AGENCIES OF THE DEPARTMENT OF LABOR believes in the positive socio-cultural value of VOLUNTEERISM
synonymous with the FILIPNO CUSTOM called “BAYANIHAN”, the DOLE shall not cause the deprivation and instead further encourage the
continuance of this practice among Filipino workers and in the enhancement of our “positive character” as Filipinos. Volunteerism MUST not be seen as
a wrongful act among nurses or any Filipino worker. Reference:http://www.y101fm.com/nursing/PositionStatementsoftheDOLE-PRC=
12. ANSWER: B- The JOINT AGENCIES OF THE DEPARTMENT OF LABOR however reminds all concerned (Nurses and Administrators of Healthcare
Institution accepting volunteers) that in such practice there exist NO EMPLOYER-EMPLOYEE RELATIONS nevertheless the doctrine of respond eat
shall ipso facto apply in any or all ethico-legal cases which may be encountered by both parties in such practice;In adherence to the Philippines
Nursing Core Competency Standards with the 11 Key Areas of Responsibilities of every Filipino nurse and considering the “volunteer nature of nursing
services” provided by the so called volunteer nurses, Nursing Service Administrators are reminded of the extent of responsibilities and accountabilities
of volunteer nurses while on volunteer practice. The Board of Nursing SHALL, when ethico-legal issues arise, ALWAYS LOOK INTO, whenever
applicable, the extent of the “respond eat superior” responsibilities and accountabilities of the various Nursing Services.
Reference:http://www.y101fm.com/nursing/PositionStatementsoftheDOLE-PRC= BONonNurseVolunteerism.pdf
13. ANSWER: D- “mindful of the application of Art:72, Chapter 1, Title II of the Philippines LABOR CODE”, or the lack of application or violation thereto
especially on the use of on-the-job-training. We strongly exhorts hospitals and/or health institutions that are affected nurses already fall under the
category of “Registered Professionals” and therefore DESERVE TO BE PAID RIGHTFUL SALARIES to provide them the dignity of earning a decent
living befitting their status as “PROFESSIONAL NURSES”. Reference:http://www.y101fm.com/nursing/PositionStatementsoftheDOLE-PRC=
14. ANSWER: C- The BOARD OF NURSING, with its rule-making authority under the Philippines Nursing Act (R.A.. 9173), SHALL issue the necessary
Guidelines for all POST-BASIC/POST-GRADUATE NURSING TRAINING PROGRAMS to establish legitimacy in adherence to its new National
Nursing Career Progression Policy; Reference:http://www.y101fm.com/nursing/PositionStatementsoftheDOLE-PRC= BONonNurseVolunteerism.pdf
15. ANSWER: D. - Concerned therefore with current and evolving events the Board of Nursing issues the following statements: PRAMOUNT
CONSIDERATION should be “safety and quality” of nursing services under the so-called VOUNTEER PRACTICE which is directly proportional with the
Ethico-Moral-Legal Dimensions of this Practice. Reference:http://www.y101fm.com/nursing/PositionStatementsoftheDOLE-PRC=
16. ANSWER: A- Philippine Health Corporation (Philhealth)- Philhealth should pay for the project’s nurse’s cooperatives for their services rendered to its
members. The OHNAP refers qualified patients from their companies to their company-based clinics to the cooperative, The PRC-Board of Nursing
promotes nurse entrepreneurship among the country’s nursing students and schools and research on the feasibility of including nurse entrepreneurship
in the BSN curriculum. The DOLE provides general management and direction. Reference: Reference: PRC Souvenir Program, Nov 2009 NLE, Project
17. ANSWER: C- 1,2,3,4- Rationale: All of the above are recipients of the project EntrepreNURSE. Reference: PRC Souvenir Program, Nov 2009 NLE,
Project EntrepreNURSE.
18. ANSWER: D- 1,2,3 Rationale: An initiative of DOLE, in collaboration with BON-PRC, DOH, PNA, UPCN, OHNAP and other government and non-
government entities to promote nurse entrepreneurship by introducing a home health care industry in the Philippines: 1) to reduce the cost of health
care for the country’s indigent population by bringing primary health care services to poor rural communities, 2) to maximize employment opportunities
for the country’s unemployed nurses and 3) to utilize the country’s unemployed human resources for health for the delivery of public health services and
the achievement of the country’s Millennium Development Goals on maternal and child health, consistent with the FourMULA One for Health framework
of the Department of Health. Reference: www.dole.gov.ph and Project EntrepreNurse
19. ANSWER: A- Form cooperatives and manage nurse’s clinic- An initiative of DOLE, in collaboration with BON-PRC, DOH, PNA, UPCN, OHNAP and
other government and non-government entities to promote nurse entrepreneurship by introducing a home health care industry in the Philippines.
Reference: Reference: PRC Souvenir Program, Nov 2009 NLE, Project EntrepreNURSE.
20. ANSWER: B- Maternal and child health- To utilize the country’s unemployed human resources for health for the delivery of public health services and
the achievement of the country’s Millennium Development Goals on maternal and child health, consistent with the Fourmula One for Health framework
of the Department of Health. Reference: Reference: PRC Souvenir Program, Nov 2009 NLE, Project EntrepreNURSE.
21. ANSWER: C- The two subspecialties of CHN in the Philippines are School Health Nursing and Occupational Health Nursing (Maglaya, A.(2004). Nursing
Practice in the Community.
22. ANSWER: D- The determinants of School Health Nursing are characteristics of clientele, policies of DepEd, programs of DOH and nursing standards.
23. ANSWER: A- Life expectancy of female has always been higher than males: females 72.8 years and males 67.53 years. Reyala, et al. (2007). Public
Health Nursing in the Philippines.
24. ANSWER: B- The Department of Health provides care services to the people in all the three levels of prevention. Maglaya, A. (2004). Nursing Practice in
the Community.
25. ANSWER: B- Case finding, cataract screening, TB multiple drug therapy, ORT and sputum microscopy are examples of secondary level of prevention.
Maglaya, A. (2004). Nursing Practice in the Community.
26. ANSWER: D- The risk of developing clinical disease is 6-12 months after exposure. TB may persist undetected for a lifetime as a latent infection with the
patient capable of transmitting it to others unknowingly. Nisce, et al (2001). Community Health Nursing Services in the Philippines.
27. ANSWER: B- Modes of transmission of TB is by the following:
 Airborne by droplet nuclei through sneezing, talking and coughing. Persons with cavity lesions are highly infectious because their sputum contains
1 million to 10 million bacilli per mL.
 Prolonged contact with the patient by household members
 Direct contact by kissing
Direct invasion of microorganism to breaks in the skin Nisce, et al (2001). Community Health Nursing Services in the Philippines.


28. ANSWER: A- Category 1 includes new pulmonary smear (+) cases, new seriously ill pulmonary smear (-) cases with extensive parenchymal
involvement, and new severely ill extra-pulmonary TB cases. Reyala, et al. (2007). Public Health Nursing in the Philippines.
29. ANSWER: D- to educate the public in mode of spread and methods of control
30. ANSWER: A- DOTS s a comprehensive strategy to detect and cure TB. The primary element of DOTS is health workers counsel and observes their
patients swallow each anti-TB medication and monitor progress until cured. Reyala, et al. (2007). Public Health Nursing in the Philippines.
31. ANSWER: C- Mother who is a class IV cardiac patient
32. ANSWER: C- Rooming-in and Breastfeeding act mandates that infants delivered by caesarian section shall be roomed-in and breastfed within 3-4 hours
after birth
33. ANSWER: B- Mothers with mild to moderate medical problems such as TB who have been adequately treated for at least 2 days shall NOT continue to
34. ANSWER: B- Saves medical costs to families and governments by preventing illnesses
35. ANSWER: C- Never store your breast milk in the door compartment of the refrigerator or freezer. It is more likely to defrost or become too warm there
making the temperature very unstable
Consider these general guidelines for healthy infants:
 Room temperature. Freshly expressed breast milk can be kept at room temperature for up to six hours. However, use or proper storage within four
hours is optimal. If the room is especially warm, the limit is also four hours.
 Insulated cooler. Freshly expressed breast milk can be stored in an insulated cooler with ice packs for up to one day.
 Refrigerator. Freshly expressed breast milk can be stored in the back of the refrigerator for up to five days in clean conditions. However, use or
freezer storage within three days is optimal.
 Deep freezer. Freshly expressed breast milk can be stored in the back of a deep freezer for up to 12 months. However, using the frozen milk within
six months is optimal.
Keep in mind research suggests that the longer you store breast milk — whether in the refrigerator or in the freezer — the greater the loss of vitamin C in the
milk. It's also important to note that breast milk expressed when a baby is a newborn won't as completely meet the same baby's needs when he or she is a
few months older. Also, storage guidelines might differ for preterm, sick or hospitalized infants.

36. ANSWER: B- Lactating women are given iron supplementations preferably for for 3 mos or 90 days AND PREGNANT WOMAN FOR 6 months
37. ANSWER: B- Children with malnutrition are given Vitamin A capsule OR 200,000 IU
38. ANSWER: D- Iodine, iron and vitamin A
39. ANSWER: B. LOI 441- Integration of Nutrition Education in the school curriculum. A- PD No. 491- declared July as the Nutrition Month and creation of
National Nutrition Council, C- RA 8976- Philippine Food Fortification Act of 2000. D- EO 382- November 7 declared National Food Fortification Day
40. ANSWER: B- Iron supplementation for low birth infants will start at 2 MONTHS However, VLBW infants fed mother’s own milk or donor human milk should
be given 2–4 mg/kg per day iron supplementation starting at 2 weeks until 6 months of age.
41. ANSWER: A- NBS is done after 48 – 72 hours after birth because PKU cannot be detected as early as 24 hours giving a false negative result.
42. ANSWER: A- Newborn screening is performed by getting a blood sample using the heel prick method. The said test can now be charged to Philhealth with a
rate of 1,600 pesos
43. ANSWER: C- AMONG THE DISEASES INCLUDED IN THE NBS, MSUD and CAH will lead to death if not detected or treated.
44. ANSWER: A- Individuals deficient in G6PD are usually asymptomatic; however, in some cases exposure to chemicals (for example, naphthalene) and
drugs (including sulfamides, antipyretics, nitrofurane, primaquine and chloroquine) can induce massive intravascular hemolysis. Among the clinical
forms of this enzymatic deficiency are jaundice, acute hemolytic anemia and chronic nonspherocytic hemolytic anemia. A more severe consequence of
neonatal hyperbilirubinemia is kernicterus, a neurological syndrome caused by the deposition of bilirubin in the brain tissues, which results in severe
consequences and even death.
45. ANSWER: B - Infants with this disease seem healthy at birth but quickly deteriorate, often with severe brain damage, which may be permanent. Death
often occurs within the first five months in severe cases of the disease, when left untreated.
46. ANSWER: D- Local health systems development
47. ANSWER: A- Integrated prevention and control of lifestyle related diseases
48. ANSWER: C - Award for excellence refers to the highest level quality standards
49. ANSWER: C- Second level quality standards for the 4 core public health programs are met
50. ANSWER: D- The pillars of sentrong sigla movement are: Quality assurance, Grants and technical assistance , Awards – Sentrong Sigla Movement seal
and Health promotion
51. ANSWER: A - P.D. 522- Mandatory implementation of sanitary permit to all food establishments; City Hall), R.A. 9003- The discipline associated with
the control of generation, storage, collection, transfer and transport, processing, and disposal of solid wastes in a manner that is in accord with the best
principles of public health economics, engineering, conservation, aesthetics and other environmental considerations, P.D. 442- Labor Code on
Prevention and Compensation. E.O. 307 - creating occupational safety and health center (OSHC)
52. ANSWER: B- Solid particles in the water binds to alum (Tawas) and settles at the bottom
- Sedimentation - Let it stand for a few hours and the solid particles will settle at the bottom of the container
- Filtration - Use of filters
- Fluoridation – Adding of fluoride to water
53. ANSWER: C- A point source facility normally serves 15-25 households and its outreach must be Within 250m from the farthest user
54. ANSWER: B- Yellow with black band - pharmaceutical, cytotoxic, or chemical wastes (labeled separately)
-Black or colorless - non-hazardous, non-biodegradable wastes, plastic covers, IV glass bottles
-Green - non-hazardous biodegradable wastes, leftovers
-Yellow with biohazard symbol - pathological/anatomical wastes
-Yellow bag that can be autoclaved - infectious wastes
-Orange with radioactive symbol - radioactive wastes
-Red - sharps, needles
-Yellow - tissues, syringe
55. ANSWER: C- an acceptable toilet should not allow the entry and exit of small animals. All other options are correct.
56. ANSWER: B- Locally Endemic disease control
57. ANSWER: B- Expanded Program on Immunization
58. ANSWER: D. Maternal and Child Health
59. ANSWER: C- Nutrition
60. ANSWER: D- ALL ARE INCLUDED. Suyurin at sirain ang pinamumugaran ng mga lamok, Sarili ay protektahan laban sa lamok, Sumangguni agad sa
pagamutan kapag may sintomas na ng dengue, Sumuporta sa “fogging/spraying” kapag may banta na ng outbreak
61. ANSWER: B- It is the birth attendant who must fill-up and register the birth of the infant. If the birth attendant is a hilot ot TBA, she must be assisted by
the midwife. The TBAs must report to the health center or BHS all deliveries that she assisted for continuing services. Reyala, et al. (2007). Public
Health Nursing in the Philippines.


62. ANSWER: B- The nurse must assess the client first in order to know what intervention is necessary.
63. ANSWER: D- Growth monitoring card provide information related to child growth and development
64. ANSWER: C- In the Philippines, many traditional beliefs are still upheld regarding the baby’s placenta. Some parents may ask the nurse to give them the
placenta so they can bury it in special places they believe will bring good luck or special traits to the child. Reyala, et al. (2007). Public Health Nursing in
the Philippines.
65. ANSWER: A- Reproductive health concepts include:
 All couple has the capability to procreate
 Exercise of reproductive right with responsibility
 Means safe pregnancy and delivery
 Sexual health which includes protection from STD, violence and harmful reproductive practices
 Access to information on sexuality
 Access to family planning
Reyala, et al. (2007). Public Health Nursing in the Philippines.
66. ANSWER: C- PD 996- Providing for compulsory basic immunization for infants and children below 8 . PP #6- Implementing a United Nations goal on
Universal Child Immunization by 1990. RA 10152-Mandatory Infants and Children Health Immunization Act of 2011, RA 7846- Hepa. B immunization
67. ANSWER: B- Tell her to bring the card to the center of the place
68. ANSWER: C- Hepatitis vaccine is given subcutaneously with a dose of 0.5ml at birth along with BCG.
69. ANSWER: A- Tetanus vaccine is a bacterial toxin but is INACTIVE
70. ANSWER: B- CORRECT. DPT is given during the 6th, 10th and 14th week. All other options are wrong/
71. ANSWER: A- There are five variables that must be identified about the community in order to make a proper community diagnosis. Environmental
factors include geographical characteristics, water supply, waste disposal, air/water/land pollution. Maglaya, A. (2004). Nursing Practice in the
72. ANSWER: A- CHN involves multi-sectoral collaboration
73. ANSWER: A- Infant mortality rate is the most sensitive index in drawing the health status of a community. Maglaya, A. (2004). Nursing Practice in the
74. ANSWER: A- When the de facto method is used, the people are assigned to the place where they are physically present at the time of the census
regardless of their usual place of residence. On the other hand, the de jure method is done when people are assigned to the place where they usually
live regardless of where they are at the time of the census. (Maglaya 2004, page 172).
75. ANSWER: B- Vital statistics should be reported where it happened. (Reyala, Jean R., et al. (2007), Public Health Nursing in the Philippines.
76. ANSWER: B- Self-reliance
77. ANSWER: B- INCORRECT- CO practice is extended to increase the benefits of the individual and the health worker ( tts: health worker)
78. ANSWER: B- It aims to develop the capability of the people in solving community health problems.
79. ANSWER: B. Identified potential leaders representing the different sectors of the community
80. ANSWER: C- Comprehensive Community Diagnosis
81. ANSWER: A- “We should be the one who will initiate sexuality education to our young children.”
82. ANSWER: B- Education about reducing unwanted pregnancies
83. ANSWER: A- National government is the only agency responsible for reproductive health (TTS: absolute term only)
84. ANSWER: C- Grade 5 to 4th year high school
85. ANSWER: B- Couple’s decision
86. ANSWER: A- AO No. 2010-0036 – AHA- Universal Health Care, AO No. 2009- 0025- Essential Intrapartal Newborn Care – Unang Yakap, RA 9709-
Universal Newborn Hearing Screening and Intervention Act of 2009 , RA 8980- Refers to the full range of health, nutrition, early education and social
services programs that provide for the basic holistic needs of young children from birth to 6 years of age, to promote their optimum growth and
87. ANSWER: D- Financial risk protection through expansion in NHIP enrollment and benefit delivery, Improved access to quality hospitals and health care
facilities and Attainment of the health-related Millennium Development Goals (MDG) are the major thrust of UHC
88. ANSWER: D- Option A,B, C are strategies to promote Enrollment of poor families in NHIP (RA 7857)
89. ANSWER: A- Financial risk protection through improvements in NHIP benefit delivery shall be achieved by:
(1) Redirecting PhilHealth operations towards the improvement of the national and regional benefit delivery ratios; (2) Expanding enrolment of the poor in the
NHIP to improve population coverage; (3) Promoting the availment of quality outpatient and inpatient services at accredited facilities through reformed
capitation and no balance billing arrangements for sponsored members, respectively; (4) Increasing the support value of health insurance through the use of
information technology upgrades to accelerate PhilHealth claims processing, etc.; and (5) A continuing study to determine the segments of the population to
be covered for specific range of services and the proportion of the total cost to be covered/supported
90. ANSWER: A- Public is a largely financed sector through tax-based budgeting system both national and local levels ( Magic word: tax- based)
91. ANSWER: B- Courtesy call to the Barangay Captain
92. ANSWER: B- It encourage dependence on the health workers and representatives of other government agencies. (tts: dependence)
93. ANSWER: B- People have limited ability to learn
94. ANSWER: B- Understand deeply the culture and lifestyle in the community
95. ANSWER: C- Make a courtesy call visiting her when she leaves
96. ANSWER: A- Febrile with a general danger sign
97. ANSWER: D- Unable to breastfeed is one of the danger signs
98. ANSWER: D- Fast breathing is not a danger sign. Remember CUVA
99. ANSWER: C- Referral- Basic Steps in IMCI include ( ACTF)Assess , Classify , Treat and Follow-up
100. ANSWER: A- Child experience occasional vomiting (tts: occasional)

