ANSWERS 1) B - The nurse administering the dose should have compared the MAR with the Kardex and

noted the discrepancy. The transcribing nurse and pharmacist aren't void of responsibility; however, the nurse administering the dose is most responsible. The facility's policy does provide for a system of checks and balances. Therefore, the facility isn't responsible for the error. 2) C - The purpose of deep palpation, in which the nurse indents the client's skin approximately 1" (3.8 cm), is to assess underlying organs and structures, such as the kidneys and spleen. Skin turgor, hydration, and temperature can be assessed by using light touch or light palpation 3) D Nursing Fundamentals Questions Rationale: When giving an I.M. injection, the nurse inserts the needle into the muscle at a 90-degree angle, using a quick, dartlike motion. A 15-degree angle is appropriate when administering an intradermal injection. A 30-degree angle isn't used for any type of injection. A 45- or 90-degree angle can be used when giving a subcutaneous injection 4) C - A client age 40 to 49 with no family history of breast cancer or other risk factors for this disease should have a mammogram every 2 years. After age 50, the client should have a mammogram every year 5) C - In Maslow's hierarchy of needs, pain relief is on the first layer. Activity (option B) is on the second layer. Safety (option D) is on the third layer. Love and belonging (option A) are on the fourth layer. 6) D - Sleeping undisturbed for a period of time would indicate that the client feels more relaxed, comfortable, and trusting and is less anxious. Decreasing eye contact, asking to see family, and joking may also indicate that the client is more relaxed. However, these also could be diversions. 7) A - A living will states that no life-saving measures are to be used in terminal conditions. There is no indication that the client is terminally ill. Furthermore, a living will doesn't apply to nonterminal events such as choking on an enteral feeding device. The nurse should clear the client's airway. Making the client comfortable ignores the life-threatening event. Cardiopulmonary resuscitation isn't indicated, and removing the NG tube would exacerbate the situation 8) D - Although the client should eat a balanced diet with foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk, because protein helps build and repair body tissue, which promotes healing. Fundamentals in nursing teaches that legumes provide incomplete protein. Cheese contains complete protein, but also fat, which should be limited to 30% or less of caloric intake. Whole grain products supply incomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates. 9) C - A client with renal failure can't eliminate sufficient fluid, increasing the risk of fluid overload and consequent respiratory and electrolyte problems. This client has signs of excessive fluid volume and is acutely ill. Fear and a toileting self-care deficit may be problems, but they take lower priority because they aren't life-threatening. Urinary retention may cause renal failure but is a less urgent concern than fluid imbalance. 10) B - The client is at risk for infection because the WBC count is dangerously low. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate. 1) C - R.A. 7305 is the Magna Carta for the Public Health Workers with objectives to promote and

improve the social and economic well-being of health workers; develop their skills and capabilities; and encourage those qualified and with abilities to remain in government service.APhilippine Medical Act B- Midwifery Law D- Dangerous Drug Act 2) D - Qualifications to be a member of the Board of Nursing are;(1) be a citizen and resident of the Philippines; (2) be a member in good standing of the accredited national nurses association; (3) be a RN and holder of a masters degree in Nursing conferred by a college or university duly recognized by the government; (4) have at least 10 years of continuous practice of nursing prior to appointment; (5) not a holder of a green card or its equivalent; and (6) not have been convicted of any offense involving moral turpitude even if previously extended pardon by the President of the Philippines. 3) A - Incident report is a record of an accident or incident. This report is used to make all facts about an accident available to agency personnel, to contribute to statistical data about accidents and incidents, and to help personnel prevent future accidents. All accidents are usually reported on incident forms. The report should be completed within 24 hours of the incident. 4) C - Before any medical or surgical procedure can be performed on a patient, consent must be obtained from the patient or his authorized representative. It is only in emergency cases that consent requirement does not apply. The intentional touching or unlawful beating of another person without authorization to do so is a legal wrong called battery. 5) A - The essential elements of an informed consent include (1) the consent must be given voluntarily; (2) the consent must be given by an individual with the capacity and competence to understand; (3) the client must be given enough information to be an ultimate decision maker. 6) C - Philippine Nursing Act of 1991 section 28 states in the administration of intravenous injections, special training shall be required according to a protocol established. Nurses should use the Intravenous Nursing Standards of Practice developed by the Association of Nursing Service Administration of the Philippines (ANSAP). 