Preboard Examination December 2006 1. A woman in a child bearing age receives a rubella vaccination.

Nurse Joy would give her which of the following instructions? a. Refrain from eating eggs or egg products for 24 hours b. Avoid having sexual intercourse c. Dont get pregnant at least 3 months d. Avoid exposure to sun 2. Jonas who is diagnosed with encephalitis is under the treatment of Mannitol. Which of the following patient outcomes indicate to Nurse Ronald that the treatment of Mannitol has been effective for a patient that has increased intracranial pressure? a. Increased urinary output b. Decreased RR c. Slowed papillary response d. Decreased level of consciousness 3. Mary asked Nurse Maureen about the incubation period of rabies. Which statement by the Nurse Maureen is appropriate? a. Incubation period is 6 months b. Incubation period is 1 week c. Incubation period is 1 month d. Incubation period varies depending on the site of the bite 4. Which of the following should Nurse Cherry do first in taking care of a male client with rabies? a. Encourage the patient to take a bath b. Cover IV bottle with brown paper bag c. Place the patient near the comfort room d. Place the patient near the door

5. Which of the following is the screening test for dengue hemorrhagic fever? a. Complete blood count b. ELISA c. Rumpel-leede test d. Sedimentation rate 6. Mr. Dela Rosa is suspected to have malaria after a business trip in Palawan. The most important diagnostic test in malaria is: a. WBC count b. Urinalysis c. ELISA d. Peripheral blood smear 7. The Nurse supervisor is planning for patients assignment for the AM shift. The nurse supervisor avoids assigning which of the following staff members to a client with herpes zoster? a. Nurse who never had chicken pox b. Nurse who never had roseola c. Nurse who never had german measles d. Nurse who never had mumps 8. Clarissa is 7 weeks pregnant. Further examination revealed that she is susceptible to rubella. When would be the most appropriate for her to receive rubella immunization? a. At once b. During 2nd trimester c. During 3rd trimester d. After the delivery of the baby 9. A female child with rubella should be isolated from a:

a. 21 year old male cousin living in the same house b. 18 year old sister who recently got married c. 11 year old sister who had rubeola during childhood d. 4 year old girl who lives next door 10. What is the primary prevention of leprosy? a. Nutrition b. Vitamins c. BCG vaccination d. DPT vaccination 11. A bacteria which causes diphtheria is also known as? a. Amoeba b. Cholera c. Klebs-loeffler bacillus d. Spirochete 12. Nurse Ron performed mantoux skin test today (Monday) to a male adult client. Which statement by the client indicates that he understood the instruction well? a. I will come back later b. I will come back next month c. I will come back on Friday d. I will come back on Wednesday, same time, to read the result 13. A male client had undergone Mantoux skin test. Nurse Ronald notes an 8mm area of indurations at the site of the skin test. The nurse interprets the result as: a. Negative b. Uncertain and needs to be repeated

c. Positive d. Inconclusive 14. Tony will start a 6 month therapy with Isoniazid (INH). Nurse Trish plans to teach the client to: a. Use alcohol moderately b. Avoid vitamin supplements while o therapy c. Incomplete intake of dairy products d. May be discontinued if symptoms subsides 15. Which is the primary characteristic lesion of syphilis? a. Sore eyes b. Sore throat c. Chancroid d. Chancre 16. What is the fast breathing of Jana who is 3 weeks old? a. 60 breaths per minute b. 40 breaths per minute c. 10 breaths per minute d. 20 breaths per minute 17. Which of the following signs and symptoms indicate some dehydration? a. Drinks eagerly b. Restless and irritable c. Unconscious d. A and B 18. What is the first line for dysentery?

a. Amoxicillin b. Tetracycline c. Cefalexin d. Cotrimoxazole 19. In home made oresol, what is the ratio of salt and sugar if you want to prepare with 1 liter of water? a. 1 tbsp. salt and 8 tbsp. sugar b. 1 tbsp. salt and 8 tsp. sugar c. 1 tsp. salt and 8 tsp. sugar d. 8 tsp. salt and 8 tsp. sugar 20. Gentian Violet is used for: a. Wound b. Umbilical infections c. Ear infections d. Burn 21. Which of the following is a live attenuated bacterial vaccine? a. BCG b. OPV c. Measles d. None of the above 22. EPI is based on? a. Basic health services b. Scope of community affected c. Epidemiological situation

d. Research studies 23. TT? provides how many percentage of protection against tetanus? a. 100 b. 99 c. 80 d. 90 24. Temperature of refrigerator to maintain potency of measles and OPV vaccine is: a. -3c to -8c b. -15c to -25c c. +15c to +25c d. +3c to +8c 25. Diptheria is a: a. Bacterial toxin b. Killed bacteria c. Live attenuated d. Plasma derivatives 26. Budgeting is under in which part of management process? a. Directing b. Controlling c. Organizing d. Planning 27. Time table showing planned work days and shifts of nursing personnel is: a. Staffing

b. Schedule c. Scheduling d. Planning 28. A force within an individual that influences the strength of behavior? a. Motivation b. Envy c. Reward d. Self-esteem 29. To be the leading hospital in the Philippines is best illustrate in: a. Mission b. Philosophy c. Vision d. Objective 30. It is the professionally desired norms against which a staff performance will be compared? a. Job descriptions b. Survey c. Flow chart d. Standards 31. Reprimanding a staff nurse for work that is done incorrectly is an example of what type of reinforcement? a. Feedback b. Positive reinforcement c. Performance appraisal

d. Negative reinforcement 32. Questions that are answerable only by choosing an option from a set of given alternatives are known as? a. Survey b. Close ended c. Questionnaire d. Demographic 33. A researcher that makes a generalization based on observations of an individuals behavior is said to be which type of reasoning: a. Inductive b. Logical c. Illogical d. Deductive 34. The balance of a researchs benefit vs. its risks to the subject is: a. Analysis b. Risk-benefit ratio c. Percentile d. Maximum risk 35. An individual/object that belongs to a general population is a/an: a. Element b. Subject c. Respondent d. Author 36. An illustration that shows how the members of an organization are connected:

a. Flowchart b. Bar graph c. Organizational chart d. Line graph 37. The first college of nursing that was established in the Philippines is: a. Fatima University b. Far Eastern University c. University of the East d. University of Sto. Tomas 38. Florence nightingale is born on: a. France b. Britain c. U.S d. Italy 39. Objective data is also called: a. Covert b. Overt c. Inference d. Evaluation 40. An example of subjective data is: a. Size of wounds b. VS c. Lethargy

d. The statement of patient My hand is painful 41. What is the best position in palpating the breast? a. Trendelenburg b. Side lying c. Supine d. Lithotomy 42. When is the best time in performing breast self examination? a. 7 days after menstrual period b. 7 days before menstrual period c. 5 days after menstrual period d. 5 days before menstrual period 43. Which of the following should be given the highest priority before performing physical examination to a patient? a. Preparation of the room b. Preparation of the patient c. Preparation of the nurse d. Preparation of environment 44. It is a flip over card usually kept in portable file at nursing station. a. Nursing care plan b. Medicine and treatment record c. Kardex d. TPR sheet 45. Jose has undergone thoracentesis. The nurse in charge is aware that the best position for Jose is:

a. Semi fowlers b. Low fowlers c. Side lying, unaffected side d. Side lying, affected side 46. The degree of patients abdominal distension may be determined by: a. Auscultation b. Palpation c. Inspection d. Percussion 47. A male client is addicted with hallucinogen. Which physiologic effect should the nurse expect? a. Bradyprea b. Bradycardia c. Constricted pupils d. Dilated pupils 48. Tristan a 4 year old boy has suffered from full thickness burns of the face, chest and neck. What will be the priority nursing diagnosis? a. Ineffective airway clearance related to edema b. Impaired mobility related to pain c. Impaired urinary elimination related to fluid loss d. Risk for infection related to epidermal disruption 49. In assessing a clients incision 1 day after the surgery, Nurse Betty expect to see which of the following as signs of a local inflammatory response? a. Greenish discharge b. Brown exudates at incision edges

c. Pallor around sutures d. Redness and warmth 50. Nurse Ronald is aware that the amiotic fluid in the third trimester weighs approximately: a. 2 kilograms b. 1 kilograms c. 100 grams d. 1.5 kilograms 51. After delivery of a baby girl. Nurse Gina examines the umbilical cord and expects to find a cord to: a. Two arteries and two veins b. One artery and one vein c. Two arteries and one vein d. One artery and two veins 52. Myrna a pregnant client reports that her last menstrual cycle is July 11, her expected date of birth is a. November 4 b. November 11 c. April 4 d. April 18 53. Which of the following is not a good source of iron? a. Butter b. Pechay c. Grains d. Beef

54. Maureen is admitted with a diagnosis of ectopic pregnancy. Which of the following would you anticipate? a. NPO b. Bed rest c. Immediate surgery d. Enema 55. Gina a postpartum client is diagnosed with endometritis. Which position would you expect to place her based on this diagnosis? a. Supine b. Left side lying c. Trendelinburg d. Semi-fowlers 56. Nurse Hazel knows that Myrna understands her condition well when she remarks that urinary frequency is caused by: a. Pressure caused by the ascending uterus b. Water intake of 3L a day c. Effect of cold weather d. Increase intake of fruits and vegetables 57. How many ml of blood is loss during the first 24 hours post delivery of Myrna? a. 100 b. 500 c. 200 d. 400 58. Which of the following hormones stimulates the secretion of milk? a. Progesterone

b. Prolactin c. Oxytocin d. Estrogen 59. Nurse Carla is aware that Mylas second stage of labor is beginning when the following assessment is noted: a. Bay of water is broken b. Contractions are regular c. Cervix is completely dilated d. Presence of bloody show 60. The leaking fluid is tested with nitrazine paper. Nurse Kelly confirms that the clients membrane have ruptures when the paper turns into a: a. Pink b. Violet c. Green d. Blue 61. After amniotomy, the priority nursing action is: a. Document the color and consistency of amniotic fluid b. Listen the fetal heart tone c. Position the mother in her left side d. Let the mother rest 62. Which is the most frequent reason for postpartum hemorrhage? a. Perineal lacerations b. Frequent internal examination (IE) c. CS

d. Uterine atomy 63. On 2nd postpartum day, which height would you expect to find the fundus in a woman who has had a caesarian birth? a. 1 finger above umbilicus b. 2 fingers above umbilicus c. 2 fingers below umbilicus d. 1 finger below umbilicus 64. Which of the following criteria allows Nurse Kris to perform home deliveries? a. Normal findings during assessment b. Previous CS c. Diabetes history d. Hypertensive history 65. Nurse Carla is aware that one of the following vaccines is done by intramuscular (IM) injection? a. Measles b. OPV c. BCG d. Tetanus toxoid 66. Asin law is on which legal basis: a. RA 8860 b. RA 2777 c. RI 8172 d. RR 6610 67. Nurse John is aware that the herbal medicine appropriate for urolithiasis is:

a. Akapulco b. Sambong c. Tsaang gubat d. Bayabas 68. Community/Public health bag is defined as: a. An essential and indispensable equipment of the community health nurse during home visit b. It contains drugs and equipment used by the community health nurse c. Is a requirement in the health center and for home visit d. It is a tool used by the community health nurse in rendering effective procedures during home visit 69. TT4 provides how many percentage of protection against tetanus? a. 70 b. 80 c. 90 d. 99 70. Third postpartum visit must be done by public health nurse: a. Within 24 hours after delivery b. After 2-4 weeks c. Within 1 week d. After 2 months 71. Nurse Candy is aware that the family planning method that may give 98% protection to another pregnancy to women a. Pills b. Tubal ligation

c. Lactational Amenorrhea method (LAM) d. IUD 72. Which of the following is not a part of IMCI case management process a. Counsel the mother b. Identify the illness c. Assess the child d. Treat the child 73. If a young child has pneumonia when should the mother bring him back for follow up? a. After 2 days b. In the afternoon c. After 4 days d. After 5 days 74. It is the certification recognition program that develop and promotes standard for health facilities: a. Formula b. Tutok gamutan c. Sentrong program movement d. Sentrong sigla movement 75. Baby Marie was born May 23, 1984. Nurse John will expect finger thumb opposition on: a. April 1985 b. February 1985 c. March 1985 d. June 1985

76. Baby Reese is a 12 month old child. Nurse Oliver would anticipate how many teeth? a. 9 b. 7 c. 8 d. 6 77. Which of the following is the primary antidote for Tylenol poisoning? a. Narcan b. Digoxin c. Acetylcysteine d. Flumazenil 78. A male child has an intelligence quotient of approximately 40. Which kind of environment and interdisciplinary program most likely to benefit this child would be best described as: a. Habit training b. Sheltered workshop c. Custodial d. Educational 79. Nurse Judy is aware that following condition would reflect presence of congenital G.I anomaly? a. Cord prolapse b. Polyhydramios c. Placenta previa d. Oligohydramios

80. Nurse Christine provides health teaching for the parents of a child diagnosed with celiac disease. Nurse Christine teaches the parents to include which of the following food items in the childs diet: a. Rye toast b. Oatmeal c. White bread d. Rice 81. Nurse Randy is planning to administer oral medication to a 3 year old child. Nurse Randy is aware that the best way to proceed is by: a. Would you like to drink your medicine? b. If you take your medicine now, Ill give you lollipop c. See the other boy took his medicine? Now its your turn. d. Heres your medicine. Would you like a mango or orange juice? 82. At what age a child can brush her teeth without help? a. 6 years b. 7 years c. 5 years d. 8 years 83. Ribivarin (Virazole) is prescribed for a female hospitalized child with RSV. Nurse Judy prepare this medication via which route? a. Intra venous b. Oral c. Oxygen tent d. Subcutaneous 84. The present chairman of the Board of Nursing in the Philippines is:

a. Maria Joanna Cervantes b. Carmencita Abaquin c. Leonor Rosero d. Primitiva Paquic 85. The obligation to maintain efficient ethical standards in the practice of nursing belong to this body: a. BON b. ANSAP c. PNA d. RN 86. A male nurse was found guilty of negligence. His license was revoked. Reissuance of revoked certificates is after how many years? a. 1 year b. 2 years c. 3 years d. 4 years 87. Which of the following information cannot be seen in the PRC identification card? a. Registration Date b. License Number c. Date of Application d. Signature of PRC chairperson 88. Breastfeeding is being enforced by milk code or: a. EO 51 b. R.A. 7600