1. ANSWER: D- The goal here is to relieve pressure on the cord from the presenting part. This can be accomplished by manually holding the presenting part
off the cord through exerting upward pressure on the presenting part. With many complications, it helps to have the woman assume the side-lying position.
In this case, however, that may not be enough to relieve pressure on the cord. She should be put in a deep Trendelenburg’s or a modified Sims’ position.
Stimulating the fetal scalp or using acoustic stimulation is sometimes called for when a nonreassuring fetal heart rate pattern is seen on the monitor. The
client shouldn’t push because that would result in pressure on the cord.
2. ANSWER: D - A client with a second episode of bleeding from a placenta previa usually needs to undergo cesarean delivery, and a CBC is necessary to
determine hemoglobin level before surgery; an order for packed RBCs will ensure replacement blood is available in case it’s needed. A scalp electrode can’t
be used because the placenta blocks access to the fetus. Vaginal examinations could promote vaginal bleeding by disturbing the placenta. The client should
remain on bed rest, and the bladder will be emptied when an indwelling urinary catheter is inserted before surgery.
3. ANSWER: B- The most accurate answer is the one that explains that several factors work together to cause labor to begin. Telling the woman that it is a
mystery is not entirely accurate because, although we don’t have all the answers, scientists do have a partial understanding of the forces that affect labor. If
there is a special hormone that signals labor to begin, it has not been discovered. Telling the woman not to worry about it is not therapeutic and dismisses her
concern unnecessarily.
4. ANSWER: C-Each woman experiences labor pain in a unique way. The “best” method is the method that coincides with the woman’s belief system and
works for the woman. It is best to learn several methods because it is difficult to predict which method will be most beneficial for the woman until she actually
experiences labor. Stating that an epidural is the best or that natural childbirth is best attempts to impose the nurse’s beliefs about labor pain management on
the woman. Stating that most women require some type of IV pain medication during labor is incorrect. Many women go through labor without IV pain
5. ANSWER: B- Counter-pressure on the lower back and intradermal water injections are interventions that are specifically indicated for intense back labor.
Intermittent labor support and reassurance that the pain is temporary are not particularly helpful for any type of labor pain. Effleurage and ambulation
generally are more helpful in early labor and are not specific to back labor. Hypnosis and imagery require special training and are not specific to back labor.
6. ANSWER: C- The more milk is removed from the breasts, the more milk will be produced. For a non-lacting mother, the breasts should not be pumped nor
manually expressed in order not to stimulate more milk secretion causing more engorgement. Cold application, instead of warm compress is used to relieve
engorgement and discomfort. Medication to relieve pain and suppress milk production may be taken as ordered.
7. ANSWER: B- Breastfeeding is best to promote mother-newborn bonding. To enhance the letdown reflex or milk ejection reflex, which is affected by material
emotions, the nurse should make sure that the lactating mother receives adequate support and reassurance. The best schedule for feeding infants is not rigid
(not necessarily every 2 hours or every 3 hours), but ‘on demand.’ Demand feeding the infant according to his biologic need for food. In the event that the
mother decides to bottlefeed the infant, she should be advised to cuddle/hold the infant while feeding, in order to have the most important prerequisite to
bonding-eye contact.
8. ANSWER: C- If the woman perceives negative attitude from others, she may be tense and letdown may not occur. A positive attitude of others toward
breastfeeding promotes relaxation and letdown reflex, the most important to successful breastfeeding. Prolactin (or milk secretion) reflex is enhanced by
complete emptying of the breasts with each feeding time.
9. ANSWER: B- Clients with HIV should not breastfeed because the infection can be transmitted to the baby through breast milk. The clients in answers A, C,
and D – those with diabetes, hypertension, and thyroid disease – can be allowed to breastfeed.
10. ANSWER: D- Success with breastfeeding depends on many factors, but the most dependable reason for success is desire and willingness to continue the
breastfeeding until the infant and mother have time to adapt. The educational level, the infant’s birth weight, and the size of the mother’s breast have nothing
to do with success, so answers A, B, and C are incorrect.
11. ANSWER: C- The initial action by the nurse observing a variable deceleration should be to turn the client to the side, preferably the left side. Administering
oxygen is also indicated. Answer A is not called for at this time. Answer B is incorrect because it is not needed, and answer D is incorrect because there is no
data to indicate that the monitor has been applied incorrectly.
12. ANSWER: A- Eating carbohydrates such as dry crackers or toast before arising helps to alleviate morning sickness. Answer B is incorrect because the
additional fat might increase the client’s nausea. Answer C is incorrect because the client does not need to skip meals. Answer D is the treatment of
hypoglycemia, not morning sickness; therefore, it is incorrect.
13. ANSWER: C- The success of the rhythm method of birth control is dependent on the client’s menses being regular. It is not dependent on the age of the
client, frequency of intercourse, or range of the client’s temperature; therefore, answers A, B, and D are incorrect.
14. ANSWER: C- The food with the most calcium is the yogurt. Answers A, B, and D are good choices, but not as good as the yogurt, which has approximately
400mg of calcium.
15. ANSWER: C- Cyanosis of the feet and hands is acrocyanosis. This is a normal finding 1 minute after birth. An apical pulse should be 120–160, and the baby
should have muscle tone, making answers A and B incorrect. Jaundice immediately after birth is pathological jaundice and is abnormal, so answer D is
16. ANSWER: C- Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder decreases the progression of labor. Answers A,
B, and D are incorrect because the bladder does not fill more rapidly due to the epidural, the client is not in a trancelike state, and the client’s level of
consciousness is not altered, and there is no evidence that the client is too embarrassed to ask for a bedpan.
17. ANSWER: C - The obstetrical client under age 18 is at greatest risk for CPD because pelvic growth is not fully completed. Answers A, B, and D are incorrect
because these clients are not as likely to have CPD.
18. ANSWER: C- Epidural anesthesia involves injecting an anesthetic into the epidural space. If the anesthetic rises above the respiratory center, the client will
have impaired breathing; thus, monitoring for respiratory depression is necessary. Answer A, seizure activity, is not likely after an epidural. Answer B,
postural hypertension, is not likely. Answer D, hematuria, is not related to epidural anesthesia.
19. ANSWER: A- Methergine is a drug that causes uterine contractions. It is used for postpartal bleeding that is not controlled by Pitocin. Answers B, C, and D
are incorrect: Stadol is an analgesic; magnesium sulfate is used for preeclampsia; and phenergan is an antiemetic.
20. ANSWER: B- Lutenizing hormone released by the pituitary is responsible for ovulation. At about day 14, the continued increase in estrogen stimulates the
release of lutenizing hormone from the anterior pituitary. The LH surge is responsible for ovulation, or the release of the dominant follicle in preparation for
conception, which occurs within the next 10–12 hours after the LH levels peak. Answers A, C, and D are incorrect because estrogen levels are high at the
beginning of ovulation, the endometrial lining is thick, not thin, and the progesterone levels are high, not low.
21. ANSWER: B- In the first 7 to 14 days the developing ovum is known as a blastocyst; it is called an embryo until the 8th week; the developing cells are then
called fetus until birth. A- heard between the 12th and 20th week. C- this is called blastocyst.
22. ANSWER: D- the function of progesterone is to relax the uterus and maintain a succulent endometrium to foster implantation of the fertilized ovum. A-
Ovulation is stimulated by increases in the level of leutinizing hormone (LH) and estrogen. B- Menstruation is controlled by regulating factors from the
hypothalamus and pituitary (FSH-RH, FSH, LH-RH, LH); these hormones stimulate the production of ovarian follicles, ovulation, estrogen, and progesterone
by the ovarian cells. C- Capillary fragility is often associated with deficiency of vitamin C (ascorbic acid); progesterone is not responsible.
23. ANSWER: B- Lutenizing hormone released by the pituitary is responsible for ovulation. At about day 14, the continued increase in estrogen stimulates the
release of lutenizing hormone from the anterior pituitary. The LH surge is responsible for ovulation, or the release of the dominant follicle in preparation for
conception, which occurs within the next 10–12 hours after the LH levels peak. Answers A, C, and D are incorrect because estrogen levels are high at the
beginning of ovulation, the endometrial lining is thick, not thin, and the progesterone levels are high, not low.
24. ANSWER: A- The greatest danger of drug-induced malformation is during the first trimester of pregnancy, because this is the period of organogenesis. B-
this may cause problems, but organogenesis has already taken place by the second trimester. C- the fetus is totally formed at this time, and damage from
drugs would not be likely. D- Drugs should be avoided throughout pregnancy, but the first trimester (period of organogenesis) is the most critical.
25. ANSWER: C- Progesterone stimulates differentiation of the endometrium into a secretory type of tissue. A- influenced by estrogen. B- influenced by high
levels of lutenizing hormone. D- influenced by testosterone.
27. ANSWER: A- Early deceleration is due to fetal head compression causing vagal nerve stimulation and only needs further assessment or to continue
28. ANSWER: B- Presence of acceleration denotes fetal well-being.
29. ANSWER: C: FHR strip shows a late deceleration and is caused by uteroplacental insufficiency
30. ANSWER: C- positioning the mother on her left side relieves pressure on the inferior vena cava increasing blood flow to the heart for increased cardiac
output and promotes adequate maternal and fetal circulation
31. ANSWER: D- Most drugs pass into breast milk and almost all medications appear in only small amounts in human milk. Very few drugs are contraindicated
for breastfeeding women. The physician must be fully advised so an appropriate recommendation can be made.
32. ANSWER: B- Its immune globulins (IgA) protects the baby against all common childhood diseases in the first two months of life.(NO RATIO)


33. ANSWER: C- A client who has twins
34. ANSWER: C- It is not unusual for the newborn to regurgitate some mucus and water following a feeding, even if it was taken without difficulty. The nurse
should observe the newborn closely and position on the right side after a feeding to aid drainage and facilitate gastric emptying.
35. ANSWER: A- Neither unmodified cow’s milk is much higher (50% to 75% greater) than in human milk, is poorly digested, and may cause bleeding of the
gastrointestinal tract. It also has higher levels of calcium, phosphorus, sodium, and potassium, which increase renal solute load and result in greater
obligatory water loss. Skim milk lacks adequate calories, fat content, and essential fatty acids necessary for proper development of the infant’s
neurologic system.
36. ANSWER: B- The 4-year-old is more prone to accidental poisoning because children at this age are much more mobile. Answers A, C, and D are incorrect
because the 6-month-old is still too small to be extremely mobile, the 12-year-old has begun to understand risk, and the 13-year-old is also aware that injuries
can occur and is less likely to become injured than the 4-year-old.
37. ANSWER : B- Children ages 18–24 months normally have sufficient sphincter control necessary for toilet training. Answer A is incorrect because the child is
not developmentally capable of toilet training. Answers C and D are incorrect choices because toilet training should already be established.
38. ANSWER: B- Parallel play, the form of play used by toddlers, involves playing beside one another with like toys but without interaction. Answer A is incorrect
because it describes associative play, typical of the preschooler. Answer C is incorrect because it describes cooperative play, typical play of the school-age
child. Answer D is incorrect because it describes solitary play, typical play of the infant.
39. ANSWER: A- Infants can discriminate speech and the human voice from other patterns of sound. Answers B, C, and D are inaccurate statements; therefore,
they are incorrect.
40. ANSWER: D - Consistently responding to the infant’s needs fosters a sense of trust. Failure or inconsistency in meeting the infant’s needs results in a sense
of mistrust. Answers A, B, and C are important to the development of the infant but do not necessarily foster a sense of trust; therefore, they are incorrect.
41. ANSWER: A- Following hypospadias repair, the child will need to avoid straddle toys, such as a rocking horse, until allowed by the surgeon. Answers B, C,
and D do not relate to the post-operative care of the child with hypospadias; therefore, they are incorrect.
42. ANSWER: C- Ortolani’s sign; it is the abnormal clicking sound when the hips are abducted. The sound is produced when the femoral head enters the
acetabulum. Letter A is wrong because its should be “asymmetrical gluteal fold”. Letter B and C are not applicable for newborns because they are seen
in older children.
43. ANSWER: B - Infants under the age of 2 years should not be fed honey because of the danger of infection with Clostridium botulinum. Answers A, C, and D
are not related to the situation; therefore, they are incorrect.
44. ANSWER: B- According to the Denver Developmental Assessment, a 4-year-old should be able to state his first and last name. Answers A and C are
expected abilities of a 5-year-old, and answer D is an expected ability of a 5- and 6-year-old.
45. ANSWER: B- The nurse should avoid giving the infant a pacifier or bottle because sucking is not permitted. Holding the infant cradled in the arms, providing
a mobile, and offering sterile water using a Breck feeder are permitted; therefore, answers A, C, and D are incorrect.
46. ANSWER: C- Children at 24 months can verbalize their needs. Answers A and B are incorrect because children at 24 months understand yes and no, but
they do not understand the meaning of all words. Answer D is incorrect; asking “why?” comes later in development.
47. ANSWER: B- The toddler has gross motor skills suited to playing with a ball, which can be kicked forward or thrown overhand. Answers A and C are
incorrect because they require fine motor skills. Answer D is incorrect because the toddler lacks gross motor skills for play on the swing set.
48. ANSWER: D- The majority of children have all their deciduous teeth by age 30 months, which should coincide with the child’s first visit with the dentist.
Answers A, B, and C are incorrect because the deciduous teeth are probably not all erupted.
49. ANSWER: B- Parallel play is play that is demonstrated by two children playing side by side but not together. The play in answers A and C is participative
play because the children are playing together. The play in answer D is solitary play because the mother is not playing with Mary.
50. ANSWER: B- A 2-year-old is expected only to use magical thinking, such as believing that a toy bear is a real bear. Answers A, C, and D are not expected
until the child is much older. Abstract thinking, conservation of matter, and the ability to look at things from the perspective of others are not skills for small
51. ANSWER: A- Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temperature is important but will not assist in
eliminating bilirubin; therefore, answer B is incorrect. Answers C and D are incorrect because they do not relate to the question.
52. ANSWER: A- A swelling over the right parietal area is a cephalhematoma, an area of bleeding outside the cranium. This type of hematoma does not cross
the suture line. Answer B, molding, is overlapping of the bones of the cranium and, thus, incorrect. In answer C, a subdural hematoma, or intracranial
bleeding, is ominous and can be seen only on a CAT scan or x-ray. A caput succedaneum, in answer D, crosses the suture line and is edema.
53. ANSWER: D - A loss of 10% is normal due to meconium stool and water loss. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the
infant formula; thus, answers A, B, and C are incorrect.
54. ANSWER: B - The first action that the nurse should take when beginning to examine the infant is to listen to the heart and lungs. If the nurse elicits the
Babinski reflex, palpates the abdomen, or looks in the child’s ear first, the child will begin to cry and it will be difficult to obtain an objective finding while
listening to the heart and lungs. Therefore, answers A, C, and D are incorrect.
55. ANSWER: C- Rice cereal, mashed ripe bananas, and strained carrots are appropriate foods for a 6-month-old infant. Answer A is incorrect because the
cocoa-flavored cereal contains chocolate and sugar, orange juice is too acidic for the infant, and strained meat is difficult to digest. Answer B is incorrect
because graham crackers contain wheat flour and sugar. Pudding contains sugar and additives unsuitable for the 6-month-old. Answer D is incorrect
because the white of the egg contains albumin, which can cause allergic reactions.
56. ANSWER: C- Though letter B would be a good answer too, this goal is too vague and not specific. Nursing interventions will not solely promote normal
G&D unless he will undergo surgical repair. So decreasing Hypoxic Spells is more SMART. (alam nyo na kung ano yun! Specific, measurable,
attainable, realistic and time bounded). Letter A and D are inappropriate.
57. ANSWER: B- The immediate intervention would be to place her on knee-chest or “squatting” position because it traps blood into the lower extremities.
Though also letter C would be a good choice but the question is asking for “Immediate” so letter B is more appropriate. Letter A and D are incorrect
because its normal for a child who have ToF to have hypoxic or “tets” spells so there is no need to transfer her to the NICU or to alert the Pediatrician.
58. ANSWER: D- Blalock-Taussig procedure its just a temporary or palliative surgery which creates a shunt between the aorta and pulmonary artery (oist
parang ductus arteriosus) so that the blood can leave the aorta and enter the pulmonary artery and thus oxygenating the lungs and return to the left
side of the heart, then to the aorta then to the body. This procedure also makes use of the subclavian vein so pulse is not palpable at the right arm. The
full repair for ToF is called the Brock procedure. Raskkind is a palliative surgery for TOGA.
59. ANSWER: A- Because toddlers views hospitalization is abandonment, separation anxiety is common. Its has 3 phases: 1. Protest 2. despair 3.
detachment (or denial). Choices B, C, D are usually seen in a child with separation anxiety (usually in the protest stage). Separation anxiety begin at: 9
months Peaks: 18 months
60. ANSWER: D- In this item letter A and B are inappropriate response so remove them. The possible answers are C and D. Fear defined as the perceived
threat (real or imagined) that is consciously recognized as danger (NANDA) is applicable in the situation but its defining characteristics are not
applicable. Crying per se can not be a subjective cue to signify fear, and most of the symptoms of fear in NANDA are physiological. Anticipatory grieving
on the other hand are intellectual and EMOTIONAL responses based on a potential loss. And remember that procedures like this cannot assure total
recovery. So letter D is a more appropriate Nursing diagnosis.
61. ANSWER: B- Strategic Planning is a long term planning wherein the hospital institution revises or modifies its overall standards, policies and goals in order
to update its programs and services, furthermore, currently adapting to the relevant health needs of the public.
62. ANSWER: B- Rationale: SWOT is the assessment of STRENGTH, WEAKNESS, OPPORTUNITIES, THREATS that is commonly done during the start of
strategic planning. It enables the management to forecast possible effective means of upgrading and updating the products and services of the company.