7) C - R.A. 2382 is the Philippine Medical Act that defines the practice of medicine. R.A. 1612 is the Profession Tax or Omnibus Tax that states to pay P50.00 on or before January 31 of every year. Exempted are those working in the government agencies. R.A. 1082 is the Rural Health Act. 8) C - PD 996 requires compulsory immunization for all children below 8 years old against communicable diseases.A- Presidential proclamation of a Nurses Week (last week of October of very year beginning in 1958).B-Seniors Citizens Act D- Amended RA 679 (women and Child Labor Law) stating the employable age shall be 16 years old. It also provided aside from the minimum employable age, the privileges of a working woman. 9) D - Principal sources of these pronouncements are (1) the constitution; (2) the statues or legislations; (3) regulations issued by the Executive branch of the government; (4) case decisions or judicial opinions, (5) Presidential decrees; (6) Letters of instructions 10) D - R.A. 2382-is the Philippine Medical Act that defines the practice of medicine. R.A. 1612 is the Profession Tax or Omnibus Tax that states to pay P50.00 on or before January 31 of every year. Exempted are those working in the government agencies? R.A. 6111 is the Philippine Medical Care Act that states "all government employees covered by SSS and GSIS are given hospitalization privileges. 1) B - Hemorrhage and shock are the most common complications after abdominal aortic aneurysm resection. Renal failure can occur as a result of shock or from injury to the renal arteries during

surgery. Graft occlusion and enteric fistula formation are rare complications of abdominal aortic aneurysm repair. 2) A - Common signs and symptoms of cardiovascular dysfunction include shortness of breath, chest pain, dyspnea, palpitations, fainting, fatigue, and peripheral edema. Insomnia seldom indicates a cardiovascular problem. Although irritability may occur if cardiovascular dysfunction leads to cerebral oxygen deprivation, this symptom more commonly reflects a respiratory or neurologic dysfunction. Lower substernal abdominal pain occurs with some GI disorders. 3) D - Answer to this cardiovascular nursing questions - Controllable risk factors include hypertension, hypercholesterolemia, obesity, lack of exercise, smoking, diabetes, stress, alcohol abuse, and use of contraceptives. Uncontrollable risk factors for coronary artery disease include gender, age, and heredity. 4) B - This client's findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenic shock also may cause cold, clammy skin and generalized weakness, fatigue, and muscle pain as lactic acid accumulates from poor blood flow, preventing waste removal. Left-sided and right-sided heart failure eventually cause venous congestion with jugular vein distention and edema as the heart fails to pump blood forward. A ruptured aneurysm causes severe hypotension and a quickly deteriorating clinical status from blood loss and circulatory collapse; this client has low but not severely decreased blood pressure. Also, in ruptured aneurysm, deterioration is more rapid and full cardiac arrest is common. 5) C - Furosemide is a potassium-wasting diuretic. The nurse must monitor the serum potassium level and assess for signs of low potassium. As water and sodium are lost in the urine, blood pressure decreases, blood volume decreases, and urine output increases. 6) B - Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema. In right-sided heart failure, the client would exhibit hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia. 7) D - TIAs are considered forerunners of cerebrovascular accident (CVA). Because CVAs may result from clots in cerebral vessels, aspirin is prescribed to prevent clot formation by reducing platelet agglutination. A 325-mg dose of aspirin is inadequate to relieve headache pain in an adult. Aspirin has no effect on the body's immune response. Intracranial bleeding isn't associated with TIAs, and the action of aspirin probably would worsen any bleeding present. 8) A - For a client recovering from CABG surgery, Decreased cardiac output is the most important nursing diagnosis because myocardial function may be depressed from anesthetics or a long cardiopulmonary bypass time, leading to decreased cardiac output. Other possible causes of decreased cardiac output in this client include fluid volume deficit and impaired electrical conduction. The nurse exam other options may be relevant but take lower priority at this time because maintaining cardiac output is essential to sustaining the client's life. 9) C - The risk factors for coronary artery disease that can be controlled or modified include obesity, inactivity, diet, stress, and smoking. Gender and family history are risk factors that can't be controlled. 10) B - Because bleeding gums are an adverse effect of heparin that may indicate excessive anticoagulation, the nurse should notify the physician, who will evaluate the client's condition. Laboratory tests, such as partial thromboplastin time, should be performed before concluding