c. R.A. 6700 d. P.D. 996 89. Self governance, ability to choose or carry out decision without undue pressure or coercion from anyone: a. Veracity b. Autonomy c. Fidelity d. Beneficence 90. A male patient complained because his scheduled surgery was cancelled because of earthquake. The hospital personnel may be excused because of: a. Governance b. Respondent superior c. Force majeure d. Res ipsa loquitor 91. Being on time, meeting deadlines and completing all scheduled duties is what virtue? a. Fidelity b. Autonomy c. Veracity d. Confidentiality 92. This quality is being demonstrated by Nurse Ron who raises the side rails of a confused and disoriented patient? a. Responsibility b. Resourcefulness c. Autonomy

d. Prudence 93. Which of the following is formal continuing education? a. Conference b. Enrollment in graduate school c. Refresher course d. Seminar 94. The BSN curriculum prepares the graduates to become? a. Nurse generalist b. Nurse specialist c. Primary health nurse d. Clinical instructor 95. Disposal of medical records in government hospital/institutions must be done in close coordination with what agency? a. Department of Health b. Records Management Archives Office c. Metro Manila Development Authority d. Bureau of Internal Revenue 96. Nurse Jolina must see to it that the written consent of mentally ill patients must be taken from: a. Nurse b. Priest c. Family lawyer d. Parents/legal guardians 97. When Nurse Clarence respects the clients self-disclosure, this is a gauge for the nurses

a. Respectfulness b. Loyalty c. Trustworthiness d. Professionalism 98. The Nurse is aware that the following tasks can be safely delegated by the nurse to a non-nurse health worker except: a. Taking vital signs b. Change IV infusions c. Transferring the client from bed to chair d. Irrigation of NGT 99. During the evening round Nurse Tina saw Mr. Toralba meditating and afterwards started singing prayerful hymns. What would be the best response of Nurse Tina? a. Call the attention of the client and encourage to sleep b. Report the incidence to head nurse c. Respect the clients action d. Document the situation 100. In caring for a dying client, you should perform which of the following activities a. Do not resuscitate b. Assist client to perform ADL c. Encourage to exercise d. Assist client towards a peaceful death 101. The Nurse is aware that the ability to enter into the life of another person and perceive his current feelings and their meaning is known: a. Belongingness b. Genuineness

c. Empathy d. Respect 102. The termination phase of the NPR is best described one of the following: a. Review progress of therapy and attainment of goals b. Exploring the clients thoughts, feelings and concerns c. Identifying and solving patients problem d. Establishing rapport 103. During the process of cocaine withdrawal, the physician orders which of the following: a. Haloperidol (Haldol) b. Imipramine (Tofranil) c. Benztropine (Cogentin) d. Diazepam (Valium) 104. The nurse is aware that cocaine is classified as: a. Hallucinogen b. Psycho stimulant c. Anxiolytic d. Narcotic 105. In community health nursing, it is the most important risk factor in the development of mental illness? a. Separation of parents b. Political problems c. Poverty d. Sexual abuse

106. All of the following are characteristics of crisis except a. The client may become resistive and active in stopping the crisis b. It is self-limiting for 4-6 weeks c. It is unique in every individual d. It may also affect the family of the client 107. Freud states that temper tantrums is observed in which of the following: a. Oral b. Anal c. Phallic d. Latency 108. The nurse is aware that ego development begins during: a. Toddler period b. Preschool age c. School age d. Infancy 109. Situation: A 19 year old nursing student has lost 36 lbs for 4 weeks. Her parents brought her to the hospital for medical evaluation. The diagnosis was ANOREXIA NERVOSA. The Primary gain of a client with anorexia nervosa is: a. Weight loss b. Weight gain c. Reduce anxiety d. Attractive appearance 110. The nurse is aware that the primary nursing diagnosis for the client is: a. Altered nutrition : less than body requirement

b. Altered nutrition : more than body requirement c. Impaired tissue integrity d. Risk for malnutrition 111. After 14 days in the hospital, which finding indicates that her condition in improving? a. She tells the nurse that she had no idea that she is thin b. She arrives earlier than scheduled time of group therapy c. She tells the nurse that she eat 3 times or more in a day d. She gained 4 lbs in two weeks 112. The nurse is aware that ataractics or psychic energizers are also known as: a. Anti manic b. Anti depressants c. Antipsychotics d. Anti anxiety 113. Known as mood elevators: a. Anti depressants b. Antipsychotics c. Anti manic d. Anti anxiety 114. The priority of care for a client with Alzheimers disease is a. Help client develop coping mechanism b. Encourage to learn new hobbies and interest c. Provide him stimulating environment d. Simplify the environment to eliminate the need to make chores

115. Autism is diagnosed at: a. Infancy b. 3 years old c. 5 years old d. School age 116. The common characteristic of autism child is: a. Impulsitivity b. Self destructiveness c. Hostility d. Withdrawal 117. The nurse is aware that the most common indication in using ECT is: a. Schizophrenia b. Bipolar c. Anorexia Nervosa d. Depression 118. A therapy that focuses on here and now principle to promote self-acceptance? a. Gestalt therapy b. Cognitive therapy c. Behavior therapy d. Personality therapy 119. A client has many irrational thoughts. The goal of therapy is to change her: a. Personality b. Communication

c. Behavior d. Cognition 120. The appropriate nutrition for Bipolar I disorder, in manic phase is: a. Low fat, low sodium b. Low calorie, high fat c. Finger foods, high in calorie d. Small frequent feedings 121. Which of the following activity would be best for a depressed client? a. Chess b. Basketball c. Swimming d. Finger painting 122. The nurse is aware that clients with severe depression, possess which defense mechanism: a. Introjection b. Suppression c. Repression d. Projection 123. Nurse John is aware that self mutilation among Bipolar disorder patients is a means of: a. Overcoming fear of failure b. Overcoming feeling of insecurity c. Relieving depression d. Relieving anxiety

124. Which of the following may cause an increase in the cystitis symptoms? a. Water b. Orange juice c. Coffee d. Mango juice 125. In caring for clients with renal calculi, which is the priority nursing intervention? a. Record vital signs b. Strain urine c. Limit fluids d. Administer analgesics as prescribed 126. In patient with renal failure, the diet should be: a. Low protein, low sodium, low potassium b. Low protein, high potassium c. High carbohydrate, low protein d. High calcium, high protein 127. Which of the following cannot be corrected by dialysis? a. Hypernatremia b. Hyperkalemia c. Elevated creatinine d. Decreased hemoglobin 128. Tony with infection is receiving antibiotic therapy. Later the client complaints of ringing in the ears. This ototoxicity is damage to: a. 4th CN b. 8th CN

c. 7th CN d. 9th CN 129. Nurse Emma provides teaching to a patient with recurrent urinary tract infection includes the following: a. Increase intake of tea, coffee and colas b. Void every 6 hours per day c. Void immediately after intercourse d. Take tub bath everyday 130. Which assessment finding indicates circulatory constriction in a male client with a newly applied long leg cast? a. Blanching or cyanosis of legs b. Complaints of pressure or tightness c. Inability to move toes d. Numbness of toes 131. During acute gout attack, the nurse administer which of the following drug: a. Prednisone (Deltasone) b. Colchicines c. Aspirin d. Allopurinol (Zyloprim) 132. Information in the patients chart is inadmissible in court as evidence when: a. The client objects to its use b. Handwriting is not legible c. It has too many unofficial abbreviations d. The clients parents refuses to use it