63. ANSWER: C- Rationale: Standard is the most important result of effective planning. It provides a basis for the Evaluation of services and programs of the
company as it attempts to achieve all the other components of planning phase – Mission, Vision, Values, Philosophy, Goals and Objective. Moreover,
effective standard conceptualization stimulates the company to think of best possible and available ways of providing the best services.
64. ANSWER: B- Rationale: Mission is defined as the reason of the company’s existence. It provides a more realistic and achievable action in providing quality
service or program. Option A – Goals are more specifically stated. Option C – Vision is the ideal aspiration of the company’s future self. Option D – Values
are stated in single word that reflects the principles that the company upholds.
65. ANSWER: D- Developed by Wilfredo Pareto believing that 80% or major results always come from 20% or minor causes. This gives an idea that in
whichever form of business, the management should give special attention to solving minor problems that can be easily overlooked and can result to bigger
problems in the future. Option A – Baylor Principle is a scheduling principle. Option B – Henry Fayol developed the 14 Principles of Management . Option C –
Decision making is a process achieved through Definition and Analysis of the Problem, Determining the different solutions, Considering the outcomes of each
solution, Select and implement the best solution and finally, Revise, Modify or Change
66. ANSWER: B- External Validity refers to the extent to which the samples represent the target population. Option A – Internal Validity refers to the accuracy,
honesty and acceptability of research findings, ensuring that the independent variable is the only cause that would affect the dependent variable. Option C –
Content Validity refers to the data-gathering tool being able to provide certain items or components that would measure and test all the different composition
of a theory. Option D – Construct Validity is defined as the ability of a data-gathering tool to measure the abstractness of data.
67. ANSWER: D - Recommendation is the only part where the researcher can put opinionated statements. All the other components of the research should be
objective, concrete, non-opinionated and non-biased. Words such as “I”, “me”, “my”, or any words in the first person should never be included in the research
68. ANSWER: B- There are only 2 groups of statistical formula – Descriptive Statistics and Inferential Statistics. Descriptive statistics is the group of formula
utilized to summarize and describe the collected data while inferential statistics would focus more testing the hypothesis in order to make valid conclusion.
69. ANSWER: A- Dissemination of conclusion/ findings is the last step in research process
70. ANSWER: D- Rationale: Journals are the best way to reach the public – it doesn’t need electricity and it is more accessible and convenient.
71. ANSWER: C. A leader doesn’t always needs or have formal power and authority. A leader guides, directs, and enhances the activities of peers and
colleagues and is an effective role model. A manager has formal position of power in an organization and should be an effective leader. An autocrat doesn’t
seek staff input and doesn’t encourage peers or subordinates to grow professionally. Authority is a characteristic of managers and is part of the formal
position of power granted to someone as a result of a job description.
72. ANSWER: D- The authoritarian leader retrains all authority and responsibility and is concerned primarily with completing tasks and accomplishing goals. The
democratic leader is people centered, allows greater individuals participation in decision making, and maintains open communications. The permissive and
the laissez-faire leaders deny responsibility and abdicate authority to the group.
73. ANSWER: D. Autocratic leadership is an approach in which the leader retains all authority and is primarily concerned with task accomplishment. It is an
effective leadership style to implement in an emergency or crisis situation. The leader assigns clearly defined tasks and establishes one-way communication
with the work group, making all of the decisions alone. Democratic leadership is a people-centered approach that is primarily concerned with human
relations and teamwork. Situational leadership is a comprehensive approach that incorporates the leader’s style, the maturity of the work group, and the
situation at hand. Laissez faire is a permissive style of leadership in which the leader gives up control and delegates all decision making to the work group.
Strategy: Use the process of elimination and knowledge of the various types of leadership styles. Note the relationship of the words “autocratic” in the
question and “authority” in the correct option. Review the various leadership styles if you had difficulty with this question.
74. Answer: B. Situational leadership style utilizes a style that depends on the situation and events. Democratic styles best empower staff toward excellence,
because this style of leadership allows nurses an opportunity to grow professionally. The autocratic style is task oriented and directive. Laissez faire allows
staff to work without assistance, direction, or supervision. Strategy: Note the key words “adaptable depending on the situation and events.” Knowledge of the
characteristic of the various leadership styles and these key words will assist in directing you to option B. If you had difficulty with this question, review the
various leadership styles.
75. Answer: C. Encouraging the staff nurse to discuss the comments will assist in identifying the concerns in a democratic way. Option A and D are autocratic.
Option B does not provide the opportunity for the staff nurse to directly share concerns. Strategy: Use the process of elimination. Eliminate option A and D
first because they are similar. From the remaining options, eliminate option B because it is not a democratic style and does not provide the opportunity for
the staff nurse to directly share concerns. Review leadership styles if you had difficulty with this question.
76. ANSWER: A- The assignment in option A has the most specific guidelines for performance. The other procedures require assessment and judgment and
should not be assigned to a nursing assistant.
77. ANSWER: C- The nurse should assign the client who is the most stable and requires the least complicated nursing care to the LPN or LVN. The client
described in option C is the most stable and would not require as much assessment and nursing judgment. The client in option A is at risk for pulmonary
embolism, the client in option B is experiencing respiratory difficulty, and the client in option D is not stable and may be experiencing cardiac problems.
78. ANSWER: B- Option B involves contact with a medication that is teratogenic and is classified as Pregnancy Risk Category X. the other clients do not post a
risk to pregnancy nurse.
79. ANSWER: A- The nurse must assign tasks based on the guidelines of nursing practice acts and the job description of the employing agency. A client who
had a BKA, a client scheduled to be transferred to the hospital for coronary artery bypass surgery, and a client scheduled for an invasive diagnostic
procedure will require strategies to meet both physiological and psychosocial needs. The nursing assistant has been trained to care for a client on bedrest
and to maintain 24-hour urine collections. The nurse would provide instructions to the nursing assistant regarding the tasks, but the tasks required for this
client are within the role description of a nursing assistant.
80. ANSWER: C- The nurse manager should meet with the staff nurse to discuss her performance and ways she can improve. Assigning the staff nurse several
clients with multiple problems would be overwhelming, counterproductive, and unsafe because she has yet to demonstrate the priority-setting and decision
making leadership skills that this client load would require. Letting her select her own assignments could impair the morale of other staff nurses. Having her
work as an assistant nurse-manager would be inappropriate until she has demonstrated improved ability and leadership skills.
81. ANSWER: D- The nurse’s responsibility in obtaining an informed consent for surgery is providing the client with the consent form and witnessing the client’s
signature. Answers A and B are the responsibility of the physician, not the nurse. Answer C is incorrect because the nurse-client relationship should never be
used to persuade the client to sign a permit for surgery or other medical treatments.
82. ANSWER: A - It is not a nursing responsibility to give detailed information about surgical procedures. The nurse can reinforce, but if the nurse feels that the
client is not adequately informed, she can serve as an advocate and request that the surgeon visit the client to explain the procedure. Answer B is not the role
of the nurse, so this is incorrect. Answers C and D are not appropriate and will not help in increasing or verifying patient understanding.
83. ANSWER: A - It is appropriate when all that can be hoped is making the best of a bad situation. Reference: ETHICS and CONFLICT second edition by
Kathleen Ouimet Perrin and James McGhee Chapter 4: Health Maintenance across the Life Span Item no 10 page 123
84. ANSWER. B- The risk and alternatives for surgical procedure have been explained
85. ANSWER: A- Assessment of the client’s understanding of the surgery is essential. If a client has signed a surgical consent form then questions what was
signed; it is a priority to assess what the client understands. After assessing what the client understands, or if the client is incompetent, then it would be
appropriate to notify the physician.
NEWBORN. To achieve this goal, B,C and D are all carried out. Even without the knowledge of the MCHN goal you SHOULD answer this question correctly.
Remember that GOALS are your plans or things you MUST ATTAIN while STRATEGIES are those that must be done [ ACTIONS ] to attain your goal.
Looking at B,C and D they are all ACTIONS. Only A correctly followed the definition of a goal.


87. ANSWER: D - Knowing that not all individuals and pregnancy are the same for all women, you can safely eliminate letter A. Personal, culture and religious
attitudes influence the meaning of pregnancy and that makes pregnancy unique for each individual. Culture and religious practice have a great impact on
pregnancy, eliminate B. Pregnancy is meaningful to each individuals, not only the mother but also the father and the family and the father of the child is as
important as the mother. MATERNAL AND CHILD HEALTH IS FAMILY CENTERED and this will guide you in correctly answering D.
answer the GOAL, they are different. GOAL: to promote and maintain optimum health for women and their newborn HOW? OBJECTIVE : By reaching all
pregnant women to give sufficient care ensuring healthy pregnancy and baby.
89. ANSWER: B- The HBMR is used in rendring prenatal care as guide in identifying risk factors. It contains health promotion message and information on the
danger signs of pregnancy.
90. ANSWER: C - Visit to the RHU should be ONCE each trimester and more frequent for those who are high risks. The visit to the BHS or health center should
be ONCE for 1st to 6th months of pregnancy, TWICE for the 7th to 8th month and weekly during the 9th month. They are different and are not to be confused
91. ANSWER: A- EVERY ACHIEVER AVOIDS RECEIVER : Remember this mnemonics and it will guide you in differentiating which is which from the goals,
visions and strategies. If a sentence begins with these words, it is automatically a GOAL. Usually, The trend in the board is that they will mix up the vision,
strategies and goals to confuse you. D is the only vision of the RH program. Anything else aside from the vision and goals are more likely strategies. [ B and
C ]. Strategies, even without knowing them or memorizing them can easily be seperated as they convey ACTIONS and ACTUAL INTERVENTIONS. This is
universal and also applies to other DOH programs. Notice that B and C convey actions and interventions.
92. ANSWER: D- Quality of life is the ultimate goal of the RH in the international framework. Way of life is the ultimate goal of RH in the local framework.
93. ANSWER: A- This is an actual board question, Gender issues affects the women participation in the social affairs. Socio economic condition is the
determinant for education, employment, poverty, nutrition, living condition and family environment. Status of women evolves in women's rights. Cultural and
psychosocial factors refers to the norms, behaviors, orientation, values and culture. Refer to your DOH manual to read more about this.
94. ANSWER: B- Health services delivery mechanism is the major factor that affect RH status. Other factors are women's behavior, Sanitation and water supply,
Employment and working conditions etc.
95. ANSWER: B- Practice RH as a WAY OF LIFE- is the vision of the RH.
96. ANSWER: B- The signs are normal for a 3-day puerperal. The problem does not say that the mother is bottle feeding so ice packs on hard and warm breasts
may not be appropriate. The nursing bra can provide support to the breasts and may minimize discomfort of breast engorgement. The sign that differentiates
breast engorgement from breast infection (mastitis) is reddened breasts. Among the significant signs of mastitis are reddened breasts, swelling and
tenderness, plus fever and malaise.
97. ANSWER: B- Postpartal blues is an adjustment reaction characterized by depressed mood and crying. This is a common reaction of postpartum women
seen in 50% to 80% of new mothers, usually transient and often by 3rd to 10th day after delivery. Management includes providing privacy and support and
reassurance that her feelings and behavior are normal and it is alright to cry. Postpartal blues usually resolves without treatment; but if the behavior persist
beyond 2 weeks and with more serious depression, she would seek medical consultation. Postpartal psychosis, a puerperal complication, is characterized by
severe depression and suicidal ideation.
98. ANSWER: C- The leading cause of early postpartal bleeding is uterine atony manifested by profuse bleeding and soft, boggy uterus. The cardinal sign of
lacerations is bright red bleeding in the presence of a firm fundus. So when there is abnormal vaginal bleeding in a postpartum woman, the first nursing
action is to check the fundus; massage when soft until firm. But when the fundus is firm in the presence of vaginal bleeding, check for lacerations and report
stat. The physician will thoroughly examine the reproductive tract fir lacerations and make the necessary repair. Bleeding in the presence of an incomplete
placenta is due to retained placental membranes, the leading cause of late postpartal bleeding.
99. ANSWER: D- The most common cause of postpartal uterine displacement is a full bladder. The nurse should initiate actions to remove the most frequent
cause of uterine displacement, which involves emptying the bladder. Massage may firm the uterus temporarily, but if a full bladder is not emptied, the uterus
will remain displaced and is likely to relax again. The puerperal client should be instructed to void regularly even in the absence of sensation to void.
100. NSWER: C- This response correctly identifies this neonatal variation and helps the client to understand simple medical terms as well as the characteristics
of her newborn. To simply say it is normal does not teach the client medical terms that may be useful in understanding other healthcare personnel. In giving
client instruction and teaching, use simple terms and avoid highly technical words. Vernix caseosa is more on the skin of term neonates. Clean, excess vernix
may be spread (and not washed away) n order to help warm the newborn.