that the client's bleeding is significant. The prescribed heparin dose may be therapeutic rather than excessive, so the nurse shouldn't discontinue the heparin infusion, unless the physician orders this after evaluating the client. Protamine sulfate, not a coumarin derivative, is given to counteract heparin. Bleeding gums aren't a normal effect of heparin. 1) D - Cryptorchidism (failure of one or both testes to descend into the scrotum) appears to play a role in testicular cancer, even when corrected surgically. Other significant history findings for testicular cancer include mumps orchitis, inguinal hernia during childhood, and maternal use of diethylstilbestrol or other estrogen-progestin combinations during pregnancy. Testosterone therapy during childhood, sexually transmitted disease, and early onset of puberty aren't risk factors for testicular cancer. 2) A - The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung, bone, and brain. The colon, reproductive tract, and WBCs are occasional metastasis sites. 3) A - Persistent hoarseness may signal throat cancer, which commonly is associated with tobacco use. To assess the client's risk for throat cancer, the nurse should ask about smoking habits. Although straining the voice may cause hoarseness, it wouldn't cause hoarseness lasting for 1 month. Consumption of red meat or spicy foods isn't associated with persistent hoarseness. 4) C - Presence of Bence Jones protein in the urine almost always confirms the disease, but absence doesn't rule it out. Serum calcium levels are elevated because calcium is lost from the bone and reabsorbed in the serum. Serum protein electrophoresis shows elevated globulin spike. The serum creatinine level may also be increased. 5) D - Kaposi's sarcoma is the most common cancer associated with AIDS. Squamous cell carcinoma, multiple myeloma, and leukemia may occur in anyone and aren't associated specifically with AIDS. 6) C - The nurse has a moral and professional responsibility to advocate for clients who experience decreased independence, loss of freedom of action, and interference with their ability to make autonomous choices. Coordinating a meeting between the physician and family members may give the client an opportunity to express his wishes and promote awareness of his feelings as well as influence future care decisions. All other options are inappropriate. 7) B - The incidence of ovarian cancer increases in women who have never been pregnant, are over age 40, are infertile, or have menstrual irregularities. Other risk factors include a family history of breast, bowel, or endometrial cancer. The risk of ovarian cancer is reduced in women who have taken oral contraceptives, have had multiple births, or have had a first child at a young age. 8) D - The correct nurse test questions answer is: Men can develop breast cancer, although they seldom do. The most reliable method for detecting breast cancer is monthly self-examination, not mammography. Lung cancer causes more deaths than breast cancer in women of all ages. A mastectomy may not be required if the tumor is small, confined, and in an early stage. 9) B - A fixed nodular mass with dimpling of the overlying skin is common during late stages of breast cancer. Many women have slightly asymmetrical breasts. Bloody nipple discharge is a sign of intraductal papilloma, a benign condition. Multiple firm, round, freely movable masses that change with the menstrual cycle indicate fibrocystic breasts, a benign condition. 10) C - Fine needle aspiration and biopsy provide cells for histologic examination to confirm a diagnosis of cancer. A breast self-examination, if done regularly, is the most reliable method for

detecting breast lumps early. Mammography is used to detect tumors that are too small to palpate. Chest X-rays can be used to pinpoint rib metastasis. 1) B - An acute addisonian crisis is a life-threatening event, caused by deficiencies of cortisol and aldosterone. Glucocorticoid insufficiency causes a decrease in cardiac output and vascular tone, leading to hypovolemia. The client becomes tachycardic and hypotensive and may develop shock and circulatory collapse. The client with Addison's disease is at risk for infection; however, reducing infection isn't a priority during an addisonian crisis. Impaired physical mobility is also an appropriate nursing diagnosis for the client with Addison's disease, but it isn't a priority in a crisis. Imbalanced nutrition: Less than body requirements is also an important nursing diagnosis for the client with Addison's disease but not a priority during a crisis. 2) C - A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest. Many clients with hyperthyroidism are hyperactive and complain of feeling very warm. Consequently, it's important to keep the environment cool and to teach the client how to manage his physical reactions to heat. Clients with hypothyroidism not hyperthyroidism complain of being cold and need warm clothing and blankets to maintain a comfortable temperature. They also receive thyroid replacement therapy, often feel lethargic and sluggish, and are prone to constipation. The nurse should encourage clients with hypothyroidism to be more active to prevent constipation. 3) B - Endocrine System Practice Tests Answer - Diabetic clients must exercise at least three times a week to meet the goals of planned exercise lowering the blood glucose level, reducing or maintaining the proper weight, increasing the serum high-density lipoprotein level, decreasing serum triglyceride levels, reducing blood pressure, and minimizing stress. Exercising once a week wouldn't achieve these goals. Exercising more than three times a week, although beneficial, would exceed the minimum requirement. 