133. Nurse Karen is revising a client plan of care. During which step of the nursing process does such revision take place? a. Planning b. Implementation c. Diagnosing d. Evaluation 134. When examining a client with abdominal pain, Nurse Hazel should assess: a. Symptomatic quadrant either second or first b. The symptomatic quadrant last c. The symptomatic quadrant first d. Any quadrant 135. How long will nurse John obtain an accurate reading of temperature via oral route? a. 3 minutes b. 1 minute c. 8 minutes d. 15 minutes 136. The one filing the criminal care against an accused party is said to be the? a. Guilty b. Accused c. Plaintiff d. Witness 137. A male client has a standing DNR order. He then suddenly stopped breathing and you are at his bedside. You would: a. Call the physician

b. Stay with the client and do nothing c. Call another nurse d. Call the family 138. The ANA recognized nursing informatics heralding its establishment as a new field in nursing during what year? a. 1994 b. 1992 c. 2000 d. 2001 139. When is the first certification of nursing informatics given? a. 1990-1993 b. 2001-2002 c. 1994-1996 d. 2005-2008 140. The nurse is assessing a female client with possible diagnosis of osteoarthritis. The most significant risk factor for osteoarthritis is: a. Obesity b. Race c. Job d. Age 141. A male client complains of vertigo. Nurse Bea anticipates that the client may have a problem with which portion of the ear? a. Tymphanic membranes b. Inner ear c. Auricle

d. External ear 142. When performing Webers test, Nurse Rosean expects that this client will hear a. On unaffected side b. Longer through bone than air conduction c. On affected side by bone conduction d. By neither bone or air conduction 143. Toy with a tentative diagnosis of myasthenia gravis is admitted for diagnostic make up. Myasthenia gravis can confirmed by: a. Kernigs sign b. Brudzinskis sign c. A positive sweat chloride test d. A positive edrophonium (Tensilon) test 144. A male client is hospitalized with Guillain-Barre Syndrome. Which assessment finding is the most significant? a. Even, unlabored respirations b. Soft, non distended abdomen c. Urine output of 50 ml/hr d. Warm skin 145. For a female client with suspected intracranial pressure (ICP), a most appropriate respiratory goal is: a. Maintain partial pressure of arterial oxygen (Pa O2) above 80mmHg b. Promote elimination of carbon dioxide c. Lower the PH d. Prevent respiratory alkalosis 146. Which nursing assessment would identify the earliest sign of ICP?

a. Change in level of consciousness b. Temperature of over 103F c. Widening pulse pressure d. Unequal pupils 147. The greatest danger of an uncorrected atrial fibrillation for a male patient will be which of the following: a. Pulmonary embolism b. Cardiac arrest c. Thrombus formation d. Myocardial infarction 148. Linda, A 30 year old post hysterectomy client has visited the health center. She inquired about BSE and asked the nurse when BSE should be performed. You answered that the BSE is best performed: a. 7 days after menstruation b. At the same day each month c. During menstruation d. Before menstruation 149. An infant is ordered to recive 500 ml of D5NSS for 24 hours. The Intravenous drip is running at 60 gtts/min. How many drops per minute should the flow rate be? a. 60 gtts/min. b. 21 gtts/min c. 30 gtts/min d. 15 gtts/min 150. Mr. Gutierrez is to receive 1 liter of D5RL to run for 12 hours. The drop factor of the IV infusion set is 10 drops per minute. Approximately how many drops per minutes should the IV be regulated?

a. 13-14 drops b. 17-18 drops c. 10-12 drops d. 15-16 drops Answer Key:

NURSING PRACTICE 3B: NURSING CARE OF CLIENT WITH PHYSIOLOGICAL AND PSYCHOSOCIAL ALTERATIONS
DIRECTION: Choose the letter of the BEST answer by shading the corresponding letter of your choice on the answer sheet provided. STRICTLY NO ERASURE! Situation 1: It is Cancer Consciousness Week and you are participating in an Early Cancer Detection Drive of the Department of Health. 1. Based on the DOH and World Health Organization (WHO) guidelines, the mainstay for early detection method for breast cancer that is recommended for developing countries is: A. a monthly breast self examination (BSE) and an annual health worker breast examination (HWBE) B. an annual hormone receptor assay C. an annual mammogram D. a physician conduct a breast clinical examination every 2 years 2. The purpose of performing the breast self examination (BSE) regularly is to discover: A. fibrocystic masses C. areas of thickness or fullness B. cancerous lumps D. changes from previous BSE 3. If you are to instruct a postmenopausal woman about BSE, when would you tell her to do BSE: A. on the same day of each month C. on the first day of her menstruation B. right after the menstrual period D. on the last day of her menstruation 4. During breast self-examination, the purpose of standing in front of the mirror it to observe the breast for: A. thickening of the tissue C. lumps in the breast tissue B. axillary D. change in size and contour 5. When preparing to examine the left breast in a reclining position, the purpose of placing a small folded towel under the clients left shoulder is to: A. bring the breast closer to the examiners right hand

B. tense the pectoral muscle C. balance the breast tissue more evenly on the chest wall D. facilitate lateral positioning of the breast Situation 2: Ensuring safety is one of your most important responsibilities. You will need to provide instruction and information to your clients to prevent complications. 6. LM has chest tube attached to a pleural drainage system. When caring for LM you should: A. change the dressing daily using aseptic technique B. empty the drainage system at the end of the shift C. palpate the surrounding areas for crepitus D. clamp the chest tube when suctioning 7. After pelvic surgery, the sign that would be indicative of a developing thrombophlebitis would be: A. a tender, painful area on the leg C. a pitting edema of the ankle B. pruritus on the calf and ankle D. a reddened area of the ankle 8. To prevent recurrent attacks on FT who has glomerulonephritis, you should instruct her to: A. continue to take the same restrictions on fluid intake B. seek early treatment for respiratory infections C. avoid situations that involve physical activity D. take showers instead of tub bath 9. GT had a laryngectomy. He is now for discharge. He verbalized his concern regarding his laryngectomy tube being dislodged. What would you teach him FIRST? A. reinsert another tubing immediately C. recognize that prompt closure of the tracheal opening B. keep calm because there is no immediate D. notify the physician at once emergency 10. When caring for TU after an exploratory chest surgery and pneumonectomy, your PRIORITY would be to maintain:

A. chest tube drainage C. ventilation exchange B. blood replacement D. supplementary oxygen Situation 3: Severe burn is one of the most devastating kinds of injury one can experience. It can affect any group. You have been ready to provide holistic care for patients with severe burns. 11. A burn that is white, painless, and leathery in texture describes a: A. second degree burn C. deep partial thickness burns B. third degree or full thickness burn D. first degree or superficial burns 12. Critically ill patients are at high risk for the following complication during the emergent phase: A. myocardial infarction C. burn shock B. neurogenic shock D. contractures 13. The MOST effective method of delivering pain medication during the emergent phase is: A. intramuscularly C. orally B. subcutaneously D. intravenously 14. Edema presents a significant problem in burn wounds because: A. loss of protein prevents tissue repair B. edema impedes tissue perfusion/oxygenation C. edema provides a milieu for bacterial proliferation D. edema can produce a tourniquet effect 15. Which of the following can be a fatal complication of upper airway burns? A. stress ulcers C. shock B. hemorrhage D. laryngeal spasms and swelling Situation 4: You are assigned to take care of four patients with different conditions. 16. KJ, who is to have a kidney transplant asks you how long will he take azathioprime (Imuran), cyclosporine and prednisone? You recognized that KJ understood the teaching when he states, I must take these medications: A. until the anastomosis heals C. until the supply is over