1. ANSWER: D- Improve the patient’s immune function
2. ANSWER: C- "Do you use any injectable drugs or have sexual activity?”
3. ANSWER: D- A needle-stick with a needle and syringe used to draw blood
4. ANSWER: B- How to prevent transmission between sexual partners
5. ANSWER: B- Varicella zoster immune globulin
6. ANSWER: B- Option C is incorrect; infection can be transmitted to the child in utero or through breastmilk. Option A is incorrect; social isolation should be
minimized. No isolation precautions are needed to enter the room to talk to the patient. Option B is correct; standard and contact precautions should be
practiced because transmission is through blood or bodily fluids. Option D is incorrect; HIV is not an airborne infection, and not treated with antibiotics.
7. ANSWER: A- Option A is correct; immunosuppression is one of the main concerns in patients with HIV. Prevention of infection is very important to avoid
serious complications. Even though this is only a potential diagnosis and not an actual one, this still should be of priority because opportunistic infections can
be fatal for the patient. Option B is incorrect; this can be a problem for the patient but risk for infection should be prioritized more. Options C and D are
incorrect; these are psychosocial problems and is of secondary in priority.
8. ANSWER: A- Option A is correct; nurses are responsible for protecting the patient’s right to privacy by safeguarding confidential information. Confidentiality is
basic to therapeutic relationship and is a client’s right. Inadvertent disclosure of confidential patient information may result in personal, financial, and
emotional hardships for HIV-infected individuals. Option B and C are incorrect; these do not maintain confidentiality. Option D is incorrect; this is a blunt
statement and does not acknowledge the issue.
9. ANSWER: A- Option A is correct; avoid foods that stimulate intestinal motility, such as vegetables and fruits, fatty, spicy, and sweet foods, alcohol, and
caffeine. Option B is incorrect; small, frequent meals are better tolerated. Option C is incorrect; lactose intolerance can contribute to diarrhea. Option D is
incorrect; drink lots of fluids, especially between meals.
10. ANSWER: B- Option B is correct; pulmonary therapy consists of deep breathing, coughing, postural drainage, percussion, and vibration should be done
every 2 hours to prevent stasis of secretions and promote airway clearance. Option A is incorrect; tepid sponge bath can help bring the temperature down.
Analgesics may also be given. Airway is of priority. Option C is incorrect; fluid loss can be replaced through oral fluid intake of 3L a day. Invasive procedures
must be avoided if the patient can tolerate fluids orally. Option D is incorrect; relaxation techniques can help relieve anxiety but airway is of priority.
11. Answer: B- Western blot assay is used to confirm seropositivity of the ELISA is positive. The EIA (enzyme immunosorbent assay) or ELISA (enzyme-linked
immunosorbent assay) is used to identify antibodies directed specifically against HIV. Target amplification methods quantify HIV RNA or DNA levels in the
plasma. Target amplification methods include reverse transcriptase polymerase chain reaction (RT-PCR). Viral Load test measures plasma HIV RNA levels.
These tests are used to track viral load and response to treatment for HIV infection.
12. ANSWER: C- Prophylactic antibiotics are given to patients with B-cell deficiency especially if they develop respiratory infections. Patients with B-cell
deficiency do not suffer from shock or fluid volume loss. Blood transfusion with whole blood is not necessary. Patients with B-cell deficiency lack plasma cells
that produce antibodies or has a diminished antibody production due to undifferentiated B-cells. Replacement therapy of immunoglobulins intravenously is


important. Patients with B-cell deficiency lack plasma cells that produce antibodies or has a diminished antibody production due to undifferentiated B-cells.
Administration of live vaccines may cause fatal infections due to immunodeficiency.
13. ANSWER: C- Option C is correct; the patient has oral candidiasis and has an impaired oral mucous membrane. Option A is incorrect; the patient already has
an existing infection. Option B is incorrect; the patient may experience fatigue but there is no supporting evidence in the question to justify fatigue. Option D is
incorrect; the patient may have imbalanced nutrition but there is no supporting evidence in the question to justify inadequate nutrition.
14. ANSWER: C- Option C is correct; use short, uncomplicated sentences; orient to daily activities by explaining the activities while they are happening. Option A
is incorrect; cognitive manifestations of AIDS dementia complex include slowed thinking, memory loss, loss of concentration, and confusion; frequently
reorient patient to person, place and time; use calendars and clocks; this answer is an assessment and this situation does not require validation. Option B is
incorrect; patient’s thinking is slowed; give patient sufficient time to respond to questions. Option D is incorrect; post a daily schedule in a prominent place;
patient may not be able to process or remember what is being said.
15. ANSWER: B- Option B is correct; energy conservation technique; sitting while washing is also helpful; place frequently used personal items within patient’s
reach. Option A is incorrect; “passing the buck”; nurse should care for patients. Option C is incorrect; should balance rest and activity. Option D is incorrect;
nurse should instruct patient in ways to improve activity tolerance. .
16. ANSWER: B. Iodine - Reference: Medical-Surgical Nursing, Copyright by: Alice M. Stein EdD, Item no.3 Chapter 12: The Endocrine System, page no.523
17. ANSWER: D- The priority care for the client with a goiter is maintaining an effective airway. Answers A, B, and C apply to the client with a goiter; however,
they are not the priority of care.
18. ANSWER: A- A thyroid scan use a dye, so the client should be assessed for allergies to iodine. The client will not have a bolus of fluid, will not be asleep,
and will not have a urinary catheter inserted, so answers B, C, and D are incorrect.
19. ANSWER: B- Excessive thyroid-stimulating hormone (TSH) stimulation. Reference: Medical-Surgical Nursing, Copyright by: Alice M. Stein EdD, Item no.28.
Chapter 12: The Endocrine System, page no.528
20. ANSWER: A- Persons with endemic goiter live in areas where the soil is depleted of iodine. Answers B and D refer to sporadic goiter and answer C is not
related to the occurrence of goiter.
21. ANSWER: D- The client should report frequent swallowing or postnasal drip after transphenoidal surgery because it could indicate cerebrospinal fluid (CSF)
leakage. The surgeon removes the nasal packing, usually after 24 hours. The client should deep breathe, but coughing is contraindicated because it could
cause increased intracranial pressure. The client should also report severe headache because it could indicate increased intracranial pressure.
22. ANSWER: B- The nurse should check the nasal packing for the presence of the “halo sign” or a light yellow color at the edge of drainage on the nasal
dressing. The presence of the halo sign indicates leakage of cerebral spinal fluid. Answer A is incorrect because the nurse provides mouth care using oral
washes not a toothbrush. Answer C is incorrect because coughing increases pressure in the incisional area and can lead to a cerebral spinal fluid leak.
Answer D is incorrect because the client should not be ambulated for 1-3 days after surgery.
23. ANSWER: A- Removal of the pituitary gland is usually done by a transphenoidal approach, through the nose. Nasal congestion further interferes with the
airway. Answers B, C, and D are not correct because they are not directly associated with the pituitary gland.
24. ANSWER: C- Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. Answers A, B, and D are incorrect because
Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure.
25. ANSWER: B - The numbness of the upper lip and gum near the incision as well as a decreased sense of smell are normal and should resolve in 3 to 4 mos.
In-depth assessment of neuromuscular function and incision site are needed, and then surgeon should be consulted immediately.
26. ANSWER: B- The major cause of primary hyperaldosteronism is an aldosterone-secreting tumor called an aldesteronoma. Surgery is the treatment of
choice. Clients undergoing a bilateral adrenalectomy will need permanent replacement of adrenal hormones. Option A, C, and D are inaccurate. Page 159
27. ANSWER: B- A glucocorticoid preparation will be administered intravenously or intramuscularly in the immediate preoperative period to a client scheduled for
an adrenalectomy. Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addison’s crisis) that occurs as a
result of the adrenalectomy. Aldactone is a potassium sparing diuretic. Prednisone is an oral corticosteroid. Fludrocortisone is a mineralocorticoid.
28. ANSWER: A- “Do you ever feel or noticed an increase in heart beating?” Reference: (pp.147 item 18, NSNA Comprehensive Review for NCLEX-RN
Examination, )
29. ANSWER: C- Blood pressure. Reference: (pp.148 item 29, NSNA Comprehensive Review for NCLEX-RN Examination, )
30. ANSWER: B- A client who had a unilateral adrenalectomy will be placed on corticosteroids temporarily to avoid a cortisol deficiency. These medications will
be gradually weaned in the postoperative period until they are discontinued. Also, because of the anti-inflammatory properties of corticosteroids produced by
the adrenals, clients who undergo an adrenalectomy are at increased risk of developing wound infections. Because of this increased risk of infection, it is
important for the client to know measures to prevent infection, early signs of infection, and what to do if an infection seems to be present. The client does not
need to maintain a diabetic diet, and the client will not have an ostomy following this surgery.
31. ANSWER: D- Encephalitis is often viral. Viral encephalitis is almost always preceded by a viral infection. The virus gains access to the central nervous
system via the bloodstream.
32. ANSWER: C- Early detection of inadequate circulating oxygen can allow the clinician to intervene before hypoxic brain damage occurs.
33. ANSWER: C- Lumbar puncture for CSF analysis is key to diagnosing meningitis. A CT scan may precede this test to rule out increased intracranial pressure.
A swift reduction in pressure in the spinal column resulting from a lumbar puncture can cause herniation of the brainstem into the foramen magnum in the
presence of increased intracranial pressure.
34. ANSWER: A- Meningococcal meningitis tends to occur in outbreaks and is most likely to occur in areas of high-density population such as college
dormitories, prisons, and military barracks.
35. ANSWER: A- Viral meningitis does not cause cloudiness or increased turbidity of the CSF. There are slightly increased protein and normal glucose levels. In
bacterial meningitis, the presence of bacteria and white blood cells cause the fluid to be cloudy.
36. ANSWER: B- Postpartum hemorrhage is the most common cause of pituitary infarction. With this injury to the pituitary gland, secretion of more than one
hormone is deficient. The condition may develop immediately postpartum or years after the delivery.
37. ANSWER: A - Although pubic hair thickness varies from person to person, loss of pubic hair is associated with gonadotropin deficiency. The nurse needs to
determine whether this manifestation is normal for this client.
38. ANSWER: B- Testosterone therapy is initiated with high-dose testosterone derivatives and continued until virilization is achieved. The dose is then
decreased, but therapy continues throughout life.
39. ANSWER: C- One of the most common causes of adrenal insufficiency, a life-threatening problem, is the sudden cessation of long-term, high-dose
corticosteroid therapy. This therapy suppresses the hypothalamic-pituitary-adrenal axis and must be withdrawn gradually to allow for pituitary production of
ACTH and adrenal production of cortisol.
40. ANSWER: D- With primary adrenocortical insufficiency, the adrenal gland is not able to produce sufficient amounts of adrenocortical hormones. The low
circulating levels of these hormones stimulates the hypothalamus to release corticotropic-releasing hormone (CRH), which in turn causes the anterior
pituitary to release large amounts of ACTH and melanocyte-stimulating hormone (MSH). The increased MSH causes increased skin pigmentation. Because
secondary adrenocortical insufficiency does not stimulate higher endocrine centers, MSH levels are not increased, and there is no increase in skin
41. ANSWER: C- Option A is incorrect; more important to determine what kind of support the patient requires. Option B is incorrect; yes/no question; when
assessing, always ask open-ended questions; it is important that patient eats small meals more frequently. Option C is correct; fatigue is a complication of
anemia; patient may be too fatigued to climb stairs; if necessary, nurse arranges for patient to have a bed on the first floor; encourage patient to balance rest
and activity. Option D is incorrect; more important to find out how patient can successfully accomplish activities of daily living.
42. ANSWER: B- Option B is correct; vitamin B12 obtained from dietary sources is normally absorbed by means of intrinsic factor found in the stomach; from
there it is carries to the ileum; patient lacks the intrinsic factor so an oral preparation of the vitamin would not be absorbed. Option A is incorrect; pernicious


anemia is caused by the lack of the intrinsic factor that causes absorption of Vitamin B12 from the intestinal tract; symptoms include severe pallor, smooth,
beefy red tongue, fatigue, paresthesia of the hands and feet; medication given by injection because gastric mucosa doesn’t secrete intrinsic factor. Option C
is incorrect; yes/no question; more important to assess patient’s concern. Option D is incorrect; can’t be absorbed through the GI tract.
43. ANSWER: C- Option C is correct; contains high amount of iron; spinach contains vitamin C. Option A is incorrect; desired diet for iron deficiency anemia
include iron sources as well as vitamin C to enhance iron sources found in plants; chicken, especially dark meat, contains iron; tomatoes contain vitamin C;
other foods listed do not contain significant amounts of iron or vitamin C. Option B is incorrect; beef in burger contains some iron; cabbage in coleslaw
contains some vitamin C. Option D is incorrect; doesn’t contain iron or vitamin C.
44. ANSWER: D- Option D is correct; for the test to be successful, the patient must comply carefully with collecting his urine over a 24-hour period; to collect 24-
hour urinalysis, instruct patient to void and discard urine; test begins at this time; save all urine during specified time in one container that is refrigerated or
kept on ice; label container with exact date and time that collection started and ended.Option A is incorrect; Schilling test used to diagnose pernicious
anemia; patient fasts for 12 hours, given small dose of radioactive B12 orally, followed by a large, nonradioactive dose IM; 24-hour urine collected; if urine is
not radioactive B12 stayed in the GI tract. Option B is incorrect; not most important to convey to patient. Option C is incorrect; important information, but more
important to explain to patient how to collect 24-hour urine specimen.
45. ANSWER: B - Option B is correct; major cause of iron deficiency anemia in adults is bleeding; nurse should carefully assess the GI system; character of
emesis, stools, diarrhea, anorexia, nausea, and vomiting. Option A is incorrect; fatigue is a major symptom of anemia, and it is appropriate to balance rest
and activity; more important to assess before implementing. Option C is incorrect; complete assessment first. Option D is incorrect; iron deficiency anemia
caused by inadequate intake of iron for hemoglobin synthesis; nurse assumes that causes of weakness due to lack of dietary iron; need to determine cause
of fatigue; nurse will instruct client about foods high in iron.
46. ANSWER: B- The most common cause of DKA is infection. Urinary tract infection and pneumonia account for the majority of infection.
47. ANSWER: C- The percentage result (normal: 4%-7%) that reflects on average of 3 months enhances accuracy because it controls for many variables such
as stress, exercise, fasting state, interfering medications, and recent changes in patient compliance.
48. ANSWER: C- Hyperosmolar hyperglycaemic syndrome is characterized by hyperglycemia ranging 400-4000 mg/dl and hyperosmolality without DKA.
Options A, B, and D are characteristics of DKA.
49. ANSWER: D- Typical treatments for hypoglycaemia include 3 glucose tablets, 6 ounces of regular cola, 6 ounces of orange juice, 4 ounces skim milk or 6 to
8 lifesaver candies.
50. ANSWER: C- Option C is correct; somogyi phenomenon is characterized by nocturnal hypoglycemia with rebound hyperglycemia. Option A is incorrect;
dawn phenomenon is characterized by prebreakfasthyperglycemia without preceding nocturnal hypoglycemia. Option B is incorrect; hypoglycemic
unawareness refers to a syndrome in which people with diabetes are unaware that they are hypoglycemic and therefore do not initiate treatment.. Option D is
incorrect; hypoglycemic reaction occurs when there is an overdose of insulin, an omitted meal, overexertion, alcohol intake, or nutritional imbalance.
51. ANSWER: B- Option B is correct; management of DKA includes administration of insulin to correct hyperglycemia because lack of insulin is the primary
cause of DKA. Aside from insulin administration, treatment also includes IV fluid administration, potassium replacement, and correction of acidosis. Option A
is incorrect; fifty percent dextrose is used to treat hypoglycemia. Option C is incorrect; dehydration is a problem in DKA so fluid replacement is very important.
Option D is incorrect; phenyotin (Dilatin) is not a usual treatment measure for DKA.
52. ANSWER: B- Option B is correct; blood glucose of less than 20 mg/dl is considered as severe hypoglycemia. 50% dextrose or glucagon is needed to reverse
the situation. Option A is incorrect; never force an unconscious client to drink liquids because fluid may be aspirated. The unconscious client with severe
hypoglycemia needs glucagon or IV glucose immediately. Option C is incorrect; medical assistance is advisable if severe hypoglycemia occurs but glucagon
administration must be given first. Option D is incorrect; insulin may aggravate the patient’s hypoglycemic state.
53. ANSWER: A- Option A is correct; major interventions, particularly in the early phases, include achievement of euglycemia, and normalization of blood
pressure. Option B is incorrect; visual impairment can be a shock for patients. Psychosocial support is also important but physiological needs come first.
Option C is incorrect; removing clutter in the patient’s environment promotes safety, however, maintaining normal blood glucose is more important to prevent
progression of disease. Option D is incorrect; encouraging the family to visit is part of psychosocial support that can be given to the patient, however,
physiological needs come first.
54. ANSWER: A- Regular insulin is a short-acting insulin that has an onset of 30 minutes to one hour. The peak is between 2 to 3 hours and the duration is
between 4 to 6 hours. A hypoglycaemia reaction is most likely to occur during the peak, so, if regular was given at 7:30 AM, a hypoglycaemia reaction would
occur between 9:30 AM and 10:30 AM.
55. Answer: B- Oral diabetic agents are indicated to help lower blood glucose, thus the possible effect of hypoglycaemia. Hypoglycemia (abnormally low blood
glucose level) occurs when the blood glucose falls to less than 50 to 60 mg/dL(2.7 to 3.3 mmol/L). It can be caused by too much insulin or oral
hypoglycaemic agents, too little food, or excessive physical activity. In mild hypoglycemia, as the blood glucose level falls, the sympathetic nervous system is
stimulated, resulting in a surge of epinephrine and norepinephrine. This causes symptoms such as sweating, tremor, tachycardia, palpitation, nervousness,
and hunger. In moderate hypoglycemia, the fall in blood glucose level deprives the brain cells of needed fuel for functioning. Signs of impaired function of the
CNS may include inability to concentrate, headache, lightheadedness, confusion, memory lapses, numbness of the lips and tongue, slurred speech, impaired
coordination, emotional changes, irrational or combative behavior, double vision, and drowsiness. Any combination of these symptoms (in addition to
adrenergic symptoms) may occur with moderate hypoglycemia. In this case, the client is most probably experiencing a hypoglycaemic reaction. As a rule, the
nurse should ascertain this first by checking the blood glucose. Option A is incorrect; common symptoms of diabetes include hyperglycemia, not
hypoglycaemia. Option C is incorrect; an increase in the medication dosage of oral antidiabetic agents would cause worsening of hypoglycaemia. Option D is
incorrect; this symptom of hypoglycaemia should be anticipated by the nurse to occur. Referral to the physician should be done after assessing the client.
56. ANSWER: C – The normal serum amylase level is 25 to 151 units/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not
exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Options A and B are within normal limits.
Option D is an extremely elevated level seen in acute pancreatitis. TTS: removing the extremes
57. ANSWER: C – The normal serum lipase level is 100 to 140 units/L. The client who is recovering from acute pancreatitis usually has elevated lipase levels for
about 10 days after the onset of symptoms. This makes lipase a valuable test in monitoring the client’s pancreatic function because serum amylase levels
usually return to normal 3 days after the onset of symptoms. Option C is the only option that contains a value just below the upper limit of normal. TTS: the
answer is in the previous number
58. ANSWER: B – The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back. The
other options are incorrect. TTS: opposing options B and C
59. ANSWER: A – The client with chronic pancreatitis should limit fat in the diet and also take in small meals, which will reduce the amount of carbohydrates and
protein that the client must digest at any one time. (option B and C) Option D - The client does not need to limit water-soluble vitamins in the diet. TTS:
anatomy and physiology (pancreas – fatty)
60. ANSWER: C – Meperidine (Demerol) rather than morphine sulfate is the medication of choice to treat pain because morphine sulfate can cause spasms in
the sphincter of Oddi. Options A, B, and D are appropriate interventions for the client with acute pancreatitis.
61. ANSWER: A – Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Options B, C and D – Hepatitis B, C, and D
are transmitted most commonly via infected blood or body fluids. TTS: odd one out
62. ANSWER: B – Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels, elevated erythrocyte sedimentation
rates, and leukopenia. Option B and D – A hemoglobin level and decreased ESR are unrelated to this diagnosis. Option C – An elevated blood urea nitrogen
level may indicate renal dysfunction.
63. ANSWER: A – Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise
are common. Option B – Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of
the bile ducts. Option C – it must be weight loss Option D – must be right upper quadrant