4) D - To control hypoglycemic episodes, the nurse should instruct the client to consume a lowcarbohydrate, high-protein diet, avoid fasting, and avoid simple sugars. Increasing saturated fat intake and increasing vitamin supplementation wouldn't help control hypoglycemia. 5) A - Excessive secretion of aldosterone in the adrenal cortex is responsible for the client's hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium and excretion of potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel metabolism. The adrenal medulla secretes the catecholamines epinephrine and norepinephrine. The parathyroids secrete parathyroid hormone. 1) C - Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes on the blood. Vomitus associated with upper GI tract bleeding commonly is described as coffee-ground-like. Clay-colored stools are associated with biliary obstruction. Bright red stools indicate lower GI tract bleeding. 2) C - In ascites, accumulation of large amounts of fluid causes extreme abdominal distention, which may put pressure on the diaphragm and interfere with respiration. If uncorrected, this may lead to atelectasis or pneumonia. Although fluid volume excess is present, the diagnosis Ineffective breathing pattern takes precedence because it can lead more quickly to life-threatening consequences. The nurse can deal with fatigue and altered nutrition after the client establishes and maintains an effective breathing pattern. 3) C - Ulcerative colitis is more common in people who have family members with the disease. (The same is true of some types of GI cancers, ulcers, and Crohn's disease.) Hepatitis, iron deficiency anemia, and chronic peritonitis are acquired disorders that don't run in families. 4) C - The nurse should collect the stool specimen using sterile technique and a sterile stool

container. The stool may be collected for 3 consecutive days; no follow-up care is needed. Although a stool culture should be taken to the laboratory as soon as possible, it need not be delivered immediately (unlike stool being examined for ova and parasites). Applying a solution to a stool specimen would contaminate it; this procedure is done when testing stool for occult blood, not organisms. The nurse shouldn't store a stool culture on ice because the abrupt temperature change could kill the organisms. 5) D - The RUQ contains the liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of the colon, portions of the ascending and transverse colon, and a portion of the right kidney. The sigmoid colon is located in the left lower quadrant; the appendix, in the right lower quadrant; and the spleen, in the left upper quadrant. 6) A - Any hole, no matter how small, will destroy the odor-proof seal of a drainage bag. Removing the bag or unclamping it is the only appropriate method for relieving gas. 7) B - Hepatic encephalopathy, a major complication of advanced cirrhosis, occurs when the liver no longer can convert ammonia (a by-product of protein breakdown) into glutamine. This leads to an increased blood level of ammonia a central nervous system toxin which causes a decrease in the level of consciousness. Fatigue, muscle weakness, nausea, anorexia, and weight gain occur during the early stages of cirrhosis. 8) B - Nursing Board Exams Rationale - Appendicitis most commonly results from obstruction of the appendix, which may lead to rupture. A high-fat diet or duodenal ulcer doesn't cause appendicitis; however, a client may require dietary restrictions after an appendectomy. 9) B - The large intestine normally contains bacteria because its alkaline environment permits growth of organisms that putrefy and break down remaining proteins and indigestible residue. These organisms include Escherichia coli, Aerobacter aerogenes, Clostridium perfringens, and Lactobacillus. Although bowel resection with anastomosis is considered major surgery, it poses no greater risk of infection than any other type of major surgery. Malnutrition seldom follows bowel resection with anastomosis because nutritional absorption (except for some water, sodium, and chloride) is completed in the small intestine. An NG tube is placed through a natural opening, not a wound, and therefore doesn't increase the client's risk of infection. 10) B - Prothrombin synthesis in the liver requires vitamin K. In cirrhosis, vitamin K is lacking, precluding prothrombin synthesis and, in turn, increasing the client's PT. An increased PT, which indicates clotting time, increases the risk of bleeding. Therefore, the nurse should expect to administer phytonadione (vitamin K1) to promote prothrombin synthesis. Spironolactone and furosemide are diuretics and have no effect on bleeding or clotting time. Warfarin is an anticoagulant that prolongs PT. 1) C - When caring for a client, the nurse must first wash her hands. Putting on gloves, removing the dressing, and observing the drainage are all parts of performing a dressing change after hand washing is completed. 2) B - Wrapping elastic bandages on dependent areas limits edema formation and bleeding and promotes graft acceptance. The nurse should wrap the client's arms and legs from the distal to proximal ends and use strict sterile technique throughout the dressing change. Maximum bandages should be avoided because bulky dressings limit mobility; instead, the nurse should use enough bandages to absorb wound drainage. Sterile gloves are required throughout all phases of the dressing change to prevent contamination. 3) C - Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.