B. during the preoperative period D. for the rest of my life 17. After the kidney transplant, you must observe KJ for signs of rejection which includes: A. fever and weight gain C. polyuria and jaundice B. hematuria and seizure D. moon face and muscle atrophy 18. FB, 28 years old with chronic renal disease plans to receive a kidney transplant. Recently, FB was told by his physician that he was a poor candidate for transplant because of his hypertension and diabetes mellitus. Now, FB tells you I want to go off dialysis, Id rather not live than to be in this treatment the rest of my life. How would you respond to him? A. leave the room and allow him to collect his thoughts B. tell FB that We all have days when we dont feel like going on C. tell FB that Treatments are only three times a week, you can live with that D. take a sit next to him and sit quietly 19. DS signed a consent form for participation in a clinical trial for implantable cardioverter defibrillators. Which statement by DS indicates the need for further teaching before true informed consent can be obtained? A. a wire from the generator will be attached to my heart B. the physician will make a small incision in my chest wall and place the generator there C. I wonder if there is another way to protect these bad rhythms D. this implanted defibrillator will protect me from those bad rhythms my heart goes into 20. KP is participating in a cardiac study in which his physician is directly involved. Which statement by KP indicates a lack of understanding about his rights as a research study participant? A. My confidentiality will not be compromised in this study B. I understand the risk associated in this study C. I can withdraw from the study anytime D. Ill have to find a new physician if I dont complete this study Situation 5. You are assigned in the neurology stroke unit. To prepare for this assignment, you should be able to answer the following questions.

21. Which of the following statements can BEST describe/define stroke or brain attack? A. it occurs when circulation to a part of the brain is disrupted B. it is usually caused by abuse of prescribed medications C. it is caused by a cerebral hemorrhage D. it may be the results of a transient ischemic attack (TIA) 22. Several diagnostic tests may be ordered for proper evaluation. The purpose of each of the following diagnostic examination is correct EXCEPT:
A. Cerebral Angiography is used to identify collateral blood circulation and may reveal site of rupture or occlusion B. ECG may reveal abnormal electrical activity, such as focal slowing and assess amount of brain wave activity. C. MRI may reveal the site of infarction, hematoma and shift of brain structures D. PET Scanning may reveal information on cerebral metabolism and blood flow characteristics.

23. Which of the following is the MOST common cause of stroke or brain attack? A. embolism C. cerebral arterial spasm B. hemorrhage D. thrombosis 24. To guide you in your assessment, it is also important for you to remember that the clinical features of stroke vary with the following factors EXCEPT: A. severity of damage C. artery affected B. gender D. the extent of collateral circulation 25. It is important for you to also teach clients and their families who are at risk to observed primary prevention which includes the following EXCEPT: A. maintain serum cholesterol level between 220 and 180 mm/dL B. treat transient ischemic attacks (TIA) early C. teach preventive health behaviors (consequences of smoking, obesity, alcoholism, drug abuse) to children of patients with stroke D. screen for systolic hypertension

Situation 6:Foot care among patients with peripheral vascular problems is very important. 26. When teaching a client with peripheral vascular disease about foot care, you should include which instructions: A. avoid wearing canvas shoes C. avoid use of cornstarch on the foot B. avoid using a nail clipper to cut toe nails D. avoid wearing cotton socks 27. FT, who has no known history of peripheral vascular disease, comes to the emergency room complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses, paresthesia and a mottled, cyanotic, cold, cadaverous left calf. While the physician determines the appropriate management, you should: A. shave the affected leg in anticipation of surgery C. keep the affected leg level or slightly dependent B. place a healing pad around the calf D. elevate the affected calf as high as possible 28. Peripheral neuropathies primarily affect: A. sensory functions C. optic functions B. vascular functions D. motor functions 29. Peripheral neuropathy can BEST be controlled by: A. good glucose control C. vitamin supplement B. steroid therapy D. nothing, there is no slowing the process 30. In addition to clients with diabetes mellitus you must be aware that acute hypoglycemia can also develop in a client with: A. hypertension C. liver disease B. hyperthyroidism D. diabetes insipidus Situation 7: You are assigned to take care of a group of elderly patients. Pain and urinary incontinence are their common concerns. You should be able to address their concerns in a holistic manner. 31. The WHO analgesic ladder provides the health professional with: A. specific pain management choices based on severity of pain B. general pain management choices based on level of pain C. pharmacologic and nonpharmacologic pain management choices

D. nonpharmacologic interventions based on level of pain 32. As a nurse caring for patients in pain, you should evaluate for opioid side effects which include the following EXCEPT: A. pruritus C. constipation B. respiratory depression D. physical dependence 33. Which of the following statements about cancer pain is NOT true? A. opioids are drugs of choice for severe pain B. pain associated with cancer and the terminal phase of the disease occurs in majority of patients C. under treatment of pain is often due to a clinicians failure or inability to evaluate or appreciate the severity of the clients problem D. adjuvant medications such as steroids, anti convulsants, nonsteroidal anti-inflammatory drugs enhance pain perception 34. TR has been on morphine on a regular basis for several weeks. He is now complaining that the usual dose he has been receiving is no longer relieving his pain as effectively. Assuming that nothing has changed in his condition, you would suspect that TR is: A. becoming psychologically dependent C. needing to have the morphine discontinued B. developing tolerance to the morphine D. exaggerating his level of pain 35. The guidelines for choosing appropriate nonpharmacologic intervention for pain include all of the following EXPECT: A. effectiveness for patient C. skill of the clinician health professional B. pain problem identification D. type of opioid being used Situation 8: To be able to provide care for patients in the critical areas, you should look into factors that will enhance your ability to provide quality nursing care. 36. Research study show that nurses who work with critically patients as opposed to nurses who work with less acute patient: A. are more satisfied with their role C. are most acceptable to burn out B. move a greater support system D. experience greater stress 37. Which of the components of HARDINESS has been linked to burnout?

A. less commitment to work C. a sense of control over the patient B. perception of change D. sense of control to life 38. Nurses who work with critically ill patients should base their practice on all of the following EXCEPT: A. recognition and appreciation of a persons unique and social environmental relationships B. delegated responsibility C. thorough knowledge of the interrelatedness of body system D. appreciation of the collaborative role of all health team members 39. Common aspects of the critical care nursing role include: A. disaster management C. direct care provider B. staff liaison D. community referral 40. Which of the following interventions would support your patients circadian rhythm cycle? A. putting a wall clock up on your patients room B. decreasing environmental noise C. encouraging normal bowel movement D. dimming light during normal sleeping time Situation 9: To ensure continuity of care and for legal purposes, you have important responsibilities to accurately document all nursing activities. 41. For the past 24 hours, TD with dry skin and dry mucous membranes has had a urine output of 600 m and a fluid intake of 800 ml. TDs urine is dark amber. These assessments indicate which nursing diagnosis? A. Impaired urinary elimination C. Excessive fluid volume B. Deficient fluid volume D. Imbalanced nutrition: less than body requirement 42. Which document addresses the patients right to information, informed consent and treatment refusal? A. Code for Nurses C. Patients Bill of Rights B. Nursing Practice Act D. Standard of Nursing Practice