64. ANSWER: B – An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important. Option A – consume a low-fat diet because
fat may be tolerated poorly because of decreased bile production. Option C – Frequently, appetite is better in the morning, so it is easier to eat a good
breakfast. Option D – Small frequent meals are preferable and may even prevent nausea. TTS: Opposing options B and D (increase intake – eat less often)
65. ANSWER: C – Jaundice occurs in the skin and mucous membranes. In dark-skinned persons, jaundice is observed in the inner canthus of the eyes and hard
palate of the mouth. Option A – In light-skinned persons, jaundice first is seen in the sclera of the eyes and later in the skin. Option B – Pallor is detected in
the nail beds. Option D – flushing associated with increased body temperature is best noted on the flexor surfaces of the extremities. TTS: odd one out,
option C is internally oral and others are superficial
66. ANSWER: D – Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric
area and spreading over the abdomen, which becomes rigid and board-like. Option A – Tachycardia may occur as hypovolemic shock develops. Option B –
Numbness in the legs is not an associated finding. Option C – Nausea and vomiting may occur. TTS: word association (perforation – rigid board)
67. ANSWER: D – Cimetidine (Tagamet), a histamine (H2) receptor antagonist, will decrease the secretion of gastric acid. Option A – Antacids neutralize acid in
the stomach. Option B – Sucralfate (Carafate) promotes healing by coating the ulcer. Option C – Omeprazole (Prilosec) inhibits gastric acid secretion. TTS:
opposing options A and D
68. ANSWER: D – A pyloroplasty involves making an incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the
duodenum. Option A – A vagotomy involves cutting the vagus nerve. Option B – A subtotal gastrectomy involves removing the distal portion of the stomach.
Option C – A Billroth II procedure involves removal of the ulcer and a large portion of the tissue that produces hydrochloric acid. TTS: word association,
(plasty – repair,)
69. ANSWER: C – A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion. Options A, B, and D are
incorrect descriptions of a vagotomy. TTS: the answer is in the previous number
70. ANSWER: D - Dietary modification for the client with peptic ulcer disease includes eliminating foods that are irritating to the client. Options A, B and C - Items
that generally are eliminated or avoided are highly spiced foods, alcohol, caffeine, chocolate, and fresh fruits. Other foods may be taken according to the
client’s tolerance of that specific food.
71. ANSWER: C – In a Billroth II procedure, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is
critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically
ordered by the physician. In this situation, the nurse should clarify the order. Options A, B, and D are appropriate postoperative interventions. TTS: safety
72. ANSWER: C – Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a Billroth II
procedure. Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the
desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to. Option B – avoid high-carbohydrate foods,
including fluids such as fruit nectars . Option D – to assume a low-Fowler’s position during meals and. Option A – to lie down for 30 minutes after eating to
delay gastric emptying; and to take antispasmodics as prescribed. TTS: safety
73. ANSWER: A – Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating,
pallor, palpitations, and the desire to lie down. Option B – tachycardia and not bradycardia Option C – Double vision and not vertigo. Option D – desire to lie
down, not cramping. TTS: location, stomach – abdormal cramping
74. ANSWER: B – The client with dumping syndrome should be placed on a high-protein, moderate-fat, and high-calorie diet. The client should lie down after
eating and should avoid drinking liquids with meals. Frequent small meals are encouraged and the client should avoid concentrated sweets. TTS: the answer
is in the previous number
75. ANSWER: D – Dumping syndrome occurs after gastric surgery because food is not held as long in the stomach and is dumped into the intestine as a
hypertonic mass. This causes fluid to shift into the intestine causing cardiovascular as well as GI symptoms. Symptoms can typically include weakness,
dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea. Options A, B, and C are incorrect and
are not signs of dumping syndrome. TTS: elimination
76. ANSWER: A – The client with cholecystitis should decrease overall intake of dietary fat. Foods that should be avoided include sauces and gravies (OPTION
C), fatty meats (OPTION B), fried foods, products made with cream (OPTION D), and heavy desserts. The correct option is baked fish, which is low in fat.
TTS: nutritious diet
77. ANSWER: D – During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula and
shoulder. This is determined by the pattern of dermatomes in the body. The other options are incorrect. TTS: opposing options C and D
78. ANSWER: D – The client with cholecystitis should decrease overall intake of dietary fat. Foods that should be avoided include sausage, gravies, fatty meats,
fried foods, products made with cream, and desserts. Appropriate food choices include fruits and vegetables, fish, and poultry without skin. TTS: negative
79. ANSWER: A – After cholecystectomy, respirations tend to be shallow because deep breathing is painful as a result of the location for the surgical procedure.
Although all of the options are correct, teaching coughing and deep breathing exercises is the priority. TTS: prioritization
80. ANSWER: A – Ultrasound examination of the gallbladder is a noninvasive procedure and frequently is used for emergency diagnosis of acute cholecystitis.
Option B – The client does not need to be NPO but may be instructed to avoid carbonated beverages for 48 hours before the test to help decrease intestinal
gas. Option C and D – It is a painless test and does not require the administration of oral tablets as preparation. TTS: opposing options A and D
81. ANSWER: C- A straight back usually limits the amount of weight that is placed on the back muscles. Good body mechanics are essential in preventing injury
to the nurse.
82. ANSWER: D- Bending at the knees results in the use of the large muscles of the legs. Keeping the back straight avoids using the small, easily injured back
muscles. When the client’s hands rest on the nurse’s shoulders, this provides security for the client. Placing the hands under the axillae of the client avoids
placing pressure on the chest, which can be uncomfortable for the client.
83. ANSWER: D Isometric exercise promotes muscle contract thus maintaining muscle strength
84. ANSWER: D- Cane movement sequence: Cane, bag leg, good leg
85. ANSWER: A- Less workload for the affected leg than in 4 point gait. The rest of the answers are very incorrect.
86. ANSWER: B- Ascertain that a written order DNR from the physician is in place
87. ANSWER: C. The competent clients values and choices should always be given the highest priority Rationale: The most patient centered option
88. ANSWER: D- Assessing client’s understanding of her illness and impending death is necessary prior to provision of assistance and comforting measures.
89. ANSWER: D - Denial is characterized as refusing to accept what has been explained. It is an immediate response to a loss. Bargaining is an attempt to
postpone the inevitable. Depression is a realization that the loss can no longer be delayed. Acceptance is characterized by growing awareness of peace and
90. ANSWER: C- The only therapeutic option
91. ANSWER: C- Disuse syndrome is a result of prolonged immobility. Stating “the client remains free of contractures” describes in active terms the desired
outcome for the client. The last two options describe nursing activities to meet the stated client goal. The nurse has no control over option 1
92. ANSWER: B- The weight of the body should be borne on the arms, not the axillae. When clients allow the axillae to bear the weight of the body, they are at
risk of developing crutch palsy, a nerve damage. The other options represent correct information about use of crutches, and therefore no further information
is needed on those points.
93. ANSWER: D- The client has bilateral weakness of the lower extremities, and the proper assistive device is on that will provide bilateral support. In this case,
a walker provides the most support. Additionally, a four-wheeled walker does not require the client to lift the walker as steps are taken.
94. ANSWER: B- To provided maximum support and appropriate body alignment while walking, the care is held in the hand on the stronger side. The tip of the
cane should have rubber to prevent slipping.


95. ANSWER: B- Unless the skin loss is extensive, the skin will continue to absorb vitamin D and prevent the loss of heat from the body. Tactile stimulation can
still occur with a wound. However, a loss of skin integrity places the client at risk for bacterial invasion and subsequent infection
96. ANSWER: B – During the first 24 to 72 hours following surgery, mucuos and serosanguineous drainage is expected from the stoma. Options C and D are
inappropriate actions. Option A – Notifying the physician is unnecessary because this is an expected finding. TTS: normals
97. ANSWER: A – The usual procedure for colostomy irrigation includes using 500 to 1000 mL of warm tap water. Option B – The solution is suspended 18
inches above the stoma. Option C – The cone is inserted 2 to 4 inches into the stoma but should never be forced. Option D – If cramping occurs, the client
should decrease the flow rate of the irrigant as needed by closing the irrigation clamp.
98. ANSWER: D – For the first 4 to 6 weeks after colostomy formation, the client should take in a low-residue diet. Options A and B – After this period, the client
should eat a high-carbohydrate, high-protein diet. The client also is instructed to add new foods, one at a time, to determine tolerance to that food.
99. ANSWER: A – The client should be taught to include deodorizing foods in the diet such as beet greens, parsley, buttermilk, and yogurt. Options B, C and D
– Spinach also may reduce odor, but it is a gas-forming food and should be avoided. Cucumbers, eggs, and broccoli also are gas-forming foods and should
be avoided or limited by the client. TTS: eliminate absolute word (options B, C and D, EVERYDAY, PER DAY)
100. ANSWER: D – A prolapsed stoma is one in which the bowel protrudes, causing an elongated and swollen appearance to the stoma. Option A – A retracted
stoma is characterized by sinking of the stoma. Option B – Ischemia of the stoma would be associated with a dusky or bluish color. Option C – A stoma with
a narrow opening is described as being stenosed. TTS: word association, prolapsed - protrusion

1. ANSWER: C- The patient receives a low-residue diet to prevent frequent bowel movements that may dislodge the implant. Option A is incorrect; while
instruction about birth control methods may be needed for some clients, treatment for cervical cancer may include total abdominal hysterectomy, so that this
would not be appropriate for all clients. Option B is incorrect; surgery and radiation therapy for cervical cancer often result in shortening of the vagina, vaginal
dryness, and loss of libido due to emotional issues related to sexuality and femininity. The client’s feelings about sexuality and the partner’s feelings should
be assessed. If a client is not sexually active, instructions should be given in the use of a vaginal dilator and lubricant to prevent adhesion of the vaginal walls.
However, this should not be the priority. Option D is incorrect; the nurse needs to explain that during the treatment, the patient must stay on absolute bed
rest. She may move from side to side with her back supported by a pillow, and the head of the bed may be raised to 15 degrees. Daily monitoring of weight
may require the client to stand up and ambulate.
2. ANSWER: C- Option C is correct; Precautions must be taken as all body secretions from the client is considered radioactive.People who are pregnant should
not come in close contact with someone who has internal radiation therapy. The radioactivity could possibly damage the fetus. Option A and D are incorrect;
patient should be placed bed rest with limited activity and in low residue diet to avoid possible dislodge of the implant.
3. ANSWER: B- Survival rates after lumpectomy are equivalent to those after mastectomy. Option A is incorrect; the fear and anxiety experienced by clients
varies according to their perception, beliefs, prognosis, and treatment. A client undergoing mastectomy may have the same anxiety level as a client
undergoing lumpectomy. Option C is incorrect; lumpectomy has a higher risk for local recurrence and the post-operative management is similar as anyone
having breast surgery. Option D is incorrect; because the skinhas been irradiated, the choices for reconstruction remain limited,and the woman should be
informed of this possibility at thetime of diagnosis and when considering her treatment options.
4. ANSWER: D- Early menstruation, before the age of 12, is a risk factor for breast cancer. Options A, B, and C are incorrect; use of foam contraceptives is not
a factor. Late menopause increases the risk for breast cancer, but not early menopause. A first birth at age of 30 is a risk factor, but first birth before age of 20
is not.
5. ANSWER: D- Lymph and blood are key mechanisms by which cancer cells spread. The most common mechanism of metastasis is lymphatic spread, which
is transport of tumor cells through the lymphatic circulation. Cancer cells can also spread through dissemination into the blood stream. Angiogenesis is the
mechanism by which the tumor cells are ensured a blood supply. Through this process, the malignant cells meet their needs for nutrients and capillaries.
6. ANSWER: B- Irrigations regulate the bowel to function at a specific time for the convenience of the client.
7. ANSWER: D- This is an open-ended response that encourages futher on an area that the nurse, not the client, feels is the problem.
8. ANSWER: B- The surface of a stoma is mucous membrane and should be dark pink to red, moist, and shiny; the stoma is usually raised beyond the skin
9. ANSWER: C- Reflection conveys acceptance and encourages further communication.
10. ANSWER: D- Removes microorganisms and irritants, protects the skin, and maintains skin integrity.
11. ANSWER: A- Cigarette smoking is the number one cause of bladder cancer. Answer B is incorrect because it is not associated with bladder cancer.
Answer C is a primary cause of gastric cancer, and answer D is a cause of certain types of lung cancer.
12. ANSWER: A- Iridium seeds can be expelled during urinary, so the client should be taught to strain his urine and report to the doctor if any of the seeds are
expelled. Increasing fluids, reporting urinary frequency, and avoiding prolonged sitting are not necessary; therefore, answer B, C, and D are incorrect.
13. ANSWER: B- Stage III means that cancer cells have spread into the outer layer of tissue surrounding the bladder and may have spread to surrounding
structures, but it has not spread to lymph nodes or metastasized. Tumors that have infiltrated surrounding tissues require a radical cystectomy-removal of the
bladder-and other adjacent structures. A urinary diversion must be created. One frequently used method involves using a segment of ileum to construct a
pouch that opens at the skin surface on the abdomen. This is called an ileal conduit.
14. ANSWER: D- The first sign of cancer of the bladder is frequently painless, intermittent hematuria.
15. ANSWER: C. Cold packs over the area of a dry reaction to radiation therapy are contraindicated because they reduce capillary circulation to the site and
hamper healing. Lubrication, cleansers, and cotton garments aren’t unconditionally contraindicated.
16. ANSWER: B- Knowing what to expect decreases anxiety.
17. ANSWER: D- The hallmark symptoms of children with brain tumors are headaches and vomiting. The treatment of choice is total surgical removal of the
tumor without residual neurological damage. Before surgery, the child’s head will be shaved, although every effort is made to shave only as much hair as
necessary. Although chemotherapy may be needed, it is not the treatment of choice.
18. ANSWER: D- An acoustic neuroma tumor is one of the eighth cranial nerve that deals with balance, hearing, and coordination, making the client at risk for
injury from falls. Answers A, B, and C are appropriate priorities with the information given.
19. ANSWER: C- The patient developed hives when eating shrimp, the nurse must make a notation of allergy to shellfish because this means that contrast may
be contraindicated. At the very least, it will require more in-depth questioning on the part of the nurse or physician to determine if there is an absolute
contraindication to contrast or whether it may be safe to administer contrast following premedication with an IV antihistamine such as Benadryl.
20. ANSWER: C - An MRI is noninvasive diagnostic test that visualizes the body’s tissues, structure, and blood flow. The client is positioned on a paddle table
and move into a cylinder-shaped scanner. Relaxation techniques or a sedative are used before the procedure to reduce claustrophobic effects. There is no
useful purpose for administering an antihistamine, corticosteroid, or antibiotic.
21. ANSWER: B- The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires two point of objective identification. For a client with an
armband, it is recommended that the nurse check the chart against the name and the hospital number on the client`s armband. Option A and C: in the
hospital environment the client should not participate in his identification. Option D should have been done to verify the correct order, not the client`s identity.
22. ANSWER: B- Abnormal skin pigmentation, erythema, and desquamation may develop after the radiation treatment.
23. ANSWER: C- A general body or system effect is fatigue, because it occurs as a result of changes in cell cycle patterns and toxic effects from cell
destruction. The other problems occur when radiation is directed as specific parts of the body.
24. ANSWER: C- The statistics support that infection is the most common cause of morbidity in the client with cancer. Good hand washing, monitoring with
blood cell counts, checking temperatures (watching for elevations), and when needed protective isolation (when client is severely immunosuppressed) are
the primary measures to prevent infection.
25. ANSWER: B- Radiodermatitis occurs 3 to 6 weeks after the start of treatment.