4) D - To prevent eye discomfort, the client must protect the eyes for 48 hours after taking medication for photochemotherapy. Protecting the eyes for a shorter period increases the risk of eye injury. 5) B - The scab formation is found in the migratory phase. It is accompanied by migration of epithelial cells, synthesis of scar tissue by fibroblasts, and development of new cells that grow across the wound. In the inflammatory phase, a blood clot forms, epidermis thickens, and an inflammatory reaction occurs in the subcutaneous tissue. During the proliferative phase, the actions of the migratory phase continue and intensify, and granulation tissue fills the wound. In the maturation phase, cells and vessels return to normal and the scab sloughs off. 6) B - Applying an emollient immediately after taking a bath or shower prevents evaporation of water from the hydrated epidermis, the skin's upper layer. Although emollients make the skin feel soft, this effect occurs whether or not the client has just bathed or showered. An emollient minimizes cracking of the epidermis, not the dermis (the layer beneath the epidermis). An emollient doesn't prevent skin inflammation. 7) B - To prevent the spread of scabies in other hospitalized clients, the nurse should isolate the client's bed linens until the client is no longer infectious usually 24 hours after treatment begins. Other required precautions include using good hand-washing technique and wearing gloves when applying the pediculicide and during all contact with the client. Although the nurse should notify the nurse in the day surgery unit of the client's condition, a scabies epidemic is unlikely because scabies is spread through skin or sexual contact. This client doesn't require enteric precautions because the mites aren't found on feces. 8) B - Answer to nursing board exam questions - Adults and children with gonorrhea may develop gonococcal conjunctivitis by touching the eyes with contaminated hands. The client should avoid sexual intercourse until treatment is completed, which usually takes 4 to 7 days, and a follow-up culture confirms that the infection has been eradicated. A client who doesn't refrain from intercourse before treatment is completed should use a condom in addition to informing sex partners of the client's health status and instructing them to wash well after intercourse. Meningitis and widespread CNS damage are potential complications of untreated syphilis, not gonorrhea. 9) C - Sunscreen should be applied even on overcast days, because the sun's rays are as damaging then as on sunny days. The sun is strongest from 10 a.m. to 2 p.m. (11 a.m. to 3 p.m. daylight saving time) not from 1 to 4 p.m. Sun exposure should be minimized during these hours. The nurse should recommend sunscreen with a sun protection factor of at least 15. Sitting in the shade when at the beach doesn't guarantee protection against sunburn because sand, concrete, and water can reflect more than half the sun's rays onto the skin. 10) B - Answer to nursing board exam questions - Impetigo is a contagious, superficial skin infection caused by beta-hemolytic streptococci. If the condition is severe, the physician typically prescribes systemic antibiotics for 7 to 10 days to prevent glomerulonephritis, a dangerous complication. The client's nails should be kept trimmed to avoid scratching; however, mitts aren't necessary. Topical antibiotics are less effective than systemic antibiotics in treating impetigo. 1) C - In pernicious anemia, the gastric mucosa doesn't secrete intrinsic factor, a protein necessary for vitamin B12 absorption. Without intrinsic factor, vitamin B12 replacements taken orally won't be absorbed; therefore, vitamin B12 must be administered through the I.M. or deep subcutaneous routes. Clients must take vitamin B12 each day for 2 weeks initially, then weekly for several months, then once each month for life. 2) C - Gingival hyperplasia may occur with long-term administration of phenytoin, an anticonvulsant.

This adverse effect presumably is dose related. Frequent toothbrushing removes food particles and helps prevent infection; regular dental care and frequent gum massage also are recommended. Gingival hyperplasia isn't a reported adverse effect of procainamide, azathioprine, or allopurinol. 3) B - Hematology Questions and Answers for number 3 is B - Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia. 4) D - In sickle cell crisis, sickle-shaped red blood cells clump together in a blood vessel, which causes occlusion, ischemia, and extreme pain. Therefore, option D is the appropriate choice. Although nutrition is important, poor nutritional intake isn't necessarily related to sickle cell crisis. During sickle cell crisis, pain or another internal stimulus is more likely to disturb the client's sleep than external stimuli. Although clients with sickle cell anemia can develop chronic leg ulcers caused by small vessel blockage, they don't typically experience pruritus. 5) A - Vitamin B12 absorption depends on intrinsic factor, which is secreted by parietal cells in the stomach. The vitamin binds with intrinsic factor and is absorbed in the ileum. Hydrochloric acid, histamine, and liver enzymes don't influence vitamin B12 absorption. 1) B - The physician usually prescribes colchicine for a client experiencing an acute gout attack. This drug decreases leukocyte motility, phagocytosis, and lactic acid production, thereby reducing urate crystal deposits and relieving inflammation. Allopurinol is used to decrease uric acid production in clients with chronic gout. Although corticosteroids are prescribed to treat gout, the nurse wouldn't give them because they must be administered interarticularly to this client. Propoxyphene, a narcotic, may be used to treat osteoarthritis. 2) B - Kyphosis refers to an increased thoracic curvature of the spine, or "humpback." Lordosis is an increase in the lumbar curve or swayback. Scoliosis is a lateral deformity of the spine. Genus varum is a bow-legged appearance of the legs. 3) A - After a myelogram, answer to musculoskeletal test questions about positioning will depend on the dye injected. When a water-soluble dye such as metrizamide is injected, the head of the bed is elevated to a 45-degree angle to slow the upward dispersion of the dye. The other positions are contraindicated when a water-soluble contrast dye is used. If an air-contrast study were performed, the client should be positioned supine with the head lower than the trunk. 