43. You are caring for GG with a history of falls. The FIRST PRIORITY when caring for GG who is at risk for falls is: A. instruct GG not to get out of bed unassisted B. keep the bedpan available so she does not have to get out of bed C. placing the call light for easy access D. keep the bed at the lowest position ever 44. Shortly after being admitted to the CCU for acute MI, JJ reports midsternal chest pain radiating down the left arm. You notice that JJ is restless, slightly diaphoretic, and has a temperature of 37.8 deg C, heart rate of 10 beats/min.; regular, slightly labored respirations at 26 breaths/min and a blood pressure of 150/90 mmHg. Which nursing diagnosis takes HIGHEST PRIORITY? A. decreased cardiac output C. acute pain B. anxiety D. risk for imbalanced body temperature 45. FF, has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. Whats the correct written client outcome for this diagnosis? A. FF states the importance of eating potassium rich foods daily B. Upon discharge, FF knows which food sources are rich in potassium C. Upon discharge, FF correctly identifies three potassium rich foods D. FF knows all the complications of the disease process Situation 10: You are taking care of LC who develops acute respiratory distress. An endotracheal tube had to be inserted to correct the hypoxia. 46. The primary purpose of the endotracheal tube cuff is to: A. seal off the oropharynx from the nasopharynx C. seal off the oropharynx from the esophagus B. seal off the lower airway from the esophagus D. seal off the lower airway from the upper airway 47. Endotracheal tube size indicated on the tube reflects what measurements: A. the circumference size of the tube C. the internal diameter of the tube B. the length of the tube D. the length of the persons airway

48. In adults, an inflated E-T tube cuff is necessary for mechanical ventilation primarily because: A. it seals off the lower airway from the upper airway B. it prevents air from getting into the stomach C. it seals off the nasopharynx from the oropharynx D. it prevents stomach contents from getting into the lungs 49. Endotracheal tube size indicated on the tube reflects what measurements: A. the internal diameter of the tube C. the circumference size of the tube B. the length of the persons airway D. the length of the tube 50. Which of the following statements is TRUE about securing the artificial airway? A. artificial airways must be secured directly to the patient B. the airway is generally sutured in place C. a nasotracheal tube does not require securing D. the inflated cuff provides sufficient securing Situation 11: Because of the serious effects of severe burns, management requires a multidisciplinary approach. You have important responsibilities as a nurse. 51. When caring for DS, who sustained 40% severe flame burn yesterday, which among these interventions should be your PRIORITY? A. provide a calm, efficient and safe environment B. keep the body parts in good alignment to prevent contractures C. assess for airway, breathing and circulation problems D. assess the injury for signs of sepsis 52. Your primary therapeutic goal for DS during the ACUTE PHASE is: a. wound healing c. emotional support b. reconstructive surgery d. fluid resuscitation 53. CV who sustained upper torso and neck burns. Which action is MOST likely to cause a functional contracture?

a. hourly hyperextension neck exercises b. helping the patient to a position of comfort c. encouraging self-care d. discouraging pillows behind the head 54. AW, 3 year old boy just sustained full thickness burns of the face, chest and neck. What will be your PRIORITY nursing action? a. Risk for infection related to epidermal disruption b. Impaired urinary elimination related to fluid loss c. Ineffective airway clearance related to edema d. Impaired body image related to physical appearance 55. FG, with a full thickness burns involving entire circumference of an extremity will require frequent peripheral vascular checks to detect: a. hypothermia c. arteriosclerotic changes b. ischemia d. adequate wound healing Situation 12: Infection can cause debilitating consequences when hosts resistance is compromised and environmental factors are favorable. As a nurse you have important roles and responsibilities in infection control. 56. EF was admitted to the hospital with a tentative diagnosis of acute pyelonephritis. To assess her risk factors, what question should you ask? a. Have you taken any analgesic recently? b. Do you have pain at your back? c. Do you hold your urine for a long time before voiding? d. Have you had any sore throat lately? 57. While caring for a patient with an infected surgical incision, you observe for signs of systemic response. These include all of the following EXCEPT: a. a febrile state due to release of pyrogens b. anorexia, malaise, and weakness c. loss of appetite and pain d. leukopenia due to increased WBC production

58. One of the MOST effective nursing procedures for reducing nosocomial infection is: a. proper handwashing technique b. aseptic wound care c. control of upper respiratory tract infection d. administration of prophylactic antibiotic 59. A wound that has hemorrhaged has increased risk for infection because: a. dead space and dead cells provide a culture medium b. retrograde bacterial contamination may occur c. the tissue becomes less resilient d. of reduced amounts of oxygen and nutrients are available 60. You are instructing EP regarding skin tests for hypersensitivity reactions. You should teach her to: a. stay out of the sun until the skin tests are read b. come back on the specified date to have the skin tests read c. wash skin test areas with soap and water daily d. keep skin test areas moist with mild lotion. Situation 13: TR attends a Health Education Class on colostomy care. The following are taken up: types of ostomies, indications and care. 61. A colostomy can BEST be defined as: a. cutting the colon and bringing the proximal end through the abdominal wall b. creating a stomal orifice from the ileum c. excising a section of the colon and doing an end-to-end anastomosis d. removing the rectum and suturing the colon to the anus. 62. When an abdominoperineal resection is done, the patient should be informed he/she will have a; a. temporary colostomy c. transverse loop colostomy

b. permanent colostomy d. double-barreled 63. A colostomy patient who wishes to avoid flatulence should not eat the following EXCEPT: a. corn and peanuts c. mangoes and pineapples b. cabbage and asparagus d. chewing gum and carbonated beverages 64. During the first post operative week, the nurse can BEST help the patient with a colostomy to accept the change in body image by: a. changing the dressing just prior to meals b. encouraging the patient to observe the stoma and its care c. deodorizing the room periodically with a spray can d. applying a large bulky dressing over the stoma to decrease odors Situation 14: These are gastrointestinal disease that can compromise life and that would necessitate extensive surgical management. You are assigned to take care of a patient with such a condition. 66. BC diagnosed with cancer of the sigmoid colon is to have an abdominoperineal resection with a permanent colostomy. Before surgery, a low residue diet is ordered. You explain to BC that this is necessary to: a. prevent irritation of the intestinal mucosa b. reduce the amount of stool in the large bowel c. limit production of flatus in the intestines d. lower the bacterial count in the GI tract 67. Several days prior to bowel surgery, the patient may be given sulfasuxidine and neomycin, primarily to: a. soften the stool by retaining water in the colon b. reduce the bacterial content of the colon c. empty the bowel of solid waste d. promote rest of the bowel by minimizing peristalsis 68. To promote perineal wound healing after an abdominoperineal resection, you should encourage BC to assume: a. dorsal recumbent position