26. ANSWER: D- A protruding and distended abdomen is common because the cystic kidneys swell and push abdominal contents forward and displace other
abdominal organs.
27. ANSWER: D- Polycystic kidney disease type 1 (PKD-1) is transmitted as an autosomal dominant trait and, therefore, is not gender-specific. If one parent
has PKD-1, each child has a 50% risk for the disorder. If both parents have PKD-1, the risk is even greater.
28. ANSWER: B- Diuretics for blood pressure control can lead to fluid volume depletion and decrease blood flow to the kidney, further decreasing renal
function. Fluid volume intake is not restricted until the kidney no longer responds to diuretics.
29. ANSWER: B- Major problems associated with PKD are constipation and hypertension. An increase in dietary fiber and unrestricted fluid intake can help
prevent or relieve constipation. Hypertension is a serious problem, and a sodium restriction can be helpful.
30. ANSWER: A (B, F, G)- Flank pain and abdominal girth size are related to the distention, and bloody urine is seen with tissue damage secondary to the
PCKD. The client may also have constipation and hypertension.
31. ANSWER: C -Rehabilitative surgery for cancer restores function after cancer treatment has altered the function of an organ, tissue, or appendage.
32. ANSWER: D -The client is emitting radioactivity and does pose a radiation hazard to others at this time. Anyone who is pregnant should not enter the room.
Individual care providers should wear a lead apron and should not spend more than 30 minutes a day in the room with the client receiving brachytherapy.
33. ANSWER: D -Chemotherapy is considered systemic therapy and is used as primary therapy or adjuvant therapy for cancers that may not be confined to a
localized body area. Because chemotherapy is systemic, it circulates through many body areas and can harm cancer cells that may be some distance from
the primary tumor. Many types of chemotherapy, however, are not able to cross the blood-brain barrier and are not useful for tumors that either develop in the
brain or metastasize to the brain.
34. ANSWER: C -Benign tumors are made up of normal cells growing in the wrong place or growing at a time when they are not needed. They grow by
expansion rather than invasion and often are encapsulated. The size and the fact that it is painless does not mean that the tumor is benign. Additionally, the
presence of any sensation (such as itching) does not rule out malignancy.
35. ANSWER: D -Most chemotherapy drugs are absorbed through the skin and mucous membranes. As a result, the health care workers who prepare or give
these drugs (especially nurses and pharmacists) are at risk for absorbing them. Even at low doses, chronic exposure to chemotherapy drugs can affect
health. The Oncology Nursing Society and OSHA have specific guideline for using caution and wearing protective clothing whenever preparing, giving, or
disposing of chemotherapy drugs.
36. ANSWER: A -Often, cancer surgery involves the loss of a body part or a decrease in function. Mourning or grieving for a body image alteration is a healthy
part of adapting or adjusting to a new image.
37. ANSWER: C -The nerves supplying the skin in the area were injured during surgery, decreasing sensation to the area. These problems frequently resolve
over time.
38. ANSWER: B -The Jackson-Pratt drain removes fluid from the wound through closed suction. The drain must be compressed and closed to create suction
as it slowly re-expands.
39. ANSWER: A -Sexual intercourse can be resumed whenever the client is comfortable. Until the incision is healed, clients should be taught how to protect the
incision and avoid contact with the surgical site during intercourse.
40. ANSWER: B- Mild exercise begins the first postoperative day. The exercises should not put stress on the incision and do not involve the shoulder at this
point. Full extension of the elbow, with support, is important, as is using grip maneuvers for the hand on the affected side.
41. ANSWER: A- There are numerous mechanisms of action for cancer chemotherapeutic drugs, but most affect rapidly dividing cells. The drugs interfere with
cell division and prevent rapid division of cells.
42. ANSWER: C- Alopecia from chemotherapy is only temporary.
43. ANSWER: C- Because of the bleeding disorders common in clients receiving chemotherapy, all body secretions, including emesis, should be assessed for
obvious and occult blood.
44. ANSWER: A - The man is mistaken (and needs more teaching) it he says that testicular self-exam should be performed immediately prior to sexual
intercourse. Te best time to do TSE is when the scrotum is relaxed, such as after a warm bath or shower.
45. ANSWER: D- Only this answer, practicing breast self-exam, will yield a “warning signal of cancer” (i.e., a breast lump). Be certain that your response
answers the question, not just that it contains factual information.
46. ANSWER: B -Research has shown that there may be a correlation between vitamin A deficiency in the diet and the development of lung cancer. Daily
consumption of green and yellow vegetables is encouraged.
47. ANSWER: D - A preventive approach to pain control provides a more consistent level of relief and reduces client anxiety, which in turn can reduce
discomfort and pain.
48. ANSWER: D- Each time the tumor is exposed to the chemotherapeutic drug, a certain percentage of cells are killed. (The exact percentage is determined
by the drug dosage used). Because a percentage of tumor is killed, a part of tumor will remain after therapy. It is up to the body’s immune system to destroy
the remaining tumor, which an intact immune system may be able to do if the tumor is made small enough.
49. ANSWER: B- Visitors younger than 18 years of age, and pregnant visitors, are not allowed during internal radiation therapy.
50. ANSWER: B- Long-handled forceps and a lead-lined container (sometimes called a “lead pig”) must be kept in the room of any client receiving internal
radiation therapy for this very occurrence.
51. ANSWER: C- In the TNM staging classification system, T refers to the primary tumor, and T2 is between 2 cm and 5 cm without extension to chest wall or
skin. The N refers to regional lymph node involvement, with N1 indicating spread to an ipsilateral movable node. N0 indicates no regional lymph node spread;
N2 indicates metastasis to an ipsilateral axillary node fixed to another node or other structure. M refers to distant metastasis, with MX indicating that
metastasis cannot be assessed, M0 that there is no distant spread, and M1 that there is spread present.
52. ANSWER: C- The patient with cancer is at risk for the development of an infection. Care for this patient should include the avoidance of rectal procedures,
including taking rectal temperatures. Foods that could harbor bacteria should be avoided such as raw meat and fresh fruits and vegetables. Intramuscular
injections should be avoided. Strict aseptic technique should be used at all times when caring for venous access devices, urinary catheters, and monitoring
53. ANSWER: A- Many patients who receive radiotherapy experience fatigue. The exact causative mechanism is unknown, although it is thought to be due to
the result of tumor breakdown, which releases by-products into the blood stream. Another explanation for the development of fatigue is the increase in basal
metabolic rate consuming the body’s energy stores. Fatigue typically begins during the third and fourth week of treatment and will gradually wane once the
treatment and will gradually wane once the treatment is over. The loss of energy and feeling of tiredness tend to be cumulative and have a significant impact
on patient’s quality of life. Patient education regarding side effects of radiation begins before treatment and needs to continue once it is over. Teaching
patients that side effects should be expected may decrease their fear that treatment is ineffective. Nursing can needs to be designed with energy
conservation in mind. Clustering patient care activities together will allow for prolonged periods of rest for patients who are experiencing fatigue. Teaching
patients and their caregivers these principles will assist the patient in coping with the tiredness experienced with fatigue while at home.
54. ANSWER: C. Nearly-one half of all malignant breast tumors are located in the Upper outer quadrant
55. ANSWER: D. Age over 50( No Rationale) Reference: Introduction to Medical-Surgical Nursing, Linton, 4th Edition, ©, Chapter 47, Item no, 37, pg. 475
56. ANSWER: A- Vaginal bleeding or spotting is a common symptom of cervical cancer. Nausea, vomiting, and foul-smelling discharge, in answers B and C,
are not specific or common to cervical cancer. Hyperthermia, in answer D, is not related to the diagnosis.
57. ANSWER: B- Clients are encouraged to participate in their normal regular screening for other cancer types while they are receiving some treatments for a
different cancer type. The mammogram radiation exposure is very low and will not interfere with the cervical cancer therapy. Also, the cervical cancer therapy
will not interfere with the mammogram.


58. ANSWER: B- The implant does emit radiation and should be placed into the secure, lead-lined container in the client's room. The nurse does not directly
touch this implant, but uses long-handled tongs for this purpose. If the proper equipment is not available in the client's room, the radiation department must
be notified.
59. ANSWER: C- Normal activity must be limited so that the implant will not become dislodged.
60. ANSWER: B- The client will have a urinary catheter inserted to keep the bladder empty during radiation therapy. Answer A is incorrect because visitors are
allowed to see the client for short periods of time, as long as they maintain a distance of 6 feet from the client. Answer C is incorrect because the client is on
bed rest. Side effects from radiation therapy includes pain, nausea, vomiting, and dehydration; therefore, answer D is incorrect.
61. ANSWER: C- Although the cause of fibrocystic breast changes is unknown, the condition seems to be related to normal fluctuations in estrogen levels
during the menstrual cycle. Symptoms usually resolve after menopause in the absence of estrogen supplementation.
62. ANSWER: D- Tamoxifen is an estrogen antagonist-agonist. Its use in breast cancer is limited to cancers that express the estrogen receptor. Tamoxifen
binds to the estrogen receptors, inhibiting the binding of estrogen to the receptors and therefore “starving” the cancer cells of an essential growth factor.
63. ANSWER: A- The radiation source is an unsealed isotope that is eliminated from the body in waste products, especially urine and feces. This material is
radioactive for about 48 hours after instillation of the isotope. Having the client not share a toilet with other people for 3 days (72 hours) ensures that the
isotope has been completely eliminated and the client’s wastes are not longer radioactive.
64. ANSWER: C- Surgery and radiation are considered local treatments for lung cancer confined to the chest. If cancer has spread beyond the chest, systemic
therapy (chemotherapy) is required to control the disease.
65. ANSWER: B- Chemotherapy causes bone marrow depression. TTS: Presenting reality/ safety
66. ANSWER: C- Phalen’s maneuver produces paresthesia in the median nerve within 60 seconds. Eighty percent of individuals with CTS have a positive
Phalen’s maneuver result.
67. ANSWER: A- Motor changes begin with a weak pinch and progress to muscle weakness and wasting. Asking the client to pick up a coin is an example of
testing the ability to pinch.
68. ANSWER: A- The client must minimize hand activities, at least temporarily, until symptoms resolve.
69. ANSWER: B- Factors associated with the development of a hallux valgus deformity (bunion) are congenital factors, arthritis, and wearing ill-fitting shoes.
70. ANSWER: A- Plantar fasciitis accounts for 10% of running-related injuries. Obesity is also thought to be a factor in the development of plantar fasciitis.
71. ANSWER: B- Sally, a 36 year old who always makes use of the procedure manual as a means of control when working with her staff
72. ANSWER: B- Makes all the final decision and considers workers’ comments and suggestions
73. ANSWER: D- It is dependent on a single style of leadership
74. ANSWER: C- Identifying the appropriate number of persons who directly report to the manager
75. ANSWER: - Evaluation
76. ANSWER: A- Art. IV section 23 states that a license can be revoked or suspended for reasons of malpractice and/or negligence. That makes a certificate of
registration temporary and not owned by the nurse. It is a PRIVILEGE because anytime, a license can be taken away from a delinquent nurse.
77. ANSWER: A- Article IV section 23 states that a license can be revoked or suspended for the following grounds: Malpractice, negligence, gross
incompetence, insanity, conviction of crime, unethical, unprofessional and immoral conduct. This also includes deceit and fraud.
78. ANSWER: D- Falsification of documents is defined as deceitful fabrication of false information. Incompetence is the lack of skill or legal qualification, Perjury
is an act of making false statement under oath in court. There is no such thing as malpresentation.
79. ANSWER: D- A profession is defined as an occupation or calling that requires knowledge, skill and experience. It entails competence in performing task or
workload correctly and efficiently. As a profession, it is also consist of a body of law that sets the boundaries on what can be performed and what are the
scope of responsibility, that is why it is considered a discipline that requires accountability for one’s own professional action,
80. ANSWER: A- RA 9173 Article VI section 28 states that the general scope of nursing responsibility includes the provision of safe and quality nursing service
either singly or in collaboration with other members of the health care team. The utilization of the nursing process is universally performed by the nurse as a
basic responsibility. This also includes the primary function of the nurse in health promotion and illness prevention through proper health education.
Collaborative functions include promotive, preventive, curative, rehabilitative and spiritual care specifically in the restoration of health, alleviation of suffering
and lastly, if all means are not possible, then assist the client towards peaceful and well-dignified death.
81. ANSWER: A- take appropriate steps to safeguard their rights and privileges. Rationale: Registered Nurses are the advocates of the patients: they shall take
appropriate steps to safeguard their rights and privileges.
82. ANSWER: B- Accurate documentation of actions and outcomes Reference: Code of Ethics for Nurses. BON Res. 220 s. 2004
83. ANSWER: B- The Code of Ethics is a guide for carrying out responsibilities that provide quality care and for the ethical obligation of the profession.
84. ANSWER: C- It is deemed a moral obligation of each professional and within the context of the concerned professional’s Code of Ethics. Rationale: The
Rationale for the implementation of the CPE program is It is deemed a moral obligation of each professional and within the context of the concerned
professional’s Code of Ethics. Other choices are objectives of the program. Reference: Art. 1, Sec 4 Revised Standardized Guidelines for the Implementation
of CPES for all Registered Nurses and Professionals
85. ANSWER: A. 3 years; 60 credit units- The total CPE credit units for registered and licensed professionals with baccalaureate degree for three years should
be 60 credit units. Reference: Art. III, Sec 16 Revised Standardized Guidelines for the Implementation of CPES for all Registered Nurses and Professionals
86. ANSWER: A. Libel- Charges may be charged to a person/agency due to defamation by written words, cartoons or such representations that cause a
person to be avoided, ridiculed or held in contempt or tend to injure him in his work. Reference: de Belen, Nursing Jurisprudence
87. ANSWER: ANSWER: A- Nursing negligence is when a nurse who is fully capable of caring does not care in the way a reasonably
prudent nurse would, and as a result the patient suffers unnecessarily. The key word here is reasonable. In healthcare, the nurse will be held to
reasonable nursing standards of care; in other words, they will be judged against what other nurses in the same situation might have done. In this case,
the nurse fails to follow the hospital policy on frequency of assessment and periodic release of restraints.
88. ANSWER: A. BATTERY- By touching or doing a procedure to a patient without consent is considered as battery, and she can be filed with lawsuit.
Reference: de Belen, Nursing Jurisprudence
89. ANSWER: C- Restraints should never be applied tightly because it could impair the circulation.- A safety (hitch) may be used on the restraint because it can
easily be released in an emergency. Restraints must be released at least every 2 hours (or per agency policy) to inspect the skin for abnormalities and to
provide range-of-motion exercises. The call light must always be at the client’s reach in case the client needs assistance.
90. ANSWER: D. Informed consent is required for emergency life-threatening procedures.- Consent is not required for life threatening events. Reference: de
Belen, Nursing Jurisprudence
91. ANSWER: A- A burn that is leathery, dry, and hard skin described a full thickness burn in the emergent phase. Options B and C are incorrect; a burn that is
a red, fluid-filled vesicle with massive edema at the injury site describes a deep, partial-thickness burn during the emergent phase. Option D is incorrect;
serous exudates from a shiny, dark-brown wound describe a partial-thickness burn in the acute phase.
92. ANSWER: B- Initial goals in burn management include saving life, maintaining and protecting airway, and restoring hemodynamic stability. The
establishment of airway and breathing should take prime importance during the emergent phase of injury. Preventing burn shock through fluid resuscitation
should be the next priority. After the client has been stabilized, assessment of the wound is done so appropriate wound care can be rendered.
93. ANSWER: B- The open method requires cleansing the wounds, applying a topical antimicrobial, and leaving the wounds open to air. Option A is incorrect;
either saline or an electrolyte solution is best to use in the debridement tank. Options C & D are incorrect; in the open method, the wound is left open to air
without gauze dressings. Also, sterile gloves are used to minimize infection.
94. ANSWER: C- Pressure garments flatten scar tissue, giving the client more mobility and better cosmetic appearance. Option A is incorrect; wearing a
pressure dressing does protect the site from further injury, but this is not the major reason for wearing a pressure garment. Option B & D is incorrect; wearing
a pressure dressing does not support or splint the body part nor does it trap the oils in the skin.