4) B - As untreated scoliosis progresses, the thoracic spinal curvature can impinge on the lungs and affect pulmonary function. Osteoporosis, spinal cord injury, and pituitary hyposecretion aren't directly attributed to untreated scoliosis. 5) B - To avoid pressure ulcers in an immobilized client, the nurse must assess the skin thoroughly and use such preventive measures as regular turning, massage of bony prominences, a low-airloss mattress, and a trapeze (if the client's condition allows). The nurse should increase, not decrease, the client's fluid intake to help prevent renal calculi, which may result from immobility. To prevent atelectasis, another complication of immobility, having the client cough, deep breathe, and use an incentive spirometer would be more effective than raising the head of the bed. Instead of bathing and feeding the client, the nurse should promote independent self-care activities whenever possible to prepare the client for a return to the previous health status. 1) C - Because of its short duration of action, edrophonium is the drug of choice for diagnosing myasthenia gravis. It's also used to differentiate myasthenia gravis from cholinergic toxicity. Ambenonium is used as an antimyasthenic. Pyridostigmine serves primarily as an adjunct in

treating severe anticholinergic toxicity; it's also an antiglaucoma agent and a miotic. Carbachol reduces intraocular pressure during ophthalmologic procedures; topical carbachol is used to treat open-angle and closed-angle glaucoma. 2) A - Phenytoin can lead to excessive gum tissue growth. However, brushing the teeth two or three times daily helps retard such growth. Some clients may require excision of excessive gum tissue every 6 to 12 months. Phenytoin may cause central nervous system stimulation, leading to insomnia, nervousness, and twitching; it doesn't cause drowsiness. Other adverse reactions to phenytoin include hypotension, not hypertension; and visual disturbances, not tinnitus. 3) D - Neurosurgical nursing answer - Levodopa-carbidopa, used to replace insufficient dopamine in clients with Parkinson's disease, may cause harmless darkening of the urine. The drug doesn't cause eye spasms, although blurred vision is an expected adverse effect. The client should take levodopa-carbidopa shortly before meals, not at bedtime, and must continue to take it for life. 4) A - To help confirm ALS, the physician typically orders EMG, which detects abnormal electrical activity of the involved muscles. To help establish the diagnosis of ALS, EMG must show widespread anterior horn cell dysfunction with fibrillations, positive waves, fasciculations, and chronic changes in the potentials of neurogenic motor units in multiple nerve root distribution in at least three limbs and the paraspinal muscles. Normal sensory responses must accompany these findings. Doppler scanning, Doppler ultrasonography, and quantitative spectral phonoangiography are used to detect vascular disorders, not muscular or neuromuscular abnormalities. 5) D- Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by a lower motor neuron lesion at the myoneural junction. It isn't a genetic disorder. A combined upper and lower motor neuron lesion generally occurs as a result of spinal injuries. A lesion involving cranial nerves and their axons in the spinal cord would cause decreased conduction of impulses at an upper motor neuron. 1) C - This is an example of a negative attitude and passive-agressive behavior to word demands for adequate performance. People with this disorder won't confront or discuss issues with others but will go to great lengths to "get even." Obsessive-compulsive disorder involves rituals or rules that interfere with normal functioning. A person with a narcissistic personality has an exaggerated sense of self-worth. A person with a dependent personality is submissive and frequently apologizes and backs down when confronted. 2) C - Denial is the avoidance of reality by ignoring or refusing to acknowledge unpleasant incidents. This defense mechanism is used to allay anxiety immediately after a stressful event. Introjection is an intense form of identification in which one incorporates the values or qualities of another person or group into one's own ego structure. Suppression is the conscious analog of repression. A person intentionally uses suppression to consciously exclude material from awareness. Repression is the unconscious exclusion of painful episodes from awareness. 3) C - Psychiatric nursing quiz answer - Children may not have the verbal and cognitive skills to express what they feel and may benefit from alternative modes of expression. It is important for the child to find a way to express internalized feelings. The child must also know that he is not to blame for this situation. In the process of doing play therapy, the child can also have fun, but that isn't the main goal of therapy. 4) D - The aggressor is negative and hostile and uses sarcasm to degrade others. The role of the blocker is to resist group efforts. The monopolizer controls the group by dominating conversations. The recognition seeker talks about accomplishments to gain attention. 5) A - Individuals in a crisis need immediate assistance. They are unable to solve problems and need structure and assistance in accessing resources. Clients in a crisis don't need lengthy

explanations or have time to develop insight on their own. They might need medication but, in most cases, support and direction can be most helpful. 1) C - The client needs to be advised to avoid strenuous activity for 4-6 weeks and to avoid lifting items that weigh more than 20 pounds. The client needs to consume a daily intake of at least 6 to 8 glasses of nonalcoholic fluids to minimize clot formation. Straining during defecation for at least 6 weeks after surgery is avoided to prevent bleeding. Prune juice is satisfactory bowel stimulant. 2) C - Ovulation occurs 14 days before the onset of menses.A- Midway between her cycles would be appropriate only if the client has a 28-day cycle.B- This would mean that ovulation would occur on approximately day 5 of the menstrual cycle.D- Variations in the cycle occur in the preovulation period; thus this is wrong information. 