b. left or right Sims position c. left or right side lying position d. knee-chest position 69. BC returns from surgery with a permanent colostomy. During the 24 hours, the colostomy does not drain. You, as the nurse should realize that this is a result of: a. the absence of intestinal motility b. a presurgical decrease in fluid intake c. proper functioning of the nasogastric tube d. intestinal edema following surgery 70. On the second day following abdominoperineal resection, you anticipate that the colostomy stoma will appear: a. moist, pink, with flushed skin and painful when touched b. moist, red and raised above the skin surface c. dry, pale pink and with flushed skin d. dry, purple and depressed below the skin surface Situation 15: Specific surgical interventions may be done when lung cancer is detected early. You have important peri-operative responsibilities in caring for patients with lung cancer. 71. GM is scheduled to have lobectomy. The purpose of closed chest drainage following a lobectomy is: a. expansion of the remaining lung b. facilitation of coughing c. prevention of mediastinal shift d. promotion of wound healing 72. Following thoracic surgery, you can BEST help GM to reduce pian during the deep breathing and coughing exercises by: a. splinting the patients chest with both hands during the exercises b. administering the prescribed analgesic immediately prior to exercises c. providing rest for 6 hours before exercises

d. placing the patient on his/her operative side during exercises 73. During the immediate post operative period following a pneumonectomy, deep tracheal suction should be done with extreme caution because: a. the remaining normal lung needs minimal stimulation b. the patient will not be able to tolerate coughing c. the tracheobronchial tree are dry d. the bronchial suture line maybe traumatized 74. What should you do as a nurse when the chest tubing is accidentally disconnected? a. reconnect the tube c. notify the physician b. change the tubing d. clamp the tubing 75. Which of the following observations indicates that the closed chest drainage system is functioning properly? a. less than 25 ml drainage in the drainage bottle b. absence of bubbling in the suction-control bottle c. the fluctuating movement of fluid in the long tube of the water-seal bottle during inspiration d. intermittent bubbling through the long tube of the suction control bottle. Situation 16: Renal stones can cause one of the most excruciating pain experienced by a patient. As a nurse of BL which of the following nursing diagnosis will be your PRIORITY? 76. BL was brought to the Emergency Room for severe left flunk pain, nausea and vomiting. The physician gave a tentative diagnosis of right ureterolithiasis. As the nurse of BL which of the following nursing diagnosis will be your PRIORITY? a. imbalance nutrition: less than body requirements b. impaired urinary elimination c. acute pain d. risk for infection 77. Which of the following is the appropriate intervention for BL who has ureterolithiasis?

a. inserting an indwelling urinary catheter b. administering opioid analgesics preferably intravenously c. administering intravenous solution at a keep vein open rate d. inserting a nasogastric tube (low suction) 78. You are caring for YA, 30 year old business woman, with renal stones. Her skin and mucous membranes are dry and her 24 hour intake and output record reveal an oral intake of 900 ml and a urinary output of 700 ml. Her urine is dark amber. Based on the above data, your nursing diagnosis is: a. imbalance nutrition, less than body requirements b. fluid volume deficit c. impaired urinary elimination d. knowledge deficit regarding health 79. KJ has an indwelling urinary catheter and she is suspected of having urinary infection. How should you collect a urine specimen for culture and sensitivity? a. clump tubing for 60 minutes and insert a sterile needle into the tubing above the clamp to aspirate urine b. drain urine from the drainage bag into the sterile container c. disconnect the tubing from the urinary catheter and let urine flow into a sterile container d. wipe the self-sealing aspiration port with antiseptic solution and aspirate urine with a sterile needle 80. You are caring for WE, a 56 year old man who is dehydrated and with urinary incontinent. Upon physical examination, you noted perineal excoriation. What will be your PRIORITY intervention? a. orient him to time, person and place b. offer the bed pan every 4 hours c. encourage oral fluid intake d. keep the perineal area clean, and dry Situation 17: You are caring for several patients with various disease problems. 81. You are obtaining a history of MR. who is admitted with acute chest pain. Which question will be MOST HELPFUL for you to ask?

a. Why do you think you had a heart attack? b. Do you need anything now? c. What seem you doing when the pain started? d. Has anyone in your family been sick lately? 82. BO who received general anesthesia returns from surgery. Post-operatively, which nursing diagnosis takes HIGHEST PRIORITY for BO? A. impaired physical mobility related to surgery B. decrease fluid volume related to blood and fluid loss from surgery C. risk for infection related to anesthesia D. acute pain related to surgery 83. WW is blind. She is admitted for treatment of gastroenteritis. Which nursing diagnosis takes HIGHEST PRIORITY for WW? A. anxiety C. activity intolerance B. risk for injury D. impaired physical mobility 84. You are documenting your care for CC who has iron deficiency anemia. Which nursing diagnosis is MOST appropriate? A. ineffective breathing pattern C. deficient fluid volume B. impaired gas exchange D. ineffective airway clearance 85. RR, age 89, has terminal cancer, he demonstrates signs of dementia. You should give HIGHEST PRIORITY to which nursing diagnosis: A. risk for injury C. ineffective cerebral tissue perfusion B. bathing or hygiene self care deficit D. dysfunctional grieving Situation 18: The physician has ordered 3 units of whole blood to be transfused to WQ following a repair of a dissecting aneurysm of the aorta. 86. You are preparing the first unit of whole blood for transfusion. From the time you obtain it from the blood bank, how long should you infuse it? A. 6 hours C. 4 hours B. 1 hour D. 2 hours 87. What should you do FIRST before you administer blood transfusion?

A. verify client identity and blood product, serial number, blood type, cross matching results, expiration date B. verify client identity and blood product serial number, blood type, cross matching results, expiration date with another nurse C. check IV site and use appropriate BT set and needle D. verify physicians order 88. As WQs nurse, what will you do AFTER the transfusion has started? A. add the total amount of blood to be transfused to the intake and output B. discontinue the primary IV of Dextrose 5% Water C. check the vital signs every 15 minutes D. stay with WQ for 15 minutes to note for any possible BT reactions 89. WQ is undergoing blood transfusions of the first unit. The EARLIEST signs of transfusion reactions are: A. oliguria and jaundice C. hypertension and flushing B. urticaria and wheezing D. headache, chills, fever 90. In case WQ will experience an acute hemolytic reaction, what will be your PRIORITY intervention? A. immediately stop the blood transfusion, infuse Dextrose 5% in Water and call the physician B. stop the blood transfusion and monitor the patient closely C. immediately stop the BT, infuse NSS, call the physician, notify the blood bank D. immediately stop the BT, notify the blood bank and administer antihistamines Situation 19. The kidneys have very important excretory, metabolic, erythropoietic functions. Any disruptions in the kidneys functions can cause disease. As a nurse it is important that you understand the rationale behind the treatment regimen used. 91. PL, who is in acute renal failure, is admitted to the Nephrology Unit. The period of oliguria usually lasts for about 10 days. Which assessment parameter for kidney function will you use during the oliguric phase? A. urine output directly related to the amount of IV fluid infused

B. urine output is less than 400 ml/24 hours C. urine output of 30-60 ml/hour D. no urine output, kidneys in a state of suspension 92. During the shock phase, what is the effect of the rennin-aldosterone-angiotensin system on renal function? A. increased urine output, increased absorption of sodium and water B. decreased urine output, decreased absorption of sodium and water C. increased urine output, decreased absorption of sodium and water D. decreased urine output, increased absorption of sodium and water 93. As you are caring for PL who has acute renal failure, one of the collaborative interventions you are expected to do is to start hypertonic glucose with insulin infusion and sodium bicarbonate to treat: A. hyperkalemia C. hypokalemia B. hypercalcemia D. hypernatremia 94. BN, 40 year old with chronic renal failure. An arteriovenous fistula was created for hemodialysis in his left arm. What diet instructions will you need to reinforce prior to his discharge? A. drink plenty of water C. monitor your fruit intake and eat plenty of bananas B. restrict your salt intake D. be sure to eat meat every meal 95. BN, is also advised not to use salt substitute in the diet because: A. salt substitute contain potassium which must be limited to prevent arrhythmias B. limiting salt substitutes in the diet prevents a buildup of waste products in the blood C. fluid retention is enhanced when salt substitutes are included in the diet D. a substance in the salt substitute interferes with fluid transfer across the capillary membrane Situation 20. You are assigned to take care of a group of elderly patients. Pain and urinary incontinence are common concerns experienced by them. You should be able to address the concerns in a holistic manner. 96. Pain in the elder persons require careful assessment because they:

A. experienced reduce sensory perception B. have increased sensory perception C. are expected to experience chronic pain D. have a decreased pain threshold 97. Administration of analgesics to the older persons requires careful patient assessment because older people: A. are more sensitive to drugs B. have increased hepatic, renal and gastrointestinal function C. have increased sensory perception D. mobilize drugs more rapidly 98. The elderly patient is at higher risk for urinary incontinence because of: A. increased glomerular filtration C. decreased bladder capacity B. diuretic use D. dilated urethra 99. Which of the following is the MOST COMMON sign of infection among the elderly? A. decreased breath sounds with crackles C. pain B. fever D. change in mental status 100. Priorities when caring for the elderly trauma patient: A. circulation, airway, breathing C. airway, breathing, disability (neurologic) B. disability (neurologic), airway, breathing D. airway, breathing, circulation

Nursing Board Exam Practice 5 some of the question came from December 2006 nursing Board exam. NURSING CARE OF CLIENT WITH PHYSIOLOGICAL AND PSYCHOSOCIAL ALTERATIONS Situation : The patient who is depressed will undergo electroconvulsive therapy. 1. Studies on biological depression support electroconvulsive therapy as a mode of treatment. The rationale is: A. ECT produces massive brain damage which destroys the specific area containing memories related to the events surrounding the development of psychotic condition

B. The treatment serves as a symbolic punishment for the client who feels guilty and worthless C. ECT relieves depression psychologically by increasing the norepinephrine level D. ECT is seen as a life-threatening experience and depressed patients mobilize all their bodily defenses to deal with this attack. 2. The preparation of a patient for ECT ideally is MOST similar to preparation for a patient for: A. electroencephalogram B. X-ray C. general anesthesia D. electrocardiogram

3. Which of the following is a possible side effect which you will discuss with the patient? A. hemorrhage within the brain C. encephalitis B. robot-like body stiffness D. confusion, disorientation and short term memory loss 4. Informed consent is necessary for the treatment for involuntary clients. When this cannot be obtained, permission may be taken from the: A. social worker B. doctor C. next of kin or guardian D. chief nurse

5. After ECT, the nurse should do this action before giving the client fluids, food or medication: A. assess the gag reflex B. assess the sensorium C. next of kin or guardian D. check O2 Sat with a pulse oximeter

Situation : The community health nurse encounters special children in the community. 6. An individual with antisocial personality disorder lacks remorse, shame and guilt in going against the norms of society. Psychodynamically, this defect in the personality reflects a disturbance of the: A. ego B. super ego C. ego ideal D. id

7. The nurse teaches parents about childrens beginning concepts of right and wrong by emphasizing child rearing attitude and practices during the: A. school age B. toddler age C. infancy period D. latency period

8. It is BEST for parents to teach healthy interpersonal relationships to their children by: A. modeling to their children B. encouraging their children to attend secondary school C. encouraging their children at home to behave properly D. teaching their children good manners and right conduct 9. An important principle for the nurse to follow in interacting with retarded children is: A. seen that if the child appears contented, his needs are being met B. provide an environment appropriate to their development task as scheduled C. treat the child according to his chronological age D. treat the child according to his developmental level 10. Mental retardation is: A. a delay in normal growth and development caused by an inadequate environment B. a lack of development of sensory abilities C. a condition of subaverage intellectual functioning that originates during the developmentalperiod and is associated with impairment in adaptive behavior D. a severe lag in neuromuscular development and motor abilities Key Answer 1. 2. 3. 4. 5. C C D C A 6. B 7. B 8. A 9. D 10. C

1.) It is important for the nurse to teach the client that metformin- Glucophage: A.) May cause nocturia B.) Should be taken at night C.) Should be taken with meals D.) May increase the effects of aspirin ANSWERS: C. Should be taken with meals 2.) A nurse assessing a client with SIADH would expect to find laboratory values of:

A.) Serum Na= 150 mEq/L and low urine osmolality B.) Serum K= 5 mEq/L and low serum osmolality C.) Serum Na=120 mEq/L and low serum osmolality D.) Serum K= 3 mEq/L and high serum osmolality ANSWERS: C. Serum Na=120 mEq/L and low serum osmolality 3.) A priority nursing diagnostic for a client admitted to the hospital with a diagnosis of diabetes insipidus is: A.) Sleep pattern deprivation related nocturia B.) Activity intolerance r/t muscle weakness C.) Fluid volume excess r/t intake greater thatoutput D.) Risk for impaired skin integrity r/t generalized edema ANSWERS: B Activity intolerance r/t muscle weakness 4.) A client admitted with a pheochrocytoma returns from the operating room after adrenalectomy. The nurse should carefully assess this client for: A.) Hypokalemia B.) Hyperglycemia C.) Marked Na and water intake D.) Marked fluctuations in BP ANSWERS: D Marked fluctuations in BP 5.) When caring for client in thyroid crisis, the nurse would question an order for: A.) IV fluid B.) Propanolol (Inderal) C.) Prophylthiouracil D.) A hyperthermia blanket ANSWERS: D hyperthermia blanket 6.) A child is scheduled for a myringotomy. What goal of this procedure will the nurse discuss with the parents? A.) Promote drainage from the ear B.) Irrigate the Eustachian tube C.) Correct a malformation in the inner ear D.) Equalize pressure on the tympanic membrane ANSWERS: A.Promote drainage from the ear

7.) After a clients eye has been anesthetized, what instructions will be important for the nurse to give the client? A.) Do not watch TV for at least one day B.) Do not rub the eye for 15-20 minutes C.) Irrigate the eye every hour to prevent dryness D.) Wear sunglasses when in direct sunlight for the next 6 hours ANSWERS : B. Do not rub the eye for 15-20 minutes 8.) A child diagnosed with conjunctivitis. Which statement reflects that the child understood the nurses teaching? A.) Its okay for me to let my friends use my sunglasses while we are playing together. B.) Its okay for me to softly rub my eye, as long as I use the back of my hand. C.) I can pick the crustly stuff out of my eyelashes with my fingers when I wake up in the morning. D.) I will use my own washrag and towel while my eyes are sick. ANSWERS : D I will use my own washrag and towel while my eyes are sick. 9.) What medication would the nurse anticipate giving a client with Menieres dse? A.) Nifedipine B.) Amoxicillin C.) Propanolol D.) Hydrochloride (Hydro DIURIL) ANSWERS: D. Hydrochloride (Hydro DIURIL) 10.) The nurse would question the administration of which eye drop in a patient with increased ICP? A.) Artificial tears B.) Betaxolol (Betoptic) C.) Acetazolamide (Diamox) D.) Epinephrine HCL (Epirate ANSWERS: D Epinephrine HCL (Epirate)