95. ANSWER: C- According to the World Health Organization analgesic ladder for pain management, severe pain should be treated with a strong opioid (e.g.
morphine), with a nonopioid analgesic (e.g. acetaminophen), and an adjuvant (e.g. NSAID). Option A is incorrect; fewer than 1% of clients become addicted
to narcotic analgesics when used appropriately for pain management; therefore in this case, addiction should not be a concern. Option B is incorrect; narcotic
doses can be increased as pain increases, and therefore do not need to be reserved for fear of using them too early. Option D is incorrect; Meperidine
(Demerol) is seldom used to treat pain associated with burn, morphine sulfate is more preferred as a drug of choice. Also, metabolites accumulate with
continued use of meperidine.
96. ANSWER: B- Asking the client if he can speak establishes that the client has something in his airway and does not have a patent airway. The ability to
speak indicates that the airway is clear or only partially obstructed. Options A, C, and D are incorrect; calling a code, beginning CPR, or providing back blows
would not be appropriate initial interventions. Calling a code and beginning CPR are done if the client cannot respond. Back blows and the Heimlich
maneuver are done of the client cannot speak anymore and airway obstruction is complete.
97. ANSWER: C- Basic life support (BLS) is a level of medical care which is used for patients with life-threatening illness or injury until the patient can be given
full medical care. The sequence for adult BLS is as follows:
1. Ensure that the scene is safe.
2. Assess the victim's level of consciousness by asking loudly "are you okay?" and by checking for the victim's responsiveness to pain.
3. Activate the local EMS system by instructing someone to call 911.
4. If the victim has no suspected cervical spine trauma, open the airway using the head-tilt/chin-lift maneuver; if the victim has suspected trauma, the airway
should be opened with the jaw-thrust technique. If the jaw-thrust is ineffective at opening/maintaining the airway, a very careful head-tilt/chin-lift should be
5. Assess the airway and look, listen, and feel for breathing for at least 5 seconds and no more than 15 seconds.
6. If the patient is breathing normally, then the patient should be placed in the recovery position and monitored and transported; do not continue the BLS
7. If patient is not breathing normally, attempt to administer two artificial ventilations using the mouth-to-mouth technique, the mouth-to-mask technique, or a
bag-valve-mask. Verify that the chest rises and falls.
8. If ventilation is still unsuccessful, and the victim is unconscious, begin chest compressions; stopping every 30 compressions, re-checking the airway for
obstructions, removing any found, and re-attempting ventilation.
9. After 5 cycles of CPR (30:2 per cycle), the BLS protocol should be repeated from the beginning, assessing the patient's airway, checking for spontaneous
breathing, and checking for a spontaneous pulse.
10. BLS protocols continue until (1) the patient regains a pulse, (2) the rescuer is relieved by another rescuer of equivalent or higher training, (3) the rescuer is
too physically tired to continue CPR, or (4) the patient is pronounced dead by a medical doctor.
11. CPR continues indefinitely, until the patient is revived, or until the caregiver is relieved, or discharged by a higher medical authority
98. ANSWER: D- A vented dressing would prevent trapping of air and decompresses the pleural cavity. Options A, B, and C are incorrect; a vented dressing
would allow escape of air preventing tension pneumothorax. The dressing won’t affect the drainage of blood and would prevent bacterial contamination.
99. ANSWER: D- Crystalloids are electrolyte solutions that move freely between the intravascular compartment and the interstitial spaces. Isotonic crystalloid
solutions are often selected because they contain the same concentration of electrolytes as the extracellular fluid and therefore can be given without altering
the concentrations of electrolytes in the plasma. Common intravenous fluids used for resuscitation in hypovolemic shock include 0.9% sodium chloride
solution (normal saline) and lactated Ringer’s solution. Ringer’s lactate is an electrolyte solution containing the lactate ion, which should not be confused with
lactic acid. The lactate ion is converted to bicarbonate, which helps to buffer the overall acidosis that occurs in shock. Options A, B, and C are incorrect; these
are hypertonic solutions, wherein the electrolytes are greater and are not used to replace fluids.
100. ANSWER: B- Activated charcoal will absorb toxins from the GI tract. Options A& D are incorrect; its primary action is not to cause vomiting or diarrhea.
Option C is incorrect; the use of charcoal can potentially decrease future serum drug levels but not current ones.

1. ANSWER: C- Hips and knees- Degenerative joint disease is known as the “wear and tear” consequences of joint use. Weight-bearing joints are most
commonly affected by degenerative joint disease.
2. ANSWER: A- Obesity- Obesity increases the stress on weight-bearing joints and contributes to the development of degenerative joint disease.
3. ANSWER: B- The hip shows subluxation- Partial joint dislocation or subluxation is an indication of progressive disease in which the repair processes
stimulated by the continuing damage are unable to keep pace with the rapid degeneration. Severely damaged joints do not keep the proximal and distal
bones in anatomic alignment.
4. ANSWER: C - Swimming 3 times per week- Exercising on a regular basis is important; however, the exercise should not put more stress on the diseased
joint. Thus, weight-bearing exercises must be engaged in cautiously. Swimming allows the movement of all joints with less stress because the force of gravity
on the joint is greatly reduced. No diet has been found effective in slowing disease progression. Aspirin may held reduce discomfort and, if inflammation is
present, may help reduce inflammation (although an aspirin daily is not a therapeutic dose), but does not prevent complications or slow progression.
5. ANSWER: D- Sulfa drugs- Many clients with an allergy to sulfa drugs have a cross-reactivity with celecoxib. This drug should be avoided in clients who have
a known allergy to sulfa drugs in order to prevent a serious allergic reaction or anaphylaxis.
6. ANSWER: D - Maximum function for ambulation occurs when the hip and leg are maintained at full extension with neutral rotation. Although the client does
not have to spend 24 hours at a time in this position, he or she should be in this position (in bed or standing) more of the time than with the hip in any degree
of flexion.
7. ANSWER: B - Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal
compensation to the stress of injury. No currently accepted intervention changes this response, and it is not the highest priority of care at this time.
8. ANSWER: D - Gentamicin does not stimulate pain in the wound. The small, pale pink bumps in the wound bed are areas of re-epithelialization and not an
adverse reaction. Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving
gentamicin by any route should have kidney function monitored.
9. ANSWER: C - Circumferential eschar can act as a tourniquet when edema forms from the fluid shift, increasing tissue pressure and preventing blood flow to
the distal extremities and increasing the risk for tissue necrosis. This problem is an emergency and, without intervention, can lead to loss of the distal limb.
This problem can be reduced or corrected with an escharotomy.
10. ANSWER: C - Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and
decreased mucosal barrier. Cimetidine inhibits the production and release of hydrochloric acid.
11. ANSWER: D. - The triage nurse should see this client first because these are symptoms of a myocardial infarction, which is potentially life threatening. A-
The child needs an x-ray to confirm the fracture, but the client is stable and does not have a life-threatening problem. B- A cut hand is priority, but not over a
client having a myocardial infarction. C- These are symptoms of a migraine headache and are not life threatening.
12. ANSWER: D- A post-incident response is important to include a critique and debriefing for all parties involved; a pre-incident response is the plan itself. Be
sure to read adjectives closely. A- Practice drills allow for troubleshooting any issues before a real-life-incident occurs. B- A deactivation response is
important so that resources are not overused, and the facility can then get back to daily activities and routine care. C- A coordinated security plan involving
facility and community agencies is the key to controlling an otherwise chaotic situation.
13. ANSWER: B- This client has a very poor prognosis, and even with treatment, survival is unlikely. A- This client would be an Immediate Category, Priority 1,
and color red. If not treated STAT, a tension pneumothorax will occur. C- This client would be a Delayed Category, Priority 2, and color yellow. This client
would receive treatment after casualties requiring immediate treatment are treated. D- This client would be a Minimal Category, Priority 3, and color green.
This client can wait days for treatment.


14. ANSWER: A- CISM is an approach to preventing and treating the emotional trauma that can affect emergency responders as a consequence of their job.
Performing CPR and treating a young child affects the emergency personnel psychologically, and the death increases the traumatic experience. B- Caring for
this type of client is an expected part of the job. If the nurse finds this traumatic enough to require a CISM, then the nurse should probably leave the
emergency department. C- This would require an intense time for triaging and caring for the victims, but without fatalities this should not be that traumatic for
the staff. D- This is a dangerous practice because medication errors and other mistakes may occur as a result of fatigue, but this is not a traumatic situation.
15. ANSWER: C- The tag should never be removed from the client until the disaster is over or the client is admitted and the tag becomes a part of the client’s
record. The physician needs to be informed immediately of the action. A- This is the correct procedure when tagging a client and would not warrant
intervention. B- Vital signs should be documented on the tag. The tag takes the place of the client’s chart, so this would not warrant intervention. D- The tag
can be attached to any part of the client’s body.
16. ANSWER: C- When a client becomes angry and resents advice from a younger health care provider to give up a lifelong habit, the nurse should apologize
and assure the client that no disrespect was intended. The other options would antagonize the client rather than reduce anger.
17. ANSWER: B- The patient should be encouraged to drink 2 liters per day to help to liquefy secretions. The patients should have only low flow oxygen (1-
2L/min) to prevent respiratory depression. Respiratory drive is dependent upon high CO2 and low O2 levels. Higher O2 levels can result in loss of respiratory
18. ANSWER: A- A client with emphysema who requires oxygen should receive a maximum of 3 L/minute. A flow rate of 6L/minute (option B) would be
excessive. The client shouldn’t adjust the oxygen flow rate (option C.) Changing the tubing at each shift (option D) is unnecessary.
19. ANSWER: B- A client who is upset with the treatment regimen should be given the opportunity to express feelings. The other options don’t provide this
20. ANSWER: D- Clients with emphysema breathe when their oxygen levels drop to a certain level; this is known as the hypoxic drive. They don’t take a breath
when their levels of carbon dioxide are higher than normal, as to those with healthy respiratory physiology. If too much oxygen is given, the client has little
stimulus to take another breath. In the meantime, his carbon dioxide levels continue to climb, and the client will pass out, leading to a respiratory arrest.
21. ANSWER: A- The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in
preventing clot formation, so the statement to drink less than 500mL is incorrect. Answers B, C, and D are incorrect because they all contribute to the
prevention of complications. Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to
preventing further red cell formation.
22. ANSWER: A- The client with polycythemia vera has an abnormal increase in the number of circulating red blood cells that results in increased viscosity of the
blood. Increases in blood pressure further tax the overworked heart. Answers B, C, and D do not directly relate to the condition; therefore, they are incorrect.
23. ANSWER: C Take anticoagulants as prescribed. Oral anticoagulation prevents thrombosis recurrence in polycythemia vera
24. ANSWER: A- A high content of red blood cells builds up in response to low oxygen concentration in the air. Because there's less oxygen in the blood, the
body attempts to overcome the lack by making more red blood cells.
25. ANSWER: D- Clients with a diagnosis of polycythemia have an increased risk for thrombosis and must be aware of the symptoms. Answers A, B, and are not
related to this disorder.
26. ANSWER: D- Have a face-to-face contact during the interview.
27. ANSWER: B- Stands approximately two feet away from the patient and covering the opposite ear, whispers a word then ask client to repeat what she said.
28. ANSWER: A- Seek rehabilitative services and use supplemental devices to improve communication with other people.
29. ANSWER: B 56 – 70 db- Moderate hearing loss: At this level, you are asking people to repeat themselves a lot during conversations – in person and on the
telephone. Individuals with this degree of hearing loss cannot hear sounds lower than 40-69 dB. Severe hearing loss: If you can’t hear what people are
saying without the use of a hearing aid or other amplification, or you tend to rely on reading lips to understand the conversation, you may have severe
hearing loss. Individuals with this degree of hearing loss cannot hear sound lower than 70-94 dB. Mild heari ng loss: If one-on-one conversations are fine but
you’re having difficulty understanding some words when there’s a lot of backgroundnoise, you may have mild hearing loss. Technically speaking, it’s defined
as having hearing loss between 26 and 40 dB in the speech frequencies. Profound hearing loss: If you have profound hearing loss, you can only hear
extremely loud conversation or sound – and even then it’s difficult to understand without a hearing aid orcochlear implant. You may prefer using sign
language to communicate. Individuals with this degree of hearing loss cannot hear sound lower than 95 dB.
30. ANSWER: C- Facing the person as directly as possible when speaking is the best optionalthough other options were correct. .
31. ANSWER: A- Electrolyte imbalances are common in patients with eating disorders. Determining present electrolyte levels is necessary to planning
replacement therapy. B. No data are given suggesting suicidal ideation. C. It is likely the patient will refuse food during the admission process. D. Bed rest
may be necessary but is not the priority for determining treatment for electrolyte replacement.
32. ANSWER: D- This response is calm, matter-of-fact and firm. The nurse is not permitting the patient to be manipulative, nor is she setting up a situation in
which a power struggle is likely to arise. Option A praises the patient for her behavior. Option B is manipulative on the part of the nurse. Option C suggests
the patient will not be weighed according to schedule.
33. ANSWER: D- This is the only behavior modification technique listed in the options. It makes use of positive reinforcement, for example, rewarding the patient
for desired behavior.
34. ANSWER: C- Priority interventions are those that support restoration of weight and normalization of eating patterns. This requires close supervision of the
patient’s eating and prevention of exercise, purging, and so forth. Options A and B are long-term treatment interventions. Option D is inappropriate; the
relationship developed should be a therapeutic relationship.
35. ANSWER: C- This question will give the nurse data about the patient’s feelings about entering treatment. Generally, patients who are willing to become
involved derive greater benefits. A. The question will not alter the patient’s level of anxiety. B. The goal of nursing assessment is to gather specific data. D.
This question is not designed to gather this information.
36. ANSWER: B- The basic education of nurses provides information sufficient to qualify the generalist to asses for sexual dysfunction and to perform health
teaching. Taking a detailed sexual history and providing sex therapy requires additional training sex education and counseling.
37. ANSWER: B- The nurse who is aware of his or her personal feelings and views about sexual issues can assist a patient with a sexual disorder. Lack of
clarity about one’s feelings and views clouds the nurse’s focus. A. Previous experience may prove to be helpful, but is not the most important qualification. C.
Thinking that all types of sexual dysfunction can be corrected is unrealistic. D. Thinking that the prognosis for most sexual dysfunction disorder is poor shows
lack of information.
38. ANSWER: D- Lack of sexual desire is the most common disorder seen among couples requesting sex therapy.
39. ANSWER: A- An ego-syntonic pedophile is cognitively aware that the behavior is inappropriate, but is not troubled by it and shows no remorse. Options B
and C suggest the pedophile’s behavior is ego-dystonic, that is, unacceptable to the ego. Option D uses rationalization.
40. ANSWER: A- The patient must come to recognize what triggers the occurrence of making obscene phone calls. When triggers are recognized, the patient
can employ strategies to help him substitute healthier behaviors. No data are available to support options B, C and D.
41. ANSWER: D- The patient has an unconscious need to focus on physical symptoms in order to feel more comfortable.
42. ANSWER: A- Option A will help the nurse see how the disorder has affected the patient’s life and may provide clues to “payoffs” the patient is receiving by
virtue of assuming the sick role. (discuss primary goal and munchausen syndrome)
43. ANSWER: B- Clients with hypochondriasis are preoccupied with the belief that they have a serious disease despite the lack of physical evidence. Clients
with somatization disorder have recurrent and multiple somatic complaints of several years duration without physiologic causes. In somatization disorders,
the client has pain without any physical basis, and in hypochondriasis, the complaints are vague and ambiguous feelings.
44. ANSWER: A- Focusing on the patient directs attention away from the symptom. This approach eventually reduces the patient’s need to gain attention via
physical symptoms. B. Assertive communication raises self-esteem. C. Small goals insure success and reinforce self-esteem. D. This intervention has no
bearing on self-esteem.