3) C - A teaching from Nursing Test Bank said that hydrocele is an abnormal collection of fluid within the layers of the tunica vaginalis that surrounds the testis. It may be unilateral or bilateral and can occur in an infant or adult. Hydrocelectomy is the excision of the fluid-filled sac in the tunica vaginalis. The client needs to be instructed that the sutures used during the procedure are absorbable. The other options are correct. 4) C - The client with genital herpes should be instructed to avoid sexual intercourse until lesions are completely healed. When the client is diagnosed with genital herpes, outbreaks may occur at any time. The perineal area should be kept dry. Clients should wear loose-fitting cotton underwear to promote drying of lesions. 5C - Catheter blockage or occlusion by clits following prostatectomy can result in urine back-up and leakage around the urethral meatus. This would be accompanied by a stoppage of outflow through the catheter into the drainage bag. Drainage that is bright red indicates that the irrigant is running too slowly; drainage that is pale pink indicates sufficient flow. A true urine output of 50 mL/hr indicates catheter patency. 6) A - Testicular cancer is highly curable particularly when it is treated in its early stage. Selfexaminations allow early detection and facilitate the early initiation of treatment. The highest mortality rates from cancer among men are in men with lung cancer. Testicular cancer is found more commonly in younger men ages 20-40 years old. 7) B - The client who suddenly becomes disoriented and confused following TURP could be experiencing early signs of hyponatremia. This may occur because of the flushing solution used during the operative procedure is hypotonic. If enough solution is absorbed through the prostate veins during surgery, the client experiences increased circulating volume and dilutional hyponatremia. The nurse needs to report these symptoms. 8) D - Based on some nursing review, sperm motility is increased at pH values near neutral or slightly alkaline; a sodium bicarbonate douche will reduce the acidity of fluids in the vagina and help optimize the pH. A- Estrogen does not alter pH.B- Sulfur does not change pH in any way.C- This would increase the acid content and kill the sperm. 9) A - Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure. Because it can occur on the vulva, a condom wont protect sexual partners. HPV can be transmitted to her parts of the body, such as the mouth, oropharynx, and larynx.

10) C - nurse should avoid removing the traction tape applied by the surgeon in the operating room. The purpose of the tape is to place pressure on the prostate to reduce bleeding Suppositories ordered on a PRN basis for bladder spasm should be warmed to a room temperature before administration. The nurse routinely monitors hourly urine output since the client has a three-way bladder irrigation running. The nurse also assesses for confusion which could result from hyponatremia secondary to the hypotonic solution irrigation during the surgical procedure. 1) D - Sitting or holding a child upright for formula feedings help prevents pooling of formula in the pharyngeal area. When the vaccum in the middle ear opens in the pharyngeal area, formula (along with bacteria) is drawn into the middle ear. A- Cleansing the ear does not reduce the incidence of otitis media because the pathogenic bacteria are in the nasopharynx, not the external area of the ears. B- Continuous low-dose antibiotic therapy is used only in cases of recurrent otitis media, when the child finishes a course of antibiotics but then develops another ear infection a few days later. C- Although accumulation of cerumen makes it difficult to visualize the tympanic membrane, it does not promote inner ear infection. 2) A - Placing ear plugs in the ears will prevent contaminated bathwater from entering the middle ear through the tympanostomy tube and causing an infection. B- Blowing the nose forcibly during a cold causes organisms to ascend through the Eustachian tube, possibly causing otitis media. CIt is not necessary to administer antibiotics continuously to a child with tympanostomy tube. Antibiotics are appropriate only when an ear infection is present.D- Drainage from the ear may be a sign of middle ear infection and should be reported to the health care provider. 3) D - According to Pediatric Nurse Education Books, a myringotomy relieves pressure and prevents spontaneous rupture of the eardrum by allowing pus and fluid to escape from the middle ear into the external auditory canal, from which the exudates drain.A, B & C-The CNS, lacrimal glands, and the urinary sytem are not involved in myringotomy. 4) A - Conjunctivitis is very contagious, so using a siblings towel is not recommended because the danger of spreading the infection. Careful and frequent handwashing is necessary to reduce risk of transmission. Typically, the child can return to school 24 hours after starting treatment. Medication for conjunctivitis is used for approximately 5 days. Teaching for the parents and the child with conjunctivitis should also include instructions to wash hands after touching the eyes, dispose of tissue used to clean the eyes after use, and launder washcloths and towels in hot water. 5) C - Prolonged oxygen administration at relatively high concentrations in a premature infant whose retina is incompletely differentiated and/or vascularized may result in retinopathy of prematurity (retrolental fibroplasias); when oxygen therapy is discontinued, capillary overgrowth in the retina and vitreous body may result and include capillary hemorrhage, fibrosis, and retinal detachment A- Though true, temperature and humidity not factors in the development of retinopathy of prematurity. B- Phototherapy is used to decrease hyperbilirubinemia; it is unrelated to retrolental fibroplasias; however eyes are covered to prevent injury for all infants receiving phototherapy. D- High oxygen concentration is dangerous and a factor in the development of retinopathy of prematurity. 6) B - Respiratory distress syndrome is predominately seen in premature infants; the more premature the infant, the more severe the disease - according to Pediatric Nursing Education Books. A & C- Intrauterine growth retardation and prolonged rupture of membrane are unlikely associated with development of respiratory distress syndrome. D - A 38- week gestation neonate usually has more mature lungs and isnt at risk for respiratory distress syndrome.

7) D - Tertbutaline, a beta2- receptor agonist, is used to inhibit preterm uterine contractions. A- Magnesium sulfate is used to treat pregnancy-induced hypertension. B- Dinoprosterone is used to induce fetal expulsion and promotes cervical dilatation and softening. C- It is used to stop uterine blood flow, for example, in hemorrhage. 8) C - Pediatric Nursing Education teaches that much of a full-term infants birth weight is gained during the last month of pregnancy (almost a third), and most of this final spurt is subcutaneous fat, which serves as insulation; the preterm infant has not has the time to grow in the uterus and has little of this insulating layer. A- There is relatively larger surface area per body weight. B- There is an extremely limited shivering and sweating response in the preterm infant. D- This is unrelated to the maintenance of body temperature. 9) D - The assessment findings are indicative of a preterm infant; therefore the nurse should closely monitor the infant for signs of respiratory distress syndrome; this occurs commonly in preterm infants because their lungs are immature. A- Preterm AGA infants do not develop polycythemia; preterm LGA infants may develop polycythemia, but there are no data to indicate the infant is LGA. B- Preterm AGA infants may become hypoglycemic. C- The neonate is preterm, not post-term. 10) A - Before 32 weeks gestation, the majority of neonates have difficulty coordinating sucking and swallowing reflexes along with breathing. Increased respiratory distress may occur with bottle feeding. Bottle feeding can be given once the neonate shows sucking and swallowing behaviors. B- high-caloric formulas can be given by bottle or by gavage feeding. C- Although frequent feeding prevents hypoglycemia, it does not have to be given via gavage tube. D- Although neonates can be stressed by cold, they can be kept warm with blankets while bottle feeding or fed while in the warm Isolette environment. 1) A - The Gynecoid is considered the normal pelvis type. This is transversely rounded or blunt. Option B is the Android. Wedge shaped or angulated. Seen in males. Not favorable for labor. Its narrow pelvic planes can cause slow descent and mid pelvis arrest. Option C is the Anthropoid type. This is oval shaped. The outlet is adequate, with a normal or moderately narrow pubic arch. Option D is what we call the platypelloid. This is flat in shape with an oval inlet. Transverse diameter is wide but anteroposterior diameter is short making the outlet inadequate. 2) D Human chorionic gonadotropin is produced by the trophoblastic tissue of the placenta and secreted into the urine and serum of a pregnant woman shortly after the onset of pregnancy. Leutinizing hormone (option a) and follicle stimulating hormone (option b) are anterior pituitary hormones necessary for developing and releasing the mature ovum and for synthesizing estrogen and progesterone. Human chorionic somatomammotropin (option c) is a placental hormone that acts similarly to the pituitary growth hormone. It produces a diabetogenic effect in pregnant women and isnt diagnostic of pregnancy. 3) C The chorionic villi and desidua basalis fuse to become the placenta. The deciduas vera is also a layer of the deciduas, but neither it or nor the deciduas capsularis is in direct contact with the ovum. The chorionic frondosum is part of the chorionic villi that fuses with deciduas basalis. The chorionic laeve is the part of the chorionic villi that does not fuse with the deciduas basalis; it degenerates and finally almost disappears. 4) C - Amniotic fluid does not provide the fetus with immune bodies but it does help dilate the cervix, protect the fetus from injury and keep the fetus at an even tenperature.

5) C - The umbilical cord normally consists of two arteries and one vein. Oxygen and other nutrients are carried to the fetal circulation by one umbilical vein. The oxygen-poor blood is pumped back to the placenta by the fetal heart through the two umbilical arteries. A single umbilical artery is sometimes associated with congenital anomalies.