45. ANSWER: B- Pain is increased when the patient experiences muscle tension. Relaxation can diminish the patient’s perceptions of the intensity of pain.
46. ANSWER: B- Option B is the only query that pertains to interpersonal relations.
47. ANSWER: C- Patients with antisocial personality disorder typically show no remorse and justify their actions as being right for them, despite being socially
unacceptable. A. Such a person would have difficulties with interactions. B. This person behaves bizarrely and has few interactions with others. D. This
person has intense, angry relationships, is impulsive, and may self-multilate.
48. ANSWER: A- Dependent patients find it difficult to make even simple decisions. They often ask advice; thus independently choosing her own attire is a
behavior to be reinforced. The other options are behaviors that reflect dependent needs and are not desirable.
49. ANSWER: C- Personality disorders involve lifelong, inflexible, dysfunctional, or deviant patterns of behavior causing distress to others, and in some cases, to
50. ANSWER: D- When a plan for limit setting is established, all staff must be committed to following the plan implicitly.
51. ANSWER: C- The presence of disorganization and inappropriate affect characterizes the disorganized type of schizophrenia.
52. ANSWER: A- A severely withdrawn patient should be met “at the patient’s own level” with silence being accepted. Short contacts are helpful to minimize both
the patient’s and the nurse’s anxiety.
53. ANSWER: D- Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increase in bizarre or
magical thinking.
54. ANSWER: C- Most patients with schizophrenia experience alternating acute and stable phases throughout life. Complete and permanent remission is rare
55. ANSWER: C- Engaging in a physical activity of some sort will help distract the patient and shift focus to something reality oriented. Making sure the activity is
noncompetitive will reduce anxiety. A and B. The patient can remain focused on delusions while appearing to be reading, listening to music, or engaged in
“concentrating” on some other activity such as a crossword puzzle. D. It may be too soon to discuss personal goals if the patient is fully focused on delusions.
56. ANSWER: C- bulimic behavior is generally a maladaptive coping response to stress and underlying issues. Option A is not a goal in the early treatment.
Option B can be done after identifying stress and underlying issues. Option D is not realistic. TTS: INITIAL- IDENTIFY FIRST
57. ANSWER: A- cognitive distortions, such as perfectionism and preoccupation with food, are similar in both disorders. Being relaxed are rare with people
having eating disorders. The anorectic client is more likely to over exercise than the bulimic TTS: ELIMINATE ABSOLUTE WORDS (NO and BUT) between
options A and D. using your concept, you will choose option A as the answer.
58. ANSWER: C- this statement explores the client’s situation. Option A is a YES/NO question and is non therapeutic. Option B gives false reassurance. Option
D dismisses the client’s concern and shows that you are ignoring the patient. TTS: FOCUS ON THE FEELINGS- explore the patient’s feelings by answering
this option.
59. ANSWER: D- the priority is for today is the patient’s pshysiologic needs. Option A occurs but not the priority at this time. Option B is body image
disturbance, a psychosocial need but also not a priority at the moment. Option C is chronic low self esteem, a psychodynamic factor, and is not a priority at
this time. TTS: MASLOW’S HERARCHY OF NEEDS- option A
60. ANSWER: B- binge eating is the rapid consumption of a large amount of food over a given period of time. Hunger doesn’t directly affect binge eating
associated with mental health disorders. Bulimic people aren’t necessarily thin; in fact, they usually of normal body size and, in many cases, slightly
overweight before the onset of the disorder. TTS: WORD ASSOCIATION- associate BINGE EATING with rapid consuming
61. ANSWER: C- this will provide consistent emotional and physical support to the client. Option A is not the first action of the nurse. Option B must not be
initiated by the nurse. Option D would eradicate the evidence TTS: SAFETY of the patient
62. ANSWER: A- this option further assesses the situation of the patient. Option B is not the priority at the moment. Option C also is not the priority at this time.
Option D is not related to the question because there is no statement saying that the client is big in her size. TTS: SAFETY of the patient- assess for injury
and signs of abuse, eliminate option D as the farthest answer.
63. ANSWER: C- family violence usually is a learned behavior, and violence begets violence, putting this couple at risk. Repeated slapping may indicate poor,
not moderate, impulse control. Violent people commonly are jealous and possessive, and feel insecure in their relationship
64. ANSWER: C- domestic violence and abuse affect all socioeconomic classes. Closed boundaries and in imbalance of power, with one member having control
over the others are common violent families. Although violent behavior may be passed from one generation to the next, it’s a learned behavior, not a genetic
trait. TTS: CONCEPT. First, eliminate option D because violent behavior is not genetically passed. Option B must be eliminated because there is no power
struggle being stated the question. Between option A and D, option D is the best answer
65. ANSWER: C- this option indicates a “NON ACCIDENT” injury. These may be from cigarettes. Toddlers are injury prone because of their developmental
stage and unsteady gait. Head injuries are uncommon. A small area of ecchymosis isn’t suspiscious in this age group. TTS: OBVIOUS ANSWER- option C
66. ANSWER: C- by treating psychosis, haloperidol, an antipsychotic drug, decreases agitation. Haloperidol is used to treat dyskinesia in clients with Tourette
syndrome and to treat dementia in elderly clients. Tardive dyskinesia may occur after prolonged haloperidol use; the client should be monitored for this
adverse reaction TTS:WORD ASSOCIATION (associated agitation with psychosis). Although haloperidol treats dyskinesia, dementia, and tardive dyskinesia,
it does not answer the question
67. ANSWER: D- Fluphenazine decanoate is a lone-acting antipsychotic agent given by injection. Because it has a 4-week duration of action, it’s commonly
prescribed for outpatients with a history of medication noncompliance. Chlorpromazine, also an antipsychotic agent, must be administered daily to maintain
adequate plasma levels, which necessitates compliance with the dosage schedule. Imipramine, a tricyclic antidepressant, and lithium carbonate, a mood
stabilizer, are rarely used to treat client with chronic schizophrenia TTS: CONCEPT, noncompliant patients should be given Prolixin decanoate
68. ANSWER: C- the dosage is too high (normal is 5 to 10 mg daily). Options A and B may lead to an overdose. Option D is incorrect because haloperidol helps
with symptoms of hallucinations TTS: SAFEST ANSWER- is to confirm first with the pysician
69. ANSWER: B- According to the DSM-IV-TR shizoaffective disorder refers to clients suffering from schizophrenia with elements of a mood disorder, either
mania or depression. The prognosis is generally better than for the other types of schizophrenia, but it’s worse than the prognosis for a mood disorder alone.
Personality disorders and psychotic illness aren’t listed together on the same axis. Schizophrenia is a major thought disorder but the question asks for
element of another disorder. Clients with schizoaffective disorder aren’t suffering from schizophrenia and an amnestic disorder TTS: ELIMINATE THE
OBVIOUS WRONG OPTION- option D. using your CONCEPT, you will choose option B as the best answer
70. ANSWER: B- a sore throat and fever are indications of an infection cause by agranulocytosis, a potentially life- threatening complication of clozapine therapy.
Because of the risk of agranulocytosis, WBC counts are necessary weekly for the first 6 months, then every 2 weeks. If the WBC count drops below 3,000/ul,
the medication must be stopped. Hypotension- not hypertension0- may occur in client taking this medication. The client should be cautioned to stand up
slowly to avoid dizziness from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If the medication
must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician. TTS: SAFEST OPTION- report to the
physician any changes
71. ANSWER: A- A nurse can be charged with false imprisonment if a client is made to believe wrongfully that he or she cannot leave the hospital. Most health
care facilities have documents that the client is asked to sign relating to the client’s responsibilities when the client leaves against medical advice. The client
should be asked to sign this document before leaving. C - The nurse should request that the client wait to speak to the physician before leaving, but if the
client refuses to do so, the nurse cannot hold the client against the client’s will. B and D - Restraining the client and calling security to block exits constitutes
false imprisonment. All clients have a right to health care and cannot be told otherwise.
72. ANSWER: C- Disulfiram is an adjunctive treatment for some clients with chronic alcoholism to assist in maintaining enforced sobriety. B - Because clients
must abstain from alcohol for at least 12 hours before the initial dose, the most important assessment is when the last alcoholic intake was consumed. A and
D - The medication should be used cautiously in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is
contraindicated in persons with severe heart disease, psychosis, or hypersensitivity to the medication.


73. ANSWER: C- Disulfiram is the medication of choice for alcoholism, and it aids in the maintenance of sobriety. A - Chlordiazepoxide hydrochloride is an
antianxiety medication, and benzodiazepine is used in the management of acute alcohol withdrawal symptoms. B - Clonidine is an antihypertensive
medication. D - Pyridoxine hydrochloride is used in the treatment of pyridoxine deficiency.
74. ANSWER: C- In the defense mechanism of denial, the person denies reality. In option A, it identifies denial. In option B, the client is relying heavily on
others, and the client’s focus of control is external. In option D, the client is concrete and procedure oriented; again, the client denies that “nothing will go
wrong that way” if the client follows all the directions. In option C, the client is expressing real concern and ambivalence about discharge from the hospital.
The client also demonstrates reality in the statement.
75. ANSWER: C- Some risk factors associated with suicide include previous suicide attempts, mental disorders, co-occurring mental and alcohol and substance
abuse disorders, family history of suicide, and impulsiveness or aggressive tendencies. The suicide rate is higher in men, although women make more
attempts at suicide. High-risk groups include those who are 19 years of age or younger and those who are 45 years of age or older (especially the elderly 65
years or older). The 18-year-old who is abusing substances is at highest risk because of the developmental potential for addiction and because of the
adolescent trait of impulsiveness. Option A is the next most lethal. Options B and D are associated with a lower risk for lethality.
76. ANSWER: A- staying and encouraging the client to eat answers the nutritional intake of the client. Options B, C and D will not meet the client’s nutritional
needs, people with Alzheimer’s disease forget how to eat. TTS: PHYSIOLOGIC NEEDS (MASLOW)
77. ANSWER: A- people in this kind of situation needs routines that would provide constant orientation. Looking at photos would orient the client every time.
Options B and C are not constant interventions to orient the client. Option D is unsafe. TTS: DETERMINING THE OUTCOME OF EACH OPTION IF IT IS
78. ANSWER: D- a client with this disease is at risk for injury because of his tendency to wander. Placing him near the station makes him easy to be monitored.
Options A, B and C does not answer why the client is placed near the station. TTS: SAFETY of the patient
79. ANSWER: D- this is the first step in assessing the orientation of the client. Option A is a negative answer, Option B is inappropriate. Option C is wrong
because the client needs consistency, it must be one nurse. TTS: ASSESSMENT.
80. ANSWER: D- this is the most common cause of dementia in the elderly. About 5% of people over age 65 have severe Alzheimer’s disease and about 12% of
people over age 65 have mild or moderate disease. Other options are not related to the question. TTS: WORD ASSOCIATION (Alzhemier’s- DEMENTIA)
81. ANSWER: A- An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. B - A flat affect is
manifested as an immobile facial expression or blank look. C - A blunted affect is a minimal emotional response or outward affect that typically does not
coincide with the client’s inner emotions. D - A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to
relate logically to the environment.
82. ANSWER: B- A flat affect is manifested as an immobile facial expression or blank look. A - An inappropriate affect refers to an emotional response to a
situation that is incongruent with the tone of the situation. D - A blunted affect is a minimal emotional response or outward affect that typically does not
coincide with the client’s inner emotions. C - A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to
relate logically to the environment.
83. ANSWER: C- The schizophrenic client is making a paranoid statement. It is important that the nurse provide the client with a supportive and protective
intervention. Option A is not therapeutic because the nurse feeds into the client’s psychosis by asking where the fantasy person is. Option B is not
therapeutic because the nurse is sarcastic and belittling to the client. Option D is not therapeutic. Although this response begins by presenting reality, it does
not demonstrate any real support for the client’s concern with safety.
84. ANSWER: C- Noncompliance with antipsychotic medication is one of the chief reasons that clients with schizophrenia have relapses. In options A and B, the
nurse is employing restating, which, although a therapeutic technique, is not useful to this client and in this client’s situation. In option D, the nurse is using an
illogical, judgmental, and biased response, which is not therapeutic.
85. ANSWER: D- word salad is an illogical word grouping. Option C is an involuntary repetition of movement. Option A is a rapid succession of unrelated ideas.
Option B are bizarre words that have meaning only to the client (e.g ECHUS) TTS: ELIMINATING OBVIOUS WRONG OPTIONS (A and D) A and D are not
related to the stem of the question. Leaving you between options B and D, using your concept, you will choose option B as the correct answer
86. ANSWER: A- Distractibility assists the nurse to direct the patient toward more appropriate, constructive activities.
87. ANSWER: B- Flight of ideas is a continuous flow of speech marked by jumping from topic to topic.
88. ANSWER: A- A calm, matter-of-fact approach minimizes the need for the patient to respond defensively and avoids power struggles. Using this approach,
the nurse conveys both control of the situation and empathy.
89. ANSWER: B- Group and competitive activities provide more stimulation than is therapeutic for a manic patient. A quiet, nonstimulating environment is
90. ANSWER: D- Seclusion is used when less restrictive measures have failed to help the patient maintain control. One of its benefits is o reduce overwhelming
environmental stimuli impacting on an extremely distractible individual.
91. ANSWER: A- The symptoms of Serotonin Syndrome include mental status changes such as confusion, hypomania and anxiety. Myoclonus, hyperreflexia
and hyperpyrexia are some of the other symptoms.
92. ANSWER: C- Any food that was pickled, aged, fermented, or smoked has to be avoided by someone on an MAOI medication as this can produce a
significant increase in blood pressure. Chinese stir fried vegetables usually use hoisin sauce (fermented sauce). Lasagna usually contains cheeses. Certain
types of beans like English broad beans or fava or Chinese pea pods have large amounts of tyramine and have to be avoided.
93. ANSWER: A- Clients who are extremely agitated require significant doses within the first few days of treatment and the dose should be delivered by injection
to ensure fast relief. Oral or sublingual doses are not rapidly absorbed. A substantial dose such as Haloperidol 10 mg may be given to agitated clients.
94. ANSWER: A- The most serious adverse effect of Clozapine is agranulocytosis and this can be manifested by sore throat and fever. The other explanations
of compromised immune system, respiratory tract infection and somatic delusions by the client are possible, but they are not the most likely explanation for
this case.
95. ANSWER: B- Promoting adherence to the medication regimen is a priority goal. The medication can be effective only if taken as prescribed. Non-adherence
to the medication regimen is thought to be a major cause of repeat hospitalization. Other options were incorrect.
96. ANSWER: B- In the honeymoon stage, the perpetrator is apologetic and kind, attempting to undo the harm of the battering incident. The perpetrator
promises never to repeat the battering. The events occurring in the other options would not be deterrents to leaving. The processing stage is not an actual
stage in the cycle.
97. ANSWER: B. Individuals who are victims of partner abuse should have an escape plan. This is of high priority when the victim’s life is endangered. Telling
the abuser to stop is futile. Encouraging the victim to take independent action is of less help than offering concrete assistance such as providing referrals and
giving emergency phone numbers. Referrals should never be contingent on leaving which might be possible only after the victim has made use of the referral
and has assistance in place.
98. ANSWER: A. Setting limits on self-mutilative behavior or purging is necessary to provide for the safety needs of the patient. As for the other options,
individuation should be fostered, the victim should not be encouraged to accept blame, and all responses are considered normal and should be accepted.
99. ANSWER: B. In the impact stage, common responses are shock, denial, and disbelief. In the recoil stage, emotional stress is high as the individual strives to
come to terms with what has happened. The victim talks about the incident and his or her feelings about the trauma. Reorganization is the third stage of
recovery, in which grief over the incident is resolved. Retribution is not a stage in the recovery process.
100. ANSWER: A. Moving from victim to survivor status is a process that can go on for months to years. It involves integrating the memories of the trauma
and moving on in life with restored functioning, a reasonable sense of safety and security, healthy relationships, and improved self-esteem. The other needs
can usually be met